South African Health Review 1997 SOUTH AFRICAN
NORTHERN HEALTH REVIEWPROVINCE
GAUTENG MPUMALANGA
NORTH WEST SWAZI- 1997 LAND
FREE STATE KWAZULU-NATAL
LESOTHO NORTHERN CAPE
EASTERN CAPE
WESTERN CAPE
Published by the Health Systems Trust 1997 Information presented in this Review is based on best available data derived from numerous sources. Discrepancies between different sources, even for important indicators such as the infant mortality rate, reflect the current quality of data. All data should thus be interpreted carefully, and with recognition of potential inaccuracy.
Published by the Health Systems Trust and supported with a grant from the Department for International Development (UK) and the Henry J. Kaiser Family Foundation (USA)
Health Systems Trust Email: [email protected] 504 General Building Tel: (031) 307-2954 Cnr Smith and Field Streets Fax: (031) 304-0775 Durban 4001 South Africa
ISSN: 1025-1715 ISBN: 1-919743-17-0 First edition November 1997
Cover photo by Jane Edwards-Miller Designed and printed by Kwik Kopy Printing, Durban FOREWORD
The South African Health Review is the most comprehensive analysis of health and health care in South Africa today. Previous Reviews focused on the development of new health policies as part of the restructuring process in the health sector. 1997 has been characterised by pressure on decision-makers to translate these policies into tangible improvements in the quality of life of South Africans. This edition of the South African Health Review attempts to evaluate the impact of these policies, reflects on progress, and points to areas where changes in health policy have not translated into significant action. Further, the Review seeks to measure the attainment of equity in health care, a major priority of the new government. The Review includes a national clinic survey that offers a snapshot of the status of health care provision at the primary level of health care. We hope to improve and further develop the survey and retain it as an annual measure of the move toward equity in health care. With this addition, the Review will continue to provide an independent perspective on the degree to which health policy reform translates into real improvements in health care. The South African Health Review is a culmination of hard work by many individuals, a task that has significantly grown in complexity over the years. The Board of Trustees of the Health Systems Trust is grateful to them and acknowledges that without their efforts, the quality of the publication would not be of the high standard that it is today. More than 40 authors wrote the 27 chapters of the Review; reviewers helped enhance the quality of the information; staff members of the Health Systems Trust took responsibility for management of the publication process including co-ordination and editing; health service managers and health workers made inputs which constitute the foundation of this publication. We trust that the Review will continue to be a valuable reference document to Departments of Health, educational institutions, libraries, the donor community and health workers.
JAIRAM REDDY CHAIRPERSON BOARD OF TRUSTEES HEALTH SYSTEMS TRUST
i TABLE OF CONTENTS
Acknowledgements iv Preface v Measuring the Move Towards Equity from the Site of Service Delivery vii The Year in Review xvii Peter Barron, Health Systems Trust Kathy Strachan, Business Day Carel Ijsselmuiden, Department of Community Health, University of Pretoria Chapter 1 The Broad Picture: Health Status and Determinants 1 Debbie Bradshaw, CERSA, Medical Research Council
Chapter 2 Health and Development 17 Dingie Van Rensburg, Centre for Health Systems Research and Development, University of the Orange Free State Ega Kruger, Centre for Health Systems Research and Development, University of the Orange Free State Peter Barron, Health Systems Trust Chapter 3 Legislation 29 Jane Stuurman-Moleleki, National Progressive Primary Health Care Network Lynette Sait, National Assembly Portfolio Committee on Health Peter Long, National Progressive Primary Health Care Network Chapter 4 Private Sector 37 Gustaaf Wolvardt, Medical Association of South Africa Natasha Palmer, Health Systems Trust
Chapter 5 Provincial Restructuring 45 David Robb, formerly Department of Health and Developmental Welfare, North West Province Marie Annandale de Villiers, Department of Health and Welfare, Northern Province Krish Vallabjee, Department of Health, Western Cape Chapter 6 Local Government Restructuring 53 Shan Naidoo, Southern Metropolitan Substructure, Johannesburg Chapter 7 Hospital Restructuring 59 Brian Ruff, Gauteng Department of Health
Chapter 8 Financing and Expenditure 81 Alex van den Heever, Centre for Health Policy, University of the Witwatersrand Vishal Brijlal, Centre for Health Policy, University of the Witwatersrand Chapter 9 Human Resources 91 Robert Van Niekerk, Centre for Health Human Resources, University of the Western Cape David Sanders, Centre for Health Human Resources, University of the Western Cape Chapter 10 Drug Policy 99 Andy Gray, Department of Pharmacy, University of Durban-Westville Peter Eagles, Department of Pharmacy, University of the Western Cape ii Chapter 11 Health Information Systems 105 Kobus Herbst, Department of Health and Welfare, Northern Province and MEDUNSA Caesar Vundule, Department of Health and Developmental Welfare, North West Province
Chapter 12 Research 113 Jane Edwards-Miller, Health Systems Trust Chapter 13 Upgrading Health Facilities 119 Geoff Abbott, Division of Building Technology, CSIR Chapter 14 Community Involvement in Health 129 Elise Levendal, National Progressive Primary Health Care Network Sheila Lapinsky, Health Department, Western Cape David Mametja, Health Systems Trust
Chapter 15 Health and the Media 137 Kathy Strachan, Business Day Chapter 16 Maternal, Child and Women’s Health 139 Marian Jacobs, Child Health Unit, University of Cape Town Alyssa Wigton, Child Health Unit, University of Cape Town Nonhlanhla Makhanya, Health Systems Trust Beatrice Ngcobo, Gender Commission Chapter 17 Mental Health 153 Tennyson Lee, Centre for Health Policy, University of the Witwatersrand Ruth Zwi, Gauteng Department of Health
Chapter 18 Oral Health 165 Usaf Chikte, Department of Community Dentistry, University of Stellenbosch Chapter 19 Occupational Health 171 David Rees, National Centre for Occupational Health Tony Davies, National Centre for Occupational Health Chapter 20 Disability 179 Pam McLaren, Disability Action Research Team Sue Philpott, Disability Action Research Team
Chapter 21 HIV/AIDS 187 Liz Floyd, Gauteng Department of Health Chapter 22 Tuberculosis 197 Karin Weyer, Tuberculosis Research Programme, Medical Research Council Chapter 23 Sexually Transmitted Diseases 203 Mark Colvin, CERSA, Medical Research Council Chapter 24 Nutrition 207 David McCoy, Child Health Unit, University of Cape Town Mmipe Saasa-Modise, Goldfields Nutrition Centre, MEDUNSA
Chapter 25 Injury and Trauma 213 Alex Butchart, Health Psychology Unit, UNISA Margaret Peden, National Trauma Research Programme, Medical Research Council References 223 Tables of health and related indicators 238 Index 248
iii ACKNOWLEDGEMENTS
EDITOR Peter Barron, Health Systems Trust
PROJECT CO-ORDINATORS Gcinile Buthelezi, Health Systems Trust Thokozile Nkabinde, Health Systems Trust
ASSISTANT EDITOR Lucinda Franklin, Health Systems Trust
ACKNOWLEDGEMENTS External Reviewers National Department of Health Joce Kane-Berman, Western Cape Department of Health David Power, Red Cross War Memorial Children’s Hospital Michael Sinclair, Henry J Kaiser Family Foundation, USA Julian Lambert, Department for International Development, UK
Internal Reviewers Peter Barron Leslie Bamford Andrew Boulle Gcinile Buthelezi Candy Day Jane Edwards David Harrison Nonhlanhla Makhanya David Mametja Thokozile Nkabinde Natasha Palmer
Other Support We wish to thank the large number of individuals as well as all the staff at the Health Systems Trust, who contributed to the production of this document. Julia Elliot, Rachael James, Jurie Thaver, and Irene Kaiser who helped type editorial changes. Alyssa Wigton, Heather Jacklin and David McCoy made useful suggestions. Lynda Campbell and her team at Kwik Kopy Printing for the excellent presentation and layout of the publication. The individual authors who gave generously of their time in writing their chapters for no monetary award. The researchers, too numerous to mention, who assisted with data collection for the clinic survey, and David Harrison who proof read the final version and compiled the index. We thank you all for your help and support.
iv PREFACE
The preface of the 1996 South African Health Review posed a number of crucial questions. One of these questions was “What has changed for the poor, rural woman or child who presents to the clinic?” With the publication of the 1997 South African Health Review, we are able to answer the question by saying that we are not yet sure what has changed; however we do have a far better picture of the activities in the clinics. A survey was undertaken by the Health Systems Trust which looked at the basic infrastructure of clinics and the types of services provided. Some of the results of this survey are presented at the beginning of this review and sketch an outline of what is happening in the clinics. Ultimately, we would like to be able to answer the question posed above, and to paint a far clearer picture than we have at present. To do that we require information. If there is one thread running through this review, it is that we need more reliable, up-to-date information in order to assess, evaluate, plan, prioritise and improve. This information is required in every part of the health system. This is clearly illustrated by the latest (1996) census figures, published in preliminary form in July 1997. The total South African population is now estimated at 37.9 million people, compared with the estimates from the previous census of 41.5 million. This is a difference of nearly 10% and will, when provincial differences are taken into account, have far reaching effects on everything from resource allocation to tuberculosis and HIV rates. The main purpose of this review is that it serves as an independent and comprehensive source of information about health and health care in South Africa by analysing and presenting available data. It also provides a critique of the main policy development and trends over the year. Finally, it highlights gaps in the available sources of data. The Project for Health Information Dissemination of the Health Systems Trust invited selected people to contribute to specific chapters of the review. Each chapter was internally and externally reviewed and referred back to authors. Most of the comments of the external reviewers were taken into account and revisions made. This year’s review has been based on the framework of the previous two reviews. However, the ordering of the chapters has been changed as have some of the titles. In addition, a number of chapters have been added to make the review more comprehensive. We hope that the South African Health Review 1997 will provide its readers with a valuable insight into health and health care, in the context of the day-to-day realities of health service delivery in South Africa.
v vi MEASURING THE MOVE TOWARDS EQUITY FROM THE SITE OF SERVICE DELIVERY
INTRODUCTION One of the guiding principles of the Government of National Unity since 1994 has been that of equity. Up to now, much of the discussion about achieving greater equity in health care in South Africa has centred around the interprovincial allocation of resources. (See Chapter 8) It is important that policies and strategies towards equity in service provision are measured in terms of their impact on health service delivery. This would begin to demonstrate the practical impact of health reform. One step would be to assess service provision at the primary care level. In other words what has changed for the man, woman and child in the street or village in terms of services at the closest public sector clinic.
