Rehabilitation Programmes: Department of Health Briefing, Equality Review Report section on disability: Adoption

Meeting report

Rehabilitation Programmes: Department of Health (DoH) Briefing
Ms Sandhya Singh, Director: Chronic Diseases, Disabilities and Geriatrics, Department of Health, briefed the Committee on the implementation of rehabilitation programmes by the Department. .

She emphasised the importance of access to health care, stating that it was a catalyst in the equalisation of opportunities.
 
She said that health care comprised various components and that rehabilitation was inclusive of that. She emphasised that prevention played an integral part in all spheres of care, ranging from community based care to tertiary care. However she recognized the need for rights-based service delivery mechanisms. The Department noted that there were barriers and that people with disabilities had a right to be fully integrated within the health system.

The implementation of policy was necessary for the improvement of lives, and the underlying policy was necessary to ensure reporting. It was highlighted that the policy needed to target those who had the greatest need and that various target groups were presently facing exclusion from rehabilitation services.

A comprehensive or holistic rehabilitation service was deemed ideal. Ms Singh noted that the Department of Health (DoH) was creating access to rehabilitation services and that they had noted environmental barriers as well as the barriers experienced by disabled persons.

The Department of Health (DoH) appreciated that a thorough understanding of legislation and policy underlying service delivery was necessary. It was noted that legislation needed to be understood from the higher echelons at national level in the first instance, and from there a full understanding should be passed down to provincial level so that service providers had no difficulty in understanding and abiding by the legislation. 

She outlined that various pieces of legislation underlay service delivery. She listed these as:
The National Health Act (No 61 of 2003)
The Mental Health Care Act (No 17 of 2002)
The National Rehabilitation Policy
The Free Health Care for Disabled People at facility level
Child Youth and Adolescent Mental Health Care Policy Guidelines and
Integrated National Disability Strategy (INDS), which was currently being reviewed.

The international governing convention underlining service delivery was the United Nations (UN) Convention on the Rights of Persons with Disabilities. Certain Articles from the Convention were translated into the National Disability Policy framework, which was currently being reviewed as the INDS.

Of further importance were articles pertaining to health, rehabilitation and habilitation. These included cross-cutting articles on prevention, which assisted the Department in considering steps for prevention of injuries that were sustained from motor vehicle accidents and domestic accidents. Other articles would deal with access to information. In this context Ms Singh made reference to foetal alcohol syndrome, a debilitating yet preventable syndrome that caused several defects to the unborn child by a mother who would drink alcohol to excess throughout gestation.

Ms Singh added that the policy needed to access those who had the greatest need and she reiterated that the Department recognised a rights-based definition. The Department had supported the 1995 Cabinet proposal that focused on disability as being the loss of opportunity due to barriers. Ms Singh said that the Cabinet proposal of 1995 was compliant with the International convention. She also made reference to the 2001 Census on “Reported impairment”.

She said that disabilities often led to further isolation and that poverty and disability were often linked very closely. Abject poverty often led to difficulty in accessing services and rehabilitation centres, thus making disabled persons more prone to disease. Ms Singh emphasised that mothers or caregivers were often highly disadvantaged due to poverty. She added that the level of literacy was lower in disabled children because they often had difficulty in accessing education.

The Department of Health (DoH) had decided to adopt a holistic approach towards rehabilitation, through a comprehensive rehabilitation programme which would also include various levels of prevention, where applicable. It had to be a goal-orientated, time-limited process to enable each disabled person to reach their fullest potential. The Comprehensive Rehabilitation Programme needed to lead into social integration.

Community Based Rehabilitation as a philosophy was discussed. Ms Singh added that any person affected by a disability, which would be the disabled person or his or her family or caregiver, needed to be considered as central to the decision-making process. The National Disability Policy Forum (NDPF) strongly recommended the advancement of a collaborative sectoral policy on Community Based Rehabilitation (CBR).

Ms Singh went on to deliberate on comprehensive rehabilitation. It comprised Primary, Secondary and Tertiary Prevention. Primary Prevention pertained to the general public, with the dissemination of adequate information that promoted healthy lifestyles and halted the onset of certain preventable diseases. An example given was the prevention of foetal alcohol syndrome. Ms Singh emphasised that women should not be informed of the adverse affects of drinking alcohol when they were already pregnant but that they should receive this type of valuable information at school before they became sexually active. Secondary intervention was inclusive of Early Childhood Development (ECD) and early identification of problems in young children. Tertiary intervention included rehabilitation. Ms Singh noted that rehabilitation was dependent on concerted collaborations with other departments. She said that rehabilitation needed to be Inter sectoral and multi-disciplinary.