CLINIC SURVEY In order to assess service provision at the primary level a rapid appraisal of clinics throughout South Africa was commissioned by the Health Systems Trust after having obtained co-operation from the national and provincial Health Departments. The overall aim of the survey was to describe some aspects of service provision rendered at the primary level in South Africa and to paint a picture of clinics around the country. Basic indicators of primary level care were chosen to describe service provision. An important factor influencing what indicators were chosen was whether there would be reliable and readily available information by which to describe them. In all health regions of the country, one district was randomly selected as the study site. Within the district, data was collected from three clinics, using a standard questionnaire. The full methodology and results will be made available in a separate publication.A Data was collected from a total number of 160 clinics. Of these, 71 were classified as rural, 39 peri-urban and 50 urban. Clinics were spread across the country with an average of 18 clinics per province.
A Measuring the Move Towards Equity. Health Systems Trust. In Press.
vii RESULTS OF THE SURVEY Workload ➣ Urban clinics see relatively more patients than do rural clinics. ➣ The figures for the Northern Cape show an unusually high workload. ➣ The average number of patients seen per nurse per month is 553. (This is based on the number of patients seen at the clinic divided by the total number of professional and staff nurses).
AVERAGE NUMBER OF PATIENTS SEEN PER NURSE PER MONTH
Urban
Peri-urban
Rural
0 100 200300 400 500 600 650
Number of patients per month
AVERAGE NUMBER OF PATIENTS SEEN PER NURSE PER MONTH
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
0 200 400 600 800 1000 Number of patients per month
viii Support and supervision ➣ Visits by doctors to urban clinics are more frequent than to rural clinics. This is supported by inter-provincial comparisons, where relatively rural provinces such as the Northern Province and the Eastern Cape had very few doctor visits. ➣ In all provinces, clinics are visited on a regular basis by a nurse supervisor. ➣ Nearly 80% of all clinics have had a nurse supervisor visit in the past month.
PERCENTAGE OF CLINICS VISITED BY A DOCTOR IN THE LAST MONTH
Urban
Peri-urban
Rural
0204060 80100 Percent
PERCENTAGE OF CLINICS VISITED BY A DOCTOR IN THE LAST MONTH
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent
Measuring the move towards equity from the site of service delivery ix PERCENTAGE OF CLINICS VISITED BY A NURSE SUPERVISOR IN THE LAST MONTH
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent
x Communication ➣ Over 90% of facilities in the urban areas have a telephone which is consistently working. Within rural areas the figure is less than 50%. ➣ Only 41% of rural clinics have an ambulance at their door step within an hour of an emergency call. This compares with 59% in peri-urban clinics and 74% in urban clinics.
CLINICS WHERE EMERGENCY COMMUNICATION WAS ALWAYS WORKING IN THE LAST MONTH
Urban
Peri-urban
Rural
0204060 80100 Percent
CLINICS WHERE EMERGENCY COMMUNICATION WAS ALWAYS WORKING IN THE LAST MONTH
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent
Measuring the move towards equity from the site of service delivery xi Water Supply ➣ Almost all (98%) urban clinics visited had taps which were “always functioning”. ➣ 22% of clinics in rural areas are without taps. ➣ In those rural clinics with taps, only 70% were always working.
PERCENTAGE OF CLINICS WITH TAPS ALWAYS WORKING OVER THE LAST MONTH
Urban
Peri-urban
Rural
40 50 6060 80 100 Percent
PERCENTAGE OF CLINICS WITH TAPS ALWAYS WORKING OVER THE LAST MONTH
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent
Electricity Supply ➣ About 80% of clinics located in the rural areas and 92% of clinics in peri-urban areas have electricity. ➣ Where electricity supply was in place, it was recorded as not working consistently over the last month in: • 36% of rural clinics; • 31% of peri-urban clinics; and • 12% of urban clinics. ➣ In the Eastern Cape only 50% of the clinics visited in this study were electrified. xii Availability of Refrigerator ➣ All of the clinics, except for three, had refrigerators. ➣ Almost a quarter, (22%) of the rural clinics reported incidences of the fridge not working. Of these, half indicated that the refrigerator had been out of order for more than 2 weeks.
Baby weighing scales ➣ Almost all (99%) clinics visited had baby weighing scales which were in good working order.
Immunisation and family planning services ➣ Only half of all the clinics visited offered immunisation services on a daily basis, ➣ Family planning services were available on a daily basis in almost three quarters (72%) of all the facilities visited.
AVAILABILITY OF IMMUNISATION AND FAMILY PLANNING SERVICES ON DAILY BASIS
Urban
Peri-urban
Rural
0204060 80100 Percent
Family Planning Immunisation
AVAILABILITY OF IMMUNISATION AND FAMILY PLANNING SERVICES ON DAILY BASIS
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent Family Planning Immunisation
Measuring the move towards equity from the site of service delivery xiii Sexually transmitted diseases ➣ A third of rural clinics (33%) do not provide syphilis testing services for pregnant women. This compares to 17% in urban areas and 7% in peri-urban clinics which do not. ➣ Eighty one percent of all clinics use a syndromic approach to STD management.
PERCENTAGE OF CLINICS PROVIDING SYPHILIS TESTING AT ANTENATAL VISITS
Urban
Peri-urban
Rural
0204060 80100 Percent
PERCENTAGE OF CLINICS PROVIDING SYPHILIS TESTING AT ANTENATAL VISITS
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent
xiv SYNDROMIC MANAGEMENT OF SEXUALLY TRANSMITTED DISEASES
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Mpumalanga
Northern Cape
Northern Province
North West
Western Cape
SOUTH AFRICA
020406080100 Percent
Tuberculosis ➣ Only 16% of the 113 clinics offering TB treatment, are able to receive sputum results within 48 hours, which is the recommended guideline set by the tuberculosis control programme. ➣ The average in this study is 10 days.
REPORTED NUMBER OF DAYS TO RECEIVE TB SPUTUM RESULTS (% OF CLINICS)
2 days or 3-5 days 6-7 days 8-14 days Greater than Average less (%) (%) (%) (%) 14 days (%) (days)
Eastern Cape 0 25 50 0 25 8 Free State 28 11 6 33 22 10 Gauteng 33 27 20 20 0 5 KwaZulu-Natal 10 50 0 30 10 9 Mpumalanga 20 13 40 7 20 9 Northern Cape 12 6 29 41 12 12 Northern Province 14 0 43 29 14 9 North West 0 7 27 53 13 20 Western Cape 8 31 38 23 0 6 South Africa 16 17 25 30 11 10
Availability of drugs ➣ There appears to be a need to improve supply of drugs to clinics. ➣ Oxygen supply is a cause for concern. ➣ Only 10% of clinics in the Eastern Cape, 39% in the Northern Cape and 76% of clinics in the Northern Province had oxygen available at the time of the survey.
Measuring the move towards equity from the site of service delivery xv AVAILABILITY OF SELECTED ESSENTIAL DRUGS AND OXYGEN (% OF CLINICS)
Asthma Antibiotics Vaccines Tuberculosis Hypertension Diabetes Oxygen Eastern Cape 63 89 90 60 75 75 10 Free State 61 78 100 53 39 39 44 Gauteng 67 100 100 100 85 85 100 KwaZulu-Natal 96 91 100 79 96 96 91 Mpumalanga 80 95 85 95 100 100 45 Northern Cape 83 100 100 94 100 100 39 Northern Province 76 94 100 59 76 76 76 North West 93 100 100 100 100 100 87 Western Cape 58 92 100 100 50 50 77 South Africa 76 93 97 82 80 65 61
DISCUSSION This study was a rapid appraisal, and while the sample size was relatively small, it gives a useful snapshot of what is happening in clinics around the country. Although the study is unable to provide an exact quantification of the problems, it highlights some areas of concern. The selected indicators for this study were basic measures of the quality of service provision. Ideally all clinics should meet these standards and if PHC services were being equitably provided all clinics should score 100% for these indicators. Generally, the rural areas faired worse, as did the poorest provinces of South Africa. This clearly indicates that inequity exists in terms of service provision and therefore warrants monitoring. A relatively high patient to nurse ratio exists in the urban clinics compared to peri-urban facilities. This may be a reflection of the influx of people into urban areas where service provision has not been designed to cope with such a demand. It may also be a result of the perception of higher quality care in urban areas. It was encouraging to note that nurse supervision appeared relatively high in all provinces, but improvements can be made in virtually all provinces. However, this was not complemented by adequate doctor visits, especially to rural clinics. This confirms the well known critical shortage of doctors in the rural areas. In some instances, the availability of drugs was dependent on the services offered at the clinic. For example, a clinic which does not offer TB treatment, would not have TB drugs. The overall availability of essential drugs was around 80%. Given the relatively recent introduction of the Essential Drugs List, this is encouraging. However, oxygen supply, regarded as an essential commodity in any health facility, was generally inadequate. Although a relatively acceptable level of child health services seems to be in place (as reflected by the availability of baby scales and adequate vaccines), this seems to be offset by the fact that only 48% of all clinics offer immunisation services on a daily basis. This is despite the policy towards integration of services. Unreliable electricity supply and functional refrigerators remain issues of concern. It is encouraging to note that family planning services are well integrated, with around 72% of clinics offering this service on daily basis. Two priority health problems, namely, sexually transmitted diseases and tuberculosis, are far from attaining the standards set for their management. These standards relate to the testing for syphilis and the timeous return of tuberculosis sputum results. It is hoped that this rapid appraisal will provide useful information for planning and implementing the continuous improvement of the quality of primary health services. Furthermore, it is planned that this study will be repeated, so as to monitor the improvements, and thereby measure South Africa’s move towards equity in primary health service provision. xvi THE YEAR IN REVIEW
INTRODUCTION Health was again never far from the headlines during 1996/97. This chapter highlights many of those moments that grabbed the public’s attention. It also points out some of the achievements, problems and changes of the health sector that were not so attention grabbing in the eyes of the media, but which were at least as important in the long term transformation of the health sector.
LEGISLATION White paper and draft health bill While the health sector has undergone many changes over the past year, this has been done in the absence of a comprehensive legislative framework which is a crucial component to ensuring the thorough transformation of the health sector. At present the Health Act of 1977 is still legally enforceable. This Act does not give the legal authority for the setting up of a district health system which is the cornerstone of the policies of the Ministry of Health. However, with the circulation of Draft 9 of the Health Bill in November 1996 and with the adoption of a White Paper on the Transformation of the Health System in April 1997, a clearer vision for the transformation of the health sector has emerged. The proposed National Health Bill will give a clear mandate for transformation of the health services, particularly the development of a district health system. Organisations are generally supportive of the proposed bill, saying that by decentralising control it will make community involvement more possible, and by allowing intersectoral collaboration it will broaden the interventions to improve health. There is, however, concern in the private health sector, specifically among the health insurers, about limitations contained in the legislation on their practices.
Termination of pregnancy After a long-protracted battle, the most emotionally-charged development this year was the introduction of legal abortion on February 1 1997. The main rationale for legal abortion up to 20 weeks was the estimated 44 000 women who had arrived at hospitals each year with complications from “backstreet” abortions and who had cost the state an estimated R18.5 million a year. Many of the hospitals designated to deal with the termination procedure had a stream of requests from the first day. Yet some institutions battled with a shortage of staff as large numbers of doctors and nurses were unwilling to perform
Authors: Peter Barron, Health Systems Trust Kathy Strachan, Business Day Carel Ijsselmuiden, Department of Community Health, University of Pretoria xvii terminations. In the first six months after the introduction of the legislation around 60 percent of all the terminations were performed in institutions in Gauteng. This reflects the failure of most of the other provinces to ensure adequate accessibility to and provision of this service.
Drugs The plans to promote the use of generic drugs, to allow parallel importation and to have stricter controls over dispensing doctors were met with criticism from the professional associations and the pharmaceutical industry. The Medicines Control Council argued that the legislation seriously limited the council’s autonomy and that the legislation contained fundamental flaws which would weaken medicine controls. The pharmaceutical industry said the proposals amounted to “nationalising the industry”, and that they violated the intellectual property rights of foreign investors. The Health Department agreed to make some changes in the Bills dealing with these issues. The Bills were temporarily withdrawn. However, a controversial clause remains which allows the Minister of Health to override concerns of the Medicines Control Council. This allows the Minister to veto the Medicines Control Council decisions on the registration of drugs, if she considers it to be in the public interest. Several other controversial clauses, notably on parallel importation and on banning brand names on medicines distributed in state hospitals, were either dropped or changed. However, the changes failed to quell the objections of the pharmaceutical industry, which had hoped that both parallel imports and the backing for generic drug substitution would fall away. At the time of writing these Bills were again being debated in the Portfolio Committee on Health prior to being submitted to the National Assembly. Many observers believe that the introduction of these pieces of legislation will help to contain the very rapidly rising costs of drugs in South Africa and also improve the overall effectiveness of the use of drugs.
RESTRUCTURING THE HEALTH SYSTEM Provincial Health Departments It has become clear that the structure of the public service with its lack of flexibility and rigid formulas, rules and regulations is not compatible with the vision of transforming the health system to a decentralised system based on districts. For the successful decentralisation of authority and responsibility to district and hospital management some radical changes in the public service are required. The successful running of the provincial Health Departments is dependent to a large extent on other provincial departments such as Administration, Works and Transport. If these departments do not function as they should, and in many cases they do not, then the efficient and effective running of the Health Departments is compromised. The policy of moving towards an equitable health service throughout the country has been driven by the allocation of provincial health budgets through a central mechanism under the control of the national Department of Health. A formula to move towards an equal per capita expenditure was implemented by the post-election national Health Department. This is no longer the case and the move towards equity in expenditure on health is now dependent on the intra- provincial budget allocations. From the beginning of the current fiscal year 1997/98 each province received a block grant from the national Treasury. The allocations to the various line departments, including health, within the provinces is at the discretion of the provincial cabinet. The policy of trying to move towards an equal per capita expenditure of the public health sector across provinces, is now in the hands of the nine provinces and is thus more uncertain.
xviii DISTRICT DEVELOPMENT The development of health districts took some steps forward during 1996/7. In the long term it has been agreed that the implementation of district health services will be the responsibility of local government. However in the short term there are three options for the governance of districts: viz ➣ local authority control; ➣ provincial control; or ➣ autonomous district health authority control. All provinces, with the exception of KwaZulu-Natal have clear district boundaries. Over 150 districts have been created with populations ranging between 125 000 people in the Northern Cape to over 300 000 in the Eastern Cape. Many district managers have been appointed. A Green Paper for Local Government (discussion document) was publishd in mid-1997. This paper suggests changes to local authority boundaries and a decrease in the number of municipalities in South Africa to make them more viable. It is likely that these changes will impact on district health boundaries. During the year two projects aimed at strengthening districts were initiated. The Health Systems Trust started a project called the “Initiative for Sub-District Support” (ISDS). This project focuses on problems of quality of care at the site of health care delivery. Starting with these problems it then aims to strengthen the delivery of health care by making interventions in the health system. It is a “bottom-up” approach to health care reform. Inevitably much attention has focused on improving the overall functioning of the district. This project has been initially funded by the Henry J. Kaiser Family Foundation. The first sites where the project is functioning are Underberg, Impendle-Pholela (KwaZulu-Natal), Mount Frere (Eastern Cape), Kakamas (Northern Cape), Tonga and Shongwe (Mpumalanga) and Bothaville (Free State). A USAID funded project to “strengthen equitable access to quality health services” started in the Eastern Cape at the beginning of 1997. The project, commonly referred to as the “Equity Project” is being co-managed by the provincial Department of Health and a non-governmental organisation from the United States called Management Sciences for Health. The total funds allocated to the project amount to US $50 million over a period of seven years. This money cannot be spent on infra-structural development, so that the focus of the project is on the development of human capacity, policy and management systems. The first few months of the project have been devoted to setting up their offices and consulting with the Department of Health and local programme managers. A strategic plan for the duration of the project and a more detailed 1997/98 work plan have been developed. The initial work of the project has focused on improving the information systems around finances, drugs and personnel. Training health workers in management as well as in clinical competencies has also commenced.
Facilities Two major studies commissioned by the national Department of Health were completed during the year. The Hospital Strategy Project which looked into inefficiency and inequity in the public hospital system made a number of strategic recommendations regarding hospitals. These included issues of staffing and bed norms, efficient and accountable hospital management through decentralisation and delegation of authority, and relationships between public hospitals and the private sector. The recommendations of this project are still to be implemented. A national health facilities audit of all 542 public sector hospitals and community health centres highlighted that it would cost around R7.6 billion to restore the existing facilities to an acceptable standard. The Northern Province, which is the worst off in terms of standard of facilities, has started work on improving its hospitals and health centres and there has been a significant improvement over the past year.
The Year in Review xix INFECTIOUS DISEASES AIDS The furore over claims by a group of University of Pretoria scientists that they had stumbled on “Virodene”, a cure for AIDS, overshadowed most other health events early in the year. While the claims were soon debunked, and the “cure” exposed as no more than an industrial solvent, questions lingered over why the health ministry had invited these three “unknowns” in the AIDS field to present their work to Cabinet and to request R3.7 million in state funding when established scientists, who had been working on AIDS for many years with little funding, received no such breaks. In addition, the public inquiries into the funding of the AIDS play Sarafina II continued, and new questions arose concerning the Health Department’s actions. A fresh AIDS controversy flared up when the Director-General of the Health Department made a statement saying that health services should inform all the partners of people found to be HIV positive. The need for confidentiality and for protection of the community should be balanced, she said, but health organisations responded by saying that the Department would do better to look to improving its own AIDS programmes, before suggesting policies that will burden an already marginalised and stigmatised group. South Africa’s AIDS situation received international prominence when President Nelson Mandela told the World Economic Forum early in the year that if current trends continued, the HIV/AIDS epidemic would cost South Africa 1% of its gross domestic product by the year 2005, and up to three-quarters of its health budget would be consumed by direct health costs relating to HIV/AIDS. The latest estimates of the spread of the HIV indicates the number of adults currently infected to be in the order of 2.4 million people, with over half of these in KwaZulu-Natal and Gauteng. The prevalence of adults who are HIV positive in KwaZulu-Natal has risen to nearly 20%.
Tuberculosis The increasing tuberculosis epidemic continued unabated and South Africa now has disease rates more than double those in most developing countries. In 1996 nearly 160 000 people were diagnosed as having tuberculosis. More than a quarter of these people are also infected with HIV and together the two infections make a deadly combination. The Minister of Health has brought her political will to bear against tuberculosis by calling it a priority health problem, whilst the MECs for Health in the Western and Eastern Cape have made tuberculosis an emergency health issue. A new focused tuberculosis control programme has been introduced by the national Department of Health. However the implementation of the strategy by the provinces has not been as effective as anticipated. Two problems have been the inadequate and slow microscopy services and the ineffectual collection and dissemination of information which is necessary for informed managerial control.
Malaria The malaria epidemic of the past year has been the worst in 50 years. There were over 20 000 cases and about 124 deaths in South Africa in 1996. In response the Medical Research Council has embarked on a million rand project to plot the geographical incidence of malaria in Africa so that large scale interventions for the continent could be carried out.