Ms Singh noted a marked change in the profile of rehabilitation as there was an overt increase in the demand from persons who had acquired these disabilities. HIV/Aids and diseases of lifestyle played an integral role. Stroke and diabetes- related impairments, such as the loss of limbs and eyesight, were noted as key examples of lifestyle disabilities.

The Department of Health, in its strategic plan focused on creating access to rehabilitation so that the quality of people’s lives could be improved. It looked primarily on free health care at facility level, accessibility of health facilities and was looking also at the final policy for orientation and mobility services.

Intra-sectoral collaboration was highlighted again. This type of collaboration was inclusive of Mother Child Women’s Health (MCWH), Care and Support at much needed step down facilities, Geriatrics for rehabilitation at the old age homes, and the planning of facilities.

Inter- Sectoral Collaboration was highlighted with regard to the Department of Education (DoE), the Department of Social Development (DSD) and the Road Accident Fund (RAF).

The access to education and information was vital. Ms Singh noted SABC educational radio stations and communication training for health service providers. The communication training included sign language and interpretation training. It was also noted that the provinces were training deaf persons to work as Voluntary Counselling and Testing (VCT) counsellors.

The promotion of access to community rehabilitation services for therapists was noted and this was for the first time resulted in access to services in numerous communities. Access to rehabilitation was also noted through economic development. The Department had initiated a project whereby persons with disabilities were repairing wheelchairs, thus creating economic spin offs. This also reduced the time period to wait for rehabilitation for the patients who needed the wheelchairs.

Barriers to access included the scarcity of resources, the fact that therapists had problems reaching patients, the need to look at recruitment of therapists, and the need to make transport available to patients in various communities. Cost and the lack of facilities for transport were of major concern. The budget was a problem and the Department set goals for the procurement of assisting devices and consumables, such as nappies and linen savers. There could be no quality of life for a child who did not have access to a simple commodity like a nappy. Caregivers needed to use the health system adequately and mothers would be able to get a script for a nappy on a monthly basis.

Ms Singh said that even when resources were existent there was the problem of space and monetary constraints. Some services, especially those of the non governmental organisations (NGOs) needed to be integrated into the existing health system. On the budget, she noted that rehabilitation was important but was also competing with other programmes within the health sector.

Ms Singh added that the model of service delivery was often a huge problem as sometimes caregivers needed to change their attitudes. Service delivery went beyond a medical model and should be viewed as a human rights model. She noted that when visiting rural areas she was impressed by the caring attitudes and mindsets of some of the service providers. Service delivery was not about operating fancy equipment but about adopting a caring and compassionate attitude towards patients.

Discussion
The Chairperson asked the Department what it was doing with regard to changing service deliverers’ attitudes and mindsets.

Ms Singh responded that it was still an ongoing battle. She said that the Department was currently engaging with service providers on compliance issues. She added that one of the components in a current programme dealt with the personal beliefs and value systems of service providers. She added that Batho Pele principles must be reinforced and that the attitudes of service providers needed to be changed towards all patients, and not only towards disabled persons. 

Mr M Moss (ANC) was concerned about the Workman’s Compensation Act (WCA) patients at the public hospitals, who were not being discharged from hospitals due to the delay or lack of rehabilitation facilities or assistive devices such as wheelchairs. The non-discharge was also adding costs for the Department of Labour.  He added that some facilities for disabled persons were closing down in certain public sector hospitals and was concerned for WCA-hospitalised patients who did not have anywhere else to go to for fundamental rehabilitation services. He added that the state had a responsibility to cater for these patients. He thought there was a need for greater interaction with the Department of Labour.

Ms Singh noted his concerns and said that she knew of patients who were unable to leave hospital for the simple reason of not having a wheelchair. She noted that issues pertaining to WCA in the public sector were of a serious nature, and there were economic repercussions. She added that she would make a note of Mr Moss’s inputs and would communicate the Department’s responses via e-mail.

Ms J Chalmers (ANC) commended the Department for its clear analysis of challenges. She was concerned, however, whether the Department had a clear understanding of the magnitude of its challenges.