Ebola The event which received probably the most media coverage of all health stories in the year was the single case of Ebola fever in Johannesburg. The nurse, who contracted it from a Gabonese patient, later died. Yet the tragedy brought with it a positive element - an appreciation of how well the health services responded at this critical time. It was the first time Ebola had occurred outside of central Africa, and the expertise and preparedness in South Africa enabled it to contain the virus xx to a single case - unlike in Zaire where it caused a major outbreak. The Ebola scare came close on the heels of an outbreak of another exotic disease, Congo Fever, where a woman in Oudtshoorn died and 16 abattoir workers received emergency treatment. This containment of Congo Fever also demonstrated the good quality that is present in our health services.
SMOKING The year 1996 ended on a loud note with Health Minister Nkosazana Zuma and Rembrandt chairman Anton Rupert squaring up against each other for the first time. The tobacco industry responded to Dr Zuma’s threats of banning all cigarette advertising with scorching attacks sent out in full page newspaper adverts. As the tobacco war raged on, Dr Zuma intensified her strategy, placing stronger and clearer health warnings on cigarette packets, reducing advertising on radio, and raising the excise tax on cigarettes. The national Department of Health has also declared their offices in Pretoria to be completely smoke-free zones, setting a good example to other institutions.
HUMAN RESOURCES Vocational training/community service Medical students took to the streets in protest against the SA Medical and Dental Council’s proposal to introduce an additional two years vocational training of doctors from January 1998. These students regarded the proposal as a thinly-veiled plan to get them to do community service in underserved areas. Yet the Medical Association supported the proposal, saying medical graduates were not adequately prepared to practise independently when they finished their one-year internship, and that further training was required. The proposal was also supported by the Deans of the Medical Schools. They proposed that the introduction of the scheme be deferred by a year to ensure that the required logistics and support are in place. Students were concerned that there would not be enough training posts or supervision to make the proposal viable. The Minister of Health put forward an interim proposal of one year of community service for doctors commencing in 1998. This proposal, at the time of writing, had not yet been passed by Parliament.
Cuban doctors Another attempt to improve the maldistribution of doctors in the country was the importation of Cuban doctors. In provinces such as the Northern Cape, Northern Province and Mpumalanga these doctors have made a significant difference to the accessibility of health care for people who make up the most deprived part of the population. However, the arrival earlier this year of a new wave of Cuban doctors to work in remote areas which have severe shortage of doctors stirred up again the questions of what the health department was doing to encourage local doctors to serve in these areas. Rural doctors said it was not only better pay that was needed as an incentive - other factors such as academic links with medical schools and professional recognition would go a long way in attracting doctors to neglected areas. The registration requirements for foreign doctors have put many rural hospitals, especially in northern KwaZulu-Natal, under threat of not being able to attract doctors. It has been estimated that less than a quarter of the doctors in rural hospitals are South Africans.
Nursing Education There appears to be a lack of coordination between the Education and Health Departments regarding responsibility for higher education in the health sector. This is exemplified by the issue of nursing education. At present Colleges of Nursing fall under the control of the various provincial Health Departments. The White Paper on Higher Education recommends that these colleges should, over time, be wholly relocated to the Department of Education.
Private Medical University A proposal by the medical aids to establish a private medical school with private funds was rejected by the Ministry of Health.
The Year in Review xxi HEALTH SECTOR HEARINGS OF THE TRUTH AND RECONCILIATION COMMISSION (TRC) On 17 and 18 June, the Truth and Reconciliation Commission (TRC) held hearings in Cape Town to examine the role of the health sector in past human rights abuses under apartheid. The hearings were particularly historic because it was the first time internationally that a Truth Commission had chosen to hold a hearing specifically for the health sector. The hearings stemmed from growing evidence presented to the TRC indicating the involvement of health professionals in human rights violations. Discussions outside the TRC also pointed to the need for the health sector to re-examine its past role in human rights abuses. A wide range of organisations and individuals submitted evidence to the TRC. The individual submissions included case studies with stories by survivors of apartheid, health professionals “in the firing line”, black health professionals talking about their own training experiences and by specialists in forensic medicine and psychiatry talking about the abuse of medico-legal evidence. The TRC heard that doctors accepted interference in their professional duties by the state and turned a blind eye to the torture and ill treatment of political detainees. In its submission, the Medical Association of South Africa admitted complacency in opposing apartheid, and closing ranks to protect doctors implicated in human rights abuses. The organisation described the Biko case as a “sad and disgraceful episode in MASA’s history”. One of the key organisations which presented to the TRC was the Health and Human Rights Project (HHRP). This organisation felt that while much had been achieved, there was a lot more left to be done. The HHRP identified a number of key strategic areas for attention. These included the need to: ➣ address the transformation of key statutory bodies, in particular the Medical and Dental Council ➣ follow up on individual cases of complicity identified in the preparation for the hearings ➣ develop a position on the Unity Process in professional organisations that ensures a human rights focus ➣ promote awareness and raise the media profile of human rights issues in health. High Technology Medicine The controversy which highlighted more clearly than any other the difficult transition that the health service was experiencing and the painful choices that had to be made was the row over heart transplants and highly-specialised services such as renal dialysis. Cuts to tertiary medicine meant that for the first time limits had to be imposed on costly procedures. While there were individuals whose lives hung in the balance as health authorities decided whether or not they would receive their life-saving operations, the point was made that those operations would have to be carried out at the expense of less dramatic programmes, such as immunisation and treatment for diarrhoea. The cost of a single transplant case was balanced against the cost of an immunisation programme which could save the lives of thousands of unknown children.
Private Sector The embattled medical aid industry was constantly in the news. Far-reaching plans to stabilise the industry, which were drawn up by the Health Department, proposed that both medical aid schemes and life insurance companies would have to put forward their health insurance products for registration. Products that had the same objective as a medical scheme but offered cover on a discriminatory basis and excluded the sick and elderly would not be permitted to register. In addition costs in the private sector continued to rise at an unacceptably high rate although the medical aid industry has attempted to curtail these costs. Managed care continued to grow as did the number of medical schemes requiring pre-hospitalisation authorisation.
xxii Primary School Nutrition Programme Stories of maladministration and corruption surrounded this programme. The Department of Health responded to these problems by introducing a system of audit of the implementation of these programmes in the provinces and also employed management consultants to improve the financial control of the scheme. A national review of the programme has made a number of wide reaching recommendations regarding refocussing and restructuring the programme.
Trauma Deaths and injuries from motor vehicle accidents make it the single largest category of mortality and morbidity in South Africa. The carnage on the roads in combination with intentional violence make South Africa one of the unsafest countries in the world. However, the murder rate of over 60 murders per 100 000 people in 1996 shows signs of dropping. Also encouraging are the moves, especially in KwaZulu-Natal, to try out innovative schemes to improve traffic safety.
Conclusion Although the stories on health covered by the media during the year have been commented on in this chapter, much of what is done by hard working health workers is not reflected. However, at the end of the day what goes on between individual health worker and individual patient, is every bit as important as the development of national health policy. This review is dedicated to the health and health care of all South Africans but especially the needy and poor.
The Year in Review xxiii THE BROAD PICTURE: 1 HEALTH STATUS AND DETERMINANTS
INTRODUCTION The health of a nation is determined by many factors. Demographic, socio-economic and environmental factors interact with individual behaviour and health service interventions to result in a particular health profile. Social inequalities in society can also be expected to be reflected in health status. Some of the terms used in this chapter are defined at the end.
POPULATION SIZE AND GROWTH RATE The first census to cover the re-integrated South Africa was conducted on 10 October 1996. Preliminary estimates suggest that there are 37.9 million people living in South Africa.1 The 37.9 million in 1996 is almost a doubling of the population since 1970. Over the last decade South Africa has experienced considerable population growth. The average growth rate during the early ‘90s has been estimated to be 2.06% per annum,2 slower than the rate for earlier periods. Despite expected declines in the fertility rates, the population growth rate is unlikely to decline to less than about 1.9% per annum in the next few decades. This is due to the young age structure of the population. A Draft White Paper for Population Policy3 was released in September 1996 with social justice, the eradication of poverty, sustainable development and reducing unsustainable consumption being key elements of the policy. Improved reproductive health and the empowerment of women are identified as important determinants of sustainable population growth.
DEMOGRAPHIC CHARACTERISTICS There are slightly more women (50.5%) than men (49.5%) in South Africa.2 Seventy six percent of the population are African, 13% are White, 8.5% are Coloured and 2.5% are Asian.2 Age distribution shows a young population with nearly half (45%) of the population younger than 20 years of age. This however, differs substantially for different groups in South Africa. For instance, there are sharp differences between African and white South Africans (Figure 1). The age pyramids show that the African population is much more youthful than the whites. Figure 2 shows the different age distributions for people living in the urban and rural areas. There is a preponderance of women and children in the rural areas.
Author: Debbie Bradshaw, CERSA, Medical Research Council 1 FIGURE 1 THE AFRICAN AND WHITE AGE CONTRAST - TOTAL POPULATION
Africans
100
90
80
70
60
50 Age
40
30
20
10
0 -8 -6 -4 -2 0 2 4 6 8 MalePercent Female
Whites 100
90
80
70
60
50 Age
40
30
20
10
0 -5 -4 -3 -2 -1 0 1 2 3 4 5 MalePercent Female
2 FIGURE 2 THE URBAN/RURAL CONTRAST
Total Urban
100
90
80
70
60
50 Age
40
30
20
10
0 -6 -4 -2 0 2 4 6 MalePercent Female
Total Non-urban 100
90
80
70
60
50 Age
40
30
20
10
0 -8 -6 -4 -2 0 2 4 6 8 MalePercent Female
The Broad Picture: Health Status and Determinants 3 The fertility levels in South Africa have been declining. Estimates of the total fertility rate (TFR) range from 3.9 to 4.09.3 Whilst higher than that experienced in industrialised countries, it is somewhat lower than the rate of 6.3 experienced in Sub-Saharan Africa.4 TFRs are higher in the rural areas than in urban areas,3 eg. the Northern Province (Table 1). TFRs differ according to race group with the estimates being 4.3 for Africans, 2.3 for coloureds, 2.2 for Asians and 1.5 for whites. There is a relatively high incidence of high-risk fertility in South Africa. In 1993, 15% and 16% of the births respectively were to teenagers and women over 35 years of age.3
TABLE 1 GENDER RATIO, AGE DISTRIBUTION AND FERTILITY BY PROVINCE
Province Gender Proportion Proportion Age Total Teenage ratioa of population of population dependancy Fertility pregnancy <5 yearsb >65yearsb ratioa Ratec ratec Western Cape 100.0 9.3 5.2 50.4 4.6 13.1 Eastern Cape 89.9 14.3 4.7 96.3 4.3 13.3 Northern Cape 102.0 10.7 5.0 63.6 3.0 12.9 Free State 110.0 12.2 4.2 60.0 4.3 15.3 KwaZulu-Natal 90.5 13.6 4.1 76.2 2.9 12.6 North West 102.8 12.4 4.3 64.0 5.8 16.4 Gauteng 113.7 8.7 4.6 40.9 4.5 12.6 Mpumalanga 102.4 14.2 3.3 72.9 3.7 14.9 Northern 84.2 17.1 3.8 107.5 2.7 11.8 South Africa 98.0 12.8 4.3 70.6 3.3 14.6
Source: a CSS. RSA Statistics in Brief 1996.2 b CSS. October Household Survey 1995.5 c HST. South African Health Review 1995.6
Urban distribution Nearly half (48.3%) of the population lives in urban areas. However, enormous urban/rural differences between the provinces exist and are shown in Figure 3.
FIGURE 3 URBAN AND NON-URBAN POPULATION BY PROVINCE, 1994
10
8
6
Population (millions) Population 4
2
0 KwaZulu Gauteng Eastern Northern Western North Mpuma- Free Northern Natal Cape Province Cape West langa State Cape
Urban Non-urban
Source: CSS RSA Statistics in Brief 1996
4 The population density in each province is shown in Table 2, again demonstrating large variations between provinces.
TABLE 2 THE POPULATION, URBAN DISTRIBUTION AND DENSITY BY PROVINCE
Province Population % in Urban Population (1995) 1000’s areas Density (km2)
Western Cape 3 721 86.5 28.8 Eastern Cape 6 481 32.6 38.2 Northern Cape 742 73.0 2.0 Free State 2 782 54.1 21.5 KwaZulu-Natal 8 713 37.6 94.5 North West 3 352 31.6 28.8 Gauteng 7 048 96.0 374.7 Mpumalanga 3 007 31.2 38.4 Northern Province 5 397 9.1 43.8 South Africa 41 244 48.3 33.8
Source: CSS RSA Statistics in Brief 1996. Migration The South African population is highly mobile. Migration is characterised by movement between rural and urban areas and within poor urban areas. Contract labour comes from other African countries and, more recently, there has been clandestine movement across the borders. In some areas migrancy has a dramatic effect on the demographic profile. Demographic surveillance in a rural area revealed that half of the males between the ages of 25 and 59 and 14% of the women of the same age were migrants, spending more than 6 months of the year living elsewhere.7 The legacy of the forced removals of African people and the lack of land ownership resulting from the apartheid system are important factors which will effect future settlement patterns.
Ageing South Africa is experiencing demographic transition and over the next 20 years, the proportion of elderly in the population can be expected to increase. The population aged 60 years and over comprised 6.1% in 1995 and will comprise 9.2% by the year 2020.8
Crime Serious crime rates are high but decreased in nine out of 20 categories during 1996. However, levels of reported assault and rape are still increasing. Table 3 shows the 1996 rates for selected crimes by province. Northern Cape Province experienced the highest reported rape and assault rates and the second highest murder rates. Emergence of such statistics is at least one step towards dealing with the problem.
TABLE 3 THE REPORTED RATE PER 100 000 POPULATION FOR MURDER, ASSAULT AND RAPE BY PROVINCE IN 1996
Province Murder Attempted Assault with Rape murder grievous bodily harm Western Cape 85.5 85.4 841.7 165.0 Eastern Cape 64.5 52.6 625.7 98.1 Northern Cape 83.7 56.1 1751.2 194.2 Free State 47.2 44.6 619.7 134.4 KwaZulu-Natal 74.8 84.1 292.0 97.5 North West 45.5 53.0 590.5 128.2 Gauteng 80.0 99.2 630.5 178.9 Mpumalanga 44.8 60.9 500.9 104.1 Northern Province 16.4 31.2 344.1 57.8 South Africa 61.6 67.5 545.6 119.5
Source::: Crime Information Management Centre. The Incidence of Serious Crime in 1996.
The Broad Picture: Health Status and Determinants 5 Infrastructure The October Household Survey conducted in 1995 indicated that there are still many households that do not have basic facilities.5 The availability of these facilities is correlated with the conditions of apartheid and rural Africans are worst off. Table 4 shows the availability of basic facilities by race group.
TABLE 4 THE PROPORTION OF HOUSEHOLDS WITH SANITATION, WATER AND ELECTRICITY AND THE HOUSING TYPE BY RACE GROUP, 1995
Group % with % with % with % informal % traditional sanitation piped water electricity structures dwellings/huts Urban African 99.0 90.0 80.9 15.4 1.7 Rural African 81.5 33.4 24.6 10.2 38.3 White 99.9 97.2 99.7 - - Coloured 96.8 92.2 85.0 4.1 0.7 Asian 100.0 98.0 98.9 0.4 - South Africa 92.3 71.6 65.5 7.1 14.3
Source: CSS 1995 October Household Survey
Data reviewed by Lerer and Delport9 gives more insight into the services available in urban areas. They considered that for the urban population, 15% had minimal access to water (boreholes, vendors or taps shared by more than 25 households) and 27% had minimal access to sanitation (bucket latrines or unimproved pits). The Government’s R1.3 billion Municipal Infrastructure Programme17 aims to benefit over 12 million people with basic infrastructure for water, sanitation, roads, refuse collection and community health care.
HEALTH STATUS Statistics reflecting health status are not readily available. For example, reliable mortality statistics, the cornerstone of health status data, are not available. The most recently published data refers to 1994 and it was estimated that for this year, only 18% of the births and 56% of the deaths were registered.10 Births and deaths have been estimated for each province to enable the extent of under-registration to be determined. Results are shown in Table 5. Clearly the figure in the Northern Cape is unreliable and reflects the underlying data collection system.
TABLE 5 THE ESTIMATED PROPORTION OF BIRTHS AND DEATHS REGISTERED IN EACH PROVINCE IN 1994
Province % births which are registered % deaths which are registered Western Cape 61.9 84.2 Eastern Cape 8.7 26.7 Northern Cape 52.8 173.1 Free State 19.8 82.0 KwaZulu-Natal 12.3 43.0 North West 6.4 28.6 Gauteng 39.5 71.9 Mpumalanga 11.5 53.5 Northern Province 3.9 24.8 South Africa 18.7 50.3
Source: Bradshaw, Nannan and Schneider.
The Departments of Health and Home Affairs together with the Central Statistical Service are currently reforming the system of registration. However, this is proving to be a lengthy process. In addition, the Department of Health has planned a national Demographic and Health Survey which will provide information on child and adult mortality levels in South Africa. Co-ordinated by the Medical Research Council, fieldwork should begin during late 1997.
6 Mortality Mortality rates in South Africa have been decreasing both for children and adults, resulting in increased life expectancy. These trends, however, are likely to be increasingly challenged by HIV/ AIDS and increased smoking levels amongst the population.
Child Mortality Levels of mortality differ markedly between the race groups as can be seen in the estimates of the Infant Mortality Rates shown in Table 6. The causes of death for children differ when comparing African children with white children (Table 7). Deaths amongst 1-4 year old African children are dominated by infectious diseases. Many of these deaths would be prevented by improved environmental conditions and access to primary health care. Injuries make up a large proportion of the deaths of white children. Many of these could also be prevented through an active injury control programme.
TABLE 6 INFANT MORTALITY RATES FOR SOUTH AFRICA IN 1990
1990 IMR (per 1000 births) Provincial range
African 54.7 37.2 - 74.5 White 7.3 3.9 - 10.9 Coloured 36.3 15.2 - 83.4 Asian 9.9 4.3 - 31.6
Source: Yach and Harrison11
TABLE 7 CAUSES OF DEATH IN AFRICAN AND WHITE CHILDREN, 1990
African White Main cause of death % Main cause of death %
Under 1 Perinatal 50 Perinatal 59 Infectious 25 Congenital 15 Respiratory 11 Respiratory 6 Endocrine 3 Infectious 6 1-4 years Infectious 36 Trauma 54 Respiratory 16 Respiratory 10 Ill-defined 14 Congenital 8 Endocrine 14 Infectious 6 5-14 years Trauma 42 Trauma 51 Ill-defined 14 Neoplasm 14 Infectious 14 Respiratory 9 Respiratory 8 Nervous 8
Source: Yach and Bradshaw12
Adult Mortality Although levels of adult mortality have been declining, they are none-the-less high. The probability of a 15 year old dying before the age 60 (45Q15 index), is a valuable indicator of premature adult mortality. Table 8 shows the estimates for 1985, compared to other countries. Adult mortality in South African males is as high as that in Sub-Saharan Africa. Even though the rates for white South Africans are lower than other race groups, these too are much higher than those of other industrialised countries.
The Broad Picture: Health Status and Determinants 7 TABLE 8 ESTIMATES OF SOUTH AFRICAN ADULT MORTALITY (45Q15) IN 1985, COMPARED WITH SELECTED COUNTRIES
Male Female
South Africa 38% 25% African 43% 29% White 22% 11% Coloured 40% 25% Asian 32% 17% Japan 12% 6% Sub-Saharan Africa 38% 32% Latin-America 23% 15% Finland, UK, Spain 15-18% 5-8%
Source: Bradshaw, Dorrington and Sitas13
Cause of death The causes of death profile were estimated for 1990. The profile is presented in Figure 4. A high proportion of deaths are classified as ‘ill- defined’ as the exact cause is unknown. It is assumed that in these cases, the person who died was not seen by a doctor at the time of death, possibly reflecting poor access to health care. The overall pattern of the deaths reflects the triple burden experienced in South Africa - the combination of poverty related diseases, chronic diseases and a high toll due to intentional and unintentional injuries.
FIGURE 4 THE ESTIMATED CAUSE OF DEATH PROFILE FOR SOUTH AFRICA, 1990
Ill defined Stroke Senility Perinatal conditions Ischaemic Heart Disease Upper respiratory infections Tuberculosis Diarrhoea Unintentional injury Injury (cause unknown) Diabetes Chronic Obstructive Pulmonary Disorder Cancer Lung Other cardiovascular Intentional injury Pulmonary circulation Septicaemia Nutritional/endocrine Other neoplasms Cancer oesophagus
05101520
Percent
Potential years of life lost is a measure which gives greater weight to deaths which occur earlier in life. Figure 5 shows that injuries, infectious disease and chronic diseases all feature in the most common causes of premature death.
8 FIGURE 5 THE YEARS OF LIFE LOST DUE TO PREMATURE DEATH IN SOUTH AFRICA, 1990
Ill defined Perinatal Diarrhoea Upper respiratory infections Tuberculosis Injury (cause unknown) Unintentional injury Stroke Ischaemic Heart Disease Intentional injury Nutritional/endocrine Diabetes Septicaemia Senility Chronic Obstructive Pulmonary Disorder Other cardiovascular Cancer lung Pulmonary circulation Nephritis Cancer oesophagus
05101520 Percent
Mortality data only partly measures the burden of disease in a country. It is important to remember that non-fatal conditions such as poor mental and oral health, blindness and arthritis are all conditions that contribute to the burden of disease. A full analysis of the burden of disease in South Africa must give due weight to such non-fatal conditions... THE UNFINISHED AGENDA: MALNUTRITION, INFECTIOUS DISEASES, MATERNAL AND PERINATAL MORTALITY Unfortunately, there is little new data to report beyond what has been presented in previous reviews.7, 14 An overview of the data previously presented is given in Table 9, followed by some recent research findings.
TABLE 9 OVERVIEW OF THE UNFINISHED AGENDA
Condition Features Malnutrition The Vitamin A survey conducted in 1994 showed: ✧ 25% women affected by iron deficiency anaemia ✧ high incidence of low birth weight (16%) ✧ 10% children underweight ✧ 25% children stunted ✧ 1 in 3 children had marginal Vitamin A Status ✧ 1 in 5 children anaemic ✧ 1 in 100 children had visible goitre Tuberculosis ✧ 3 000 deaths per year ✧ role of HIV in promoting TB ✧ multidrug resistance is emerging Measles ✧ 56 cases per 100 000 children under 1 Upper respiratory infections ✧ accounts for 4.8% of deaths Diarrhoea ✧ accounts for 3.8% of deaths Malaria ✧ approximately 24 000 cases in 1996 ✧ mostly found in the provinces to the north and east Peri-natal mortality ✧ still-births not known reliably Maternal mortality ✧ 250 per 100 000 births for African women ✧ 3 per 100 000 births for White women
Source: HST South African Health Review 199614
The Broad Picture: Health Status and Determinants 9 Malnutrition Iodine deficiency was identified as a problem in the Vitamin A survey, with 1% of children found to have visible goitre.14 A survey in 4 communities in the Langkloof15 area of the Western Cape found prevalences of endemic goitre ranging from 14% to 30%. These were found to be related to mild to severe iodine deficiency levels. Similar findings in school-aged children in the rural Ndunakazi16 area of KwaZulu-Natal province suggest that the problem may be quite widespread. Compulsory iodation of table salt was introduced in 1995. A study of the nutritional status of elderly coloured people living in the Cape Peninsula17 found suboptimal levels of Vitamin D, which plays an important role in maintaining healthy bones.
Tuberculosis As in other countries, Tuberculosis is being affected by HIV. It has been estimated that there were 160 000 TB cases in 1996, of which 42 000 cases could be attributed to HIV.18 The prevalence of HIV in adult TB patients in the Hlabisa health district of KwaZulu-Natal has risen from 36% in 1993 to 58% in 1995.19 The disease case load in the service has risen 3 fold and the clinical features of the disease are different. Furthermore, the HIV infected patients were 3 times more likely to fail to complete their treatment.20
Malaria The entire southern African region has experienced one of the most severe epidemics recorded in recent times.21 South Africa experienced 20 960 cases and 108 deaths due to malaria by May 1996.22 Increases have been attributed to high rainfall during the previous summer; the resistance of mosquitoes to insecticides; and of the parasite to chemotherapy.21
Parasitic Infections Bilharzia remains a neglected public health problem. Bilharzia has been found to be endemic in parts of the Transkei region. In a survey of school children undertaken in the Port St Johns district,23 a prevalence of 42% was found. Untreated intestinal parasitic infections are also a public health problem. A study in Durban found that a parasite, cryptosporiduim, was the second most common enteric pathogen related to gastro-enteritis admissions to hospital.24 The three main worms found in South African children are roundworm, whipworm and hookworm. Research in 3 communities in different settings, found whipworm in 25% of children in a rural area, 71% in a serviced urban area and 85% in a partially serviced metropolitan area.25
“HIV/AIDS” And Sexually Transmitted Diseases The HIV/AIDS epidemic has been on the horizon since the late eighties. At the end of 1996 there were an estimated 2.4 million adults infected with HIV. Antenatal surveillance has revealed an increased prevalence from 10.4% in 1995 to 14.1% in 1996.26 HIV/AIDS is now the biggest single disease influencing the health of the nation. Based on the 1993 prevalence of 3%, projections for Soweto demonstrate considerable variations from 8% to 24%, depending on whether there is a low, medium or high AIDS scenario.27 It is projected that by the year 2010, AIDS will have caused 135 000 - 270 000 deaths in Soweto and that these will account for 28 to 52% of all the deaths. The role of other sexually transmitted diseases (STDs) in the transmission of HIV has highlighted the public health concern regarding these diseases. There is a significant burden of STD in the asymptomatic population, particularly women.28 Around 17% of antenatal attenders have at least one urogenital tract infection and between 5-15% of asymptomatic clinic attenders have ulcerative infections, mainly caused by syphilis and chancroid. Gonorrhoea prevalence rates average 8% and there is increasing evidence of penicillin resistance. It appears that on average, vaginal infections are found in 20-49% of antenatal and family planing clinic attenders and chlamydia in 16%. Syphilis is currently the only STD for which there is on-going surveillance via antenatal screening. However a sentinel surveillance system to monitor STD syndromes has been developed in the Gauteng province.29
10 Chronic Diseases of Lifestyle Chronic diseases related to lifestyle are becoming increasingly important as the health transition proceeds. According to the 1995 Survey of Inequalities in Health,30 70% of people over the age of 65 reported that they had a chronic disease. A summary of previously presented information on chronic diseases is given in Table 10.
TABLE 10 OVERVIEW OF CHRONIC DISEASES
Condition Features Chronic Diseases ✧ 24.5% of all deaths are due to chronic diseases ✧ 25% of adults 15-64 and 70% adults over 65 years reported they had chronic diseases (hypertension, arthritis, respiratory, epilepsy, cancer) ✧ obesity, a risk factor for some chronic diseases, ranges from 3% for Indian men to 34% for African women ✧ mortality due to chronic obstructive respiratory disease is increasing while acute respiratory deaths are declining ✧ Cancer of the cervix, breast and basal cell skin cancer are the most common cancers for women ✧ basal cell skin cancer, prostate, oesophagus and lung cancer are most common for men ✧ smoking, a risk factor for some chronic diseases, has a prevalence of 52% in men and 17% in women ✧ smoking rates are rising in lower socio-economic groups and women
Source: HST South African Review 1996.
The National Cancer Registry figures for 1992 show that the lifetime risk of cancer was 1 in 4 for men and 1 in 5 for women.31 These differed by race group (Table 11). Tobacco and HIV related cancers can be expected to increase.
TABLE 11 SUMMARY LIFETIME RISKS OF THE TOP FIVE CANCERS BY SEX AND RACE GROUP
Population Group Male Lifetime risk Female Lifetime risk African/Black Oesophagus 1 in 39 Cervix 1 in 26 Prostate 1 in 58 Breast 1 in 68 Lung 1 in 89 Oesophagus 1 in 97 Liver, bile duct 11 in 137 Uterus 1 in 204 Mouth 1in 185 Liver, bile duct 1 in 400 All cancers 1 in 8 All cancers 1 in 9 Coloured Prostate 1 in 35 Cervix 1 in 30 Stomach 1 in 52 Breast 1 in 33 Lung 1 in 53 Colorectal 1 in 139 Oesophagus 1 in 56 Stomach 1 in 164 Bladder 1 in 88 Lung 1 in 227 All cancers 1 in 5 All cancers 1 in 5 White Prostate 1 in 20 Breast 1 in 15 Bladder 1 in 37 Colorectal 1 in 52 Colorectal 1 in 40 Melanoma 1 in 80 Lung 1 in 41 Cervix 1 in 83 Melanoma 1 in 64 Ovary 1 in 108 All cancers 1 in 4 All cancers 1 in 5 Asian Stomach 1 in 64 Breast 1 in 20 Prostate 1 in 67 Cervix 1 in 58 Colorectal 1 in 71 Stomach 1 in 68 Bladder 1 in 74 Uterus 1 in 91 Lung 1 in 91 Colorectal 1 in 94 All cancers 1 in 7 All cancers 1 in 6
Source: Sitas et al. Cancer in South Africa, 1992.
The Broad Picture: Health Status and Determinants 11 Smoking During the 1990’s, tobacco smoking increased by 1% per year.32 A survey in 1995 found that 52% of men and 17% of women over the age of 18 years smoked (Table 12).33 Prevalence was particularly high amongst the coloured population, almost reaching 60% who smoke. The October Household Survey5 data suggests that of the males who currently smoke, half had started by the age of 18 years and of the females who currently smoke, half had started by the age of 19 years. These data suggest that interventions aimed at school children are very important.
TABLE 12 SMOKING PREVALENCE (%) BY PROVINCE AND GENDER, 1995
Province Male Female Total Northern Cape 72 33 55 Western Cape 51 45 48 North West 62 31 46 Free State 56 23 40 Gauteng 51 20 37 KwaZulu-Natal 56 8 33 Eastern Cape 48 12 29 Mpumalanga 43 7 23 Northern Province 35 3 14 South Africa 52 17 34
Source: Reddy et al. Smoking status, knowledge of health effects and attitudes towards tobacco control in SA.
Highly Contagious Diseases The first case of Ebola virus outside of Central Africa occurred in Johannesburg towards the end of 1996. The South African health service was able to mount a response that appears to have prevented an outbreak. Congo Fever was also reported in Oudtshoorn near the end of 1996.
NEGLECTED PROBLEMS Injuries Road traffic injury rates are high in South Africa.34 Approximately 10 000 people die each year through road traffic collisions and a further 35 000-40 000 people sustain serious injuries. Double that number sustain slight injuries.34 Table 13 shows the number of collisions, deaths and injuries from 1990-1996. During this period, injuries have become more serious and the average number of casualties per collision has increased from 1.2 to 1.6. The number of collisions, deaths and injuries decreased in 1996. But it is premature to assess whether a real downward trend has been established or not and the accuracy of the surveillance system needs to be evaluated.
TABLE 13 THE NUMBER OF ROAD COLLISIONS, DEATHS AND INJURIES IN SOUTH AFRICA, 1990-1996
Year Collisions resulting Deaths Serious Injuries Slight Injuries in death or injury 1990 89 013 11 157 32 343 87 273 19 91 91 4 28 11 067 3 4 765 9 0 612 1992 83 804 10 142 32 792 93 470 1993 84 368 9 443 33 383 84 914 1994 90 938 9 981 36 548 91 892 1995 93 583 10 195 39 510 96 350 1996 84 173 9 790 38 159 86 291
Source: Ministry of Transport., 1997
12 Firearms and alcohol emerge as key factors in violence and injury. In a recent survey conducted in Cape Town,35 homicide was found to be the leading cause of deaths due to injury (52%), with firearms playing a major role. Twenty six percent of injury deaths in Cape Town were due to transport accidents. Alcohol was a factor in 62% of injuries to pedestrians.36 Despite accounting for more deaths than any other disease, injuries remain a neglected problem.
Mental Health Information about mental health status in South Africa is still scanty. Localised studies have identified that 20-30% of the population have psychiatric diagnoses and 10-14% of adults attending a primary health care clinic in Soweto had a diagnosable psychiatric disorder.37 A quarter of adult residents in two settlements outside Cape Town were found to be suffering from clinical depression, with higher levels among women.37
Substance Abuse The prevalence of alcohol-related injuries is very high and alcohol appears to play a role in both fatal and non-fatal injuries. It has been estimated that the cost of this misuse probably exceeds R9.5 billion, accounting for 2% of GNP.37 The consumption of alcohol has been rising and South Africa now ranks 23rd internationally with an annual per capita consumption of 8.5 litres per adult. An investigation into the drinking habits of pregnant women from poorer socio- economic communities in the Western Cape has demonstrated that 26% of pregnant mothers consume enough alcohol to place babies at risk for Fetal Alcohol Syndrome.38 It has been estimated that narcotic drugs are costing the country between 0.3% - 1.3% of GNP.18 The availability of drugs is constantly changing and a new generation of designer drugs are emerging on the South African scene. The South African Community Network on Drug Use (SACENDU)39 has been set up to develop a network of role-players concerned with the prevention of drug and alcohol abuse. The network aims to set up a sentinel surveillance system which can identify changes in the nature and extent of alcohol and other drug abuse.
Disability The prevalence of different disabilities is not known. The National Department of Health is planning to conduct a disability survey to identify the needs of disabled people. Self-reported disabilities were included in the Survey of Inequalities in Health30 (Table 14).
TABLE 14 THE PREVALENCE OF SELF-REPORTING OF DIFFICULTIES, 1994
16-64 years 65+ years Difficulty seeing 11% 36% Difficulty hearing 4% 20% Difficulty with speech 1% 3% Difficulty moving 3% 20% Difficulty learning 2% 12%
Source: CASE/Kaiser Family Foundation, 1995
Occupational Health A high prevalence of TB, pneumoconiosis and chronic obstructive airways diseases are found particularly among ex-mineworkers.40 For most occupational diseases there is a lack of reliable information.
The Broad Picture: Health Status and Determinants 13 Oral Health It has been estimated that 30 million South Africans have dental caries.18
TABLE 15 SUMMARY OF ORAL HEALTH STATUS
Condition Features Oral Health ✧ 67% children (2-5 years) had one or more tooth decayed ✧ only 31% adolescents (12-15 years) caries free ✧ 37% of adults (35-44 years) edentulous; 65% of adults over 65 years edentulous
Source: HST South African Health Review, 1996
Overall burden of diseases Given the paucity of both current data and projections of the future health status in South Africa, it is important to take note of recent international projections. Murray and Lopez41 have estimated the global burden of disease in 1990 for different regions of the world. They have also made projections to the year 2020.41 Table 16 shows the changing pattern of the burden of disease that they expect for developing countries. The current profile in South Africa is a little different from that of the developing countries in 1990. However, similarities can be recognised in the transition. The projected extent of depression in the year 2020 is particularly important as the current lack of mental health data in South Africa has possibly led to inadequate identification of a potential problem.
TABLE 16 THE CHANGING PATTERN OF DISEASE BURDEN IN DEVELOPING COUNTRIES (% OF THE TOTAL DALYA LOSS)
1990 2020 Rank Cause % total Rank Cause % total 1 Lower respiratory infections 9.0 1 Unipolar major depression 5.6 2 Diarrhoeal disease 8.1 2 Road-traffic accidents 5.2 3 Perinatal conditions 7.3 3 Ischaemic heart disease 5.2 4 Unipolar major depression 3.4 4 Chronic destructive pulmonary diseases 4.3 5 Tuberculosis 3.1 5 Cerebrovascular disease 4.2 6 Measles 3.0 6 Tuberculosis 3.5 7 Malaria 2.6 7 Lower respiratory infections 3.4 8 Ischaemic heart disease 2.5 8 War 3.3 9 Congenital anomalies 2.4 9 Diarrhoeal disease 3.0 10 Cerebrovascular accidents 2.4 10 HIV 2.8 11 Road-traffic accidents 2.2 11 Perinatal conditions 2.7 12 Chronic destructive pulmonary diseases 2.1 12 Violence 2.4 13 Falls 2.0 13 Congenital anomalies 2.4 14 Iron-deficiency anaemia 1.9 14 Self-inflicted injuries 1.8 15 Protein-energy malnutrition 1.7 15 Falls 1.6 16 War 1.6 16 Bipolar disorder 1.5 17 Tetanus 1.4 17 Osteoarthritis 1.5 18 Violence 1.3 18 Trachea, bronchus and lung cancers 1.5 19 Self-inflicted injuries 1.3 19 Alcohol use 1.4 20 Drowning 1.2 20 Cataracts 1.3 21 Pertussis 1.1 21 Malaria 1.3 All other causes 38.4 22 Measles 1.3 23 Schizophrenia 1.2 24 Liver cancer 1.2 25 Cirrhosis of the liver 1.1 26 Stomach cancer 1.1 27 Obsessive compulsive disorders 1.0 All other causes 33.2 Total all causes 100 Total all causes 100
Source: Murray and Lopez.
A See definition at end of chapter
14 CONCLUSION As this chapter demonstrates, South Africa is in need of a much improved National Health Information System. It is of the utmost importance to establish this in order to monitor the impact of policy changes in South Africa. The system also needs to be able to monitor inequalities in health - not only on the basis of race but also on the basis of poverty and urban/rural differences. The broad picture, however, reveals numerous health problems. While attempts to extend basic primary care to all who need it will be particularly important, a more comprehensive approach including more preventive and health promotion initiatives is still needed.
The Broad Picture: Health Status and Determinants 15 Demographic and Health Indicators (Definitions)
Adolescent mortality rate
The number of deaths per year between the ages of 14-24 years per thousand population in this age category.
Adult mortality rate
The probability of a 15 year dying prematurely before the age of 65 years if the prevailing mortality rates remain unchanged. This is a technical calculation.
Age dependency ratio
The ratio of the combined child population (0-14 years) and the aged population (65+ years) to the intermediate age population (15-64 years).
Child (under 5) mortality rate
The proportion of children who die before reaching the age of 5 years per 1000 live births in a given year.
DALY
The disability adjusted life year (DALY) is a measure of the burden of disease. In the DALY, the years of life lost due to premature death are combined with the years of life lived with a disability weighted according to the severity of the disability. Particular age weights for years of life lived at different ages, as well as a discount rate for years lost in the future were used in estimating the Global Burden of Disease.
Gender ratio
The number of males per 100 females.
Global Burden of Disease
The Global Burden of Disease has been estimated by Murray and Lopez for 1990 using the disability adjusted life year (DALY) as the measure.
Infant mortality rate (IMR)
The number of live born children who die before the age of one, per 1000 live births in a given year.
Life expectancy at birth
The number of years that a newborn baby would live if the patterns of mortality prevailing at the time of its birth were to stay the same throughout its life.
Population density
The average number of individuals in each square kilometer.
Population growth rate
The rate at which the population is increasing or decreasing in a given year expressed as a percentage of the base population size. It takes into account all the components of population growth, namely births, deaths and migration.
Racial classification
The categories reflect the system of racial classification under apartheid. The use of these classifications is necessary in order to indicate the challenges and progress made in achieving goals of equity. The terms African, Asian, coloured and white are used except when referring to Africans, Asians and coloured collectively, in which case the term black is used.
Teenage birth rate
The proportion of all live births during a specific year which are to women who are less than 20 years of age, irrespective of marital status.
Total Fertility Rate (TFR)
The average number of children that a woman gives birth to during her lifetime, assuming that the prevailing rates remain unchanged.
16 HEALTH AND 2 DEVELOPMENT
THE LINK BETWEEN HEALTH AND DEVELOPMENT Health and development are two closely related phenomena. In numerous respects the development of a society determines the health of its people. Development is an instrument to improve human welfare so health is an essential goal of national development.1 The opposite is equally true; the health of people is a precondition for development. The improvement of the health of individuals and communities is therefore part of social development.1, 2 To a large extent both health and development are sensitive to and determined by socio-economic conditions. Both are reflections of class position, prospering among the “haves”, while constrained among the “have-nots”.3
MAIN FEATURES OF SOCIAL DEVELOPMENT IN SOUTH AFRICA Development literature generally relates social development to socio-economic parameters, in particular defining it in terms of economic growth, income and expenditure levels, material infrastructure (eg. housing) and non-material aspects of development such as education. Phrased negatively, the lack of development is generally depicted in terms of poverty and associated indicators. Our analysis will review the standard indicators of development in South Africa. In addition, we review crime, violence and family break- down from a development perspective. Economic growth is essential for development. For development to be successful it must be people-centred, equitably distributed and environmentally and socially sustainable.1,4 At the basis of all development lies individual development. Development also encompasses the development of communities, families and neighbourhoods. Social development comprises the development of social institutions. Traditional health indicators (eg. life-expectancy, infant mortality rates) are also indicative of the development status of populations and their sub-groups. Certain groups are particularly vulnerable to disease and ill-health; in particular the poor, the deprived and the marginalised. In our society these groups are represented by the very young, women and rural Africans. Generally the overall mortality profile in South Africa reflects a mixture of poverty-related diseases, chronic diseases related to an industrialised lifestyle, and the effects of trauma. It is also apparent that these conditions strike according to the broad divides in the population, particularly along the lines of racial grouping, the urban/ rural divide, and socio-economic position. Within these parameters the provinces also show divergent profiles of ill-health.5
Authors: Dingie van Rensburg, Centre for Health Systems Research & Development, University of the Orange Free State Ega Kruger, Centre for Health Systems Research & Development, University of the Orange Free State Peter Barron, Health Systems Trust 17 SOUTH AFRICA IN GLOBAL CONTEXT - THE HUMAN DEVELOPMENT INDEX In Africa, South Africa is in seventh place in terms of the Human Development Index (HDI).A Only two African countries fall in the high category of the HDI, with the first of these in the 60th position; 14 African countries present themselves in the medium category; and the remaining 36 are found in the low category.4,6,7,8 Within the global context South Africa ranks 95th. In recent years a notable increase occurred in South Africa’s overall HDI from 0.5 in 1980 to 0.7 in 1995. If white South Africa were a separate country, in 1995 it would have been positioned 24th in the global ranking and well into the high category, while a black South Africa would have been in the 128th position, 17th among the African countries, and moving into the low category of countries.5,7,9 Large disparities exist in the HDI for the different provinces and for the rural/urban divide. Provincially,,, the Northern Province has the lowest HDI, followed by the Eastern Cape.
SOCIO-ECONOMIC BACKGROUND AND DIMENSIONS OF DEVELOPMENT Undereducation and illiteracy The maintenance and elevation of the development levels of a society is dependent on the successful functioning of its education system.10 South Africa’s performance globally appears to be particularly poor in the domain of human development.11 International indicators show that South African investment in human resource development is inadequate.12 Radical imbalances accompanied by severe deprivation and exclusion exist in education at every level. Recently the South African average literacy rate was reported to be 73%.13 ,14 Despite near-universal enrolment in primary education, only some 40% of children currently complete secondary schooling successfully.12 Educational disparities also exist at provincial level. The highest literacy rates are in Gauteng (88%) and Western Cape (81%), with the lowest in the Northern Province (65%) and the Northern Cape (67%). Levels of illiteracy amongst those aged 50+ are very high.5 It should be noted that there are reforms under way which aim at improvements in the educational system. It can be expected that public resources will be targeted at enhancing the educational opportunities of historically disadvantaged communities.12
Income/expenditure disparities The inequalities in income and expenditure have direct effects on the standard of living and the life chances of South Africans. The income disparities are captured in the fact that the poorest 40% of households earn less than 6% of total income, while the richest 10% earn more than half. The average income of the richest 20% of households is 45 times higher than the income of the poorest 20%.14,15,16 Undeniably the country has one of the highest income inequality rates in the world. It appears that the gap between rich and poor has been growing persistently. Increasingly the income gap is shifting from being race-based to being class-based.9,17
Employment/unemployment Unemployment in South Africa is a widespread problem with an estimated 30% - 40% of the economically active population unemployed.14 The highest unemployment rates were encountered in the Northern Province and Eastern Cape. Rural areas in South Africa are most severely affected by unemployment, with an average of 40%, compared to an urban rate of 28%. Rural Northern Province (51%) and rural Eastern Cape (56%) are by far the hardest hit.5 Survey findings showed that only 33% of the women aged 16- 64, compared to 54% of men, were employed.
A The HDI is a measure of the relative socio-economic development of countries on a scale of 0 - 1; with low being < 0.5; medium 0.5 - 0.8; and high > 0.8.
18 FIGURE 1 GDP ANNUAL GROWTH18
% Change at constant 1990 Prices 5
4
3
2
1
0
-1
-2
-3 87 88 89 90 91 92 93 94 95 96
FIGURE 2 EMPLOYED TODAY19
Employed 57%
Unemployed 32.5%
Informal 10.5% sector
Millions 0 246810
Regular wages are the main source of income for 72% of the non-poor; for 38% of the poor; and for 32% of the ultra-poor. Remittances or social pensions are the main income sources for over 40% of the poor and nearly 50% of the ultra-poor.14,20,21 Disparities occur in income distribution by province. The most unfavourable situations are in the Eastern Cape (R2 845 per capita) and the Northern Province (R2 343 per capita), compared with the Western Cape (R11 162 per capita) and Gauteng (R14 612 per capita).9
Health and Development 19
FIGURE 3 UNEMPLOYMENT WORSENS22
Million workers 16 a a a a a a a a a a a a aa a 14 Labour force a a a a aa a a a 12 a Unemployment gap a a a a a a a a a a 10 a a a a a a a a a a a a a a a 8 a aaa a a aa Government aa aaa aa aa aa 6 a Other formal aaa aa aa aa aa a sector 4 aaaaaaTotal formal employment Industry 2 Mining Agriculture 0 1980 82 84 86 88 90 92 94
FIGURE 4 JOB-CREATION THE AIM22
'000 500
400
300
200
100
0 96 97 98 99 2000 New jobs per year, according to GEAR
Poverty Poverty in South Africa is extensive.23 The profile of the poor in South Africa coincides to a large extent with that of the poor in Africa.24 In South Africa poverty is to a large extent an African, rural, female and child phenomenon. Broadly speaking, more than a third of all South African households, or half the population, can be classified as being poor.25 Women are disproportionately represented among the poor - some 60% of the poor are women. Female-headed households are particularly vulnerable to poverty. Fifty percent of the ultra-poor live in families without a resident male head. With reference to poverty among children, in 1995 more than 9 million children (54% of all children) were living in poverty. Poverty prevails particularly among African children in rural areas with 75.4% of poor African children found in rural areas.25 “For poverty reduction strategies to be effective, the poor must be sufficiently empowered to initiate, design and implement what they perceive to be good for them. This requires political, social and economic empowerment within the overall framework of sustainable development that combines growth with poverty reduction and protection of the environment”.24 Adds the PPHC Network: “The key to eliminating poverty lies therefore in the willingness of the wealthy to eliminate the obstacles that stand before the poor.”26
20 Provision of basic needs A shortage of the most basic of needs is a daily experience of millions of South Africans, exposing them to conditions highly conducive to ill-health. In recent times a stream of Africans departed from the poverty stricken rural areas to the large industrial cities where many ended in squatter towns. The material standard of living of this sub-sector of Africans declined. This in turn slowed down the decline of mortality and fertility.27 For many of these deprived people improvement in basic amenities such as water supplies, and better housing would have a far greater effect on their health than investment in health services.28 Housing or shelter has a direct bearing on well-being and health. Recently, the demand for housing was estimated at around 3 million housing units, with the current urban housing backlog estimated at 1.5 million units. Unless there is a dramatic increase in urban housing supply, the housing backlog will increase at a rate of 178 000 units per annum.29 To date the building of low- cost houses has not met expectations.17,20,30,31
FIGURE 5 PROVINCIAL EXPENDITURE ON HOUSING vs AVAILABLE BUDGET 1996/9718
Eastern Cape 14.5%
Free State 84.0%
Gauteng 79.2%
KwaZulu-Natal 31.6%
Mpumalanga 66.4%
Northern Cape 71.3%
Northern Province 14.6%
North West 25.9%
Western Cape 94.1%
Millions of Rands 0 150 300 450 600
Available Budget 1996/97
Expenditure 1996/97
Health and Development 21 FIGURE 6 MONTHLY DELIVERY - TOTAL HOUSING SUBSIDIES APPROVED18
Monthly delivery '000 16
14
12
10
8
6
4
2
0 Aug Oct Dec Feb Apr Jun Aug Sep
95 96
In 1996 there was a shift in the governments’ housing policy. The minimum standards were lowered; bureaucratic red tape was lessened and unrealistic expectations were tempered. As can be seen in figure 6, the monthly delivery increased markedly. The provision of water poses another problem as does the provision of electricity. In 1994 about 73% of houses in urban areas had electricity, compared with 15% in rural areas. Only 3% of rural areas in the Eastern Cape were supplied.5,13,14 This picture is aggravated by the culture of non- payment for basic services. Government sources recently revealed that “a third of the country’s 425 municipalities did not have the managerial capacity or funds to deliver services at an acceptable level.32
Erosion of the social and moral fibre of society The socio-economic indicators reviewed above give insight into the nature and state of social development of our society. South African society is in the midst of fundamental transformation and reform. The transition from the old regime to the new, as yet not a fully defined and firmly established social order, inevitably brought former patterns of social life into disarray