Ms Singh responded that the Department’s infrastructure allowed for a programme manager for Provincial Departments of Health, and those managers would be responsible for ascertaining the challenges pertaining to their specific provinces. She added that if there was no Provincial Rehabilitation Manager there would be a District Coordinator. The National Department of Health simply did not have enough information to be able to fully understand the magnitude of challenges it faced. 
 
Ms Chalmers suggested the use of the constituency offices for conducting surveys pertaining to the needs of disabled persons.

Ms Chalmers asked whether there were any community based structures, especially in the rural areas, that facilitated the training of the families of disabled persons to assist therapists. She added that there were never going to be enough professionals and that the training of people at grassroots level to perform simple tasks to assist the disabled was fundamental.

Ms Singh spoke of Create, a programme that was used to train community based workers. Caregivers had to negotiate with health care professionals. She added that there were some provinces, such as Mpumalanga, where these programmes were being run and that some of those trained were themselves disabled persons. There was still much debate around the issue of whether or not the structure could be incorporated into a statutory function. The Department noted that it was currently undertaking a training module for community health workers and that it was very positive about it.

Ms Chalmers had concerns as to what the reporting protocol of the provinces was.

Members noted the importance of adequate researching. 

Ms Singh noted that the reported impairments were not a true refection of disability. She added that an understanding of how to measure barriers was necessary.

A clarification of the statistics on wheelchairs was provided by Ms Singh.

The Chairperson was concerned about how assistive devices such as hearing aids were being issued by the Provincial departments.

The Chairperson was concerned about the number of school children who were issued with devices at schools, but were not permitted to take them home with them at weekends or holidays. She noted that there were different allocations for the devices in different provinces and noted also that some provinces did not have the required testing units in hospitals. She was also concerned about pensioners who needed assistive devices. She noted her concerns regarding the Departments’ disability assessment protocol. She was also worried how the provinces accessed the needs of multi-disabled children.

The Chairperson further raised a query whether the Department was creating enough public awareness on acquired diseases such as HIV/Aids and diabetes.

She noted that she was not aware of mothers being able to access a script for monthly supplies of nappies.

Ms Singh said the issuing of nappies on a monthly basis via the obtaining of a script could be accessed as many people access their chronic medication. She added that it was currently in practice in many districts and provinces.
 
Ms P Bengu (ANC) was concerned about the funding of the wheelchair repair project and the employment and integration of those workers into the Department of Health.

Ms Singh noted that the wheelchair repair project added great value to many lives and that some provinces were doing better than others. However, there was still concern around employment issues.

A Member discussed the need for departmental collaborations especially with the Departments of Education, Health and Social Development regarding the creation of awareness pertaining to Foetal Alcohol Syndrome.

Ms Singh agreed that there was a need for more public awareness around issues pertaining to acquired diseases such as diabetes, stroke and HIV/Aids. She added education through public awareness needed to be looked at holistically.

The Chairperson raised the issue of what the Department had planned for the additional acquired disabilities resulting from the current xenophobic attacks. 

Ms Singh responded collectively to the Committees’ concerns around the provinces and accessibility. Regarding the process of accessing the assistive devices at Provincial Level, she said that the first requirement would be for the disabled person to have a proper disability assessment done. It was imperative that the assessment be done by a trained professional, to prevent future problems if the device was inadequate. Where there were no assessment facilities available, the disabled person needed to go to a locally accessible site. She added that disabled persons often did not go for assessments because they were unable to reach the assessment venue. The cost of going to an assessment venue was another stumbling block. She said that once the assessment was done, the correct device needed to be prescribed and then an application for the assistive device needed to be put though. Assistive device ordering capacity was necessary as well as the capacity to ensure delivery of the assistive devices. She noted that often Provincial Departments said they had no funds for assistive devices and added that this was one of the Department’s concerns.

The debate as to which department was responsible for the issuing of assistive devices to school going children had resulted in a decision that the Department of Health was responsible for the assessment and issuing of the device to the child, and that the Department of Education (DoE) was responsible for creating access for the effective working of the device.

Adoption of Equality Review Report – Disability Sector
The Chairperson noted that the Committee would not be adopting the entire report but only the sector pertaining to disability. After the motion for adoption had been made and seconded, the Committee adopted the disability sector of the report.

Adoption of Committee Minutes
The Committee adopted the minutes of meetings on 22 and 29 February 2008 and 5 March 2008.

The meeting was adjourned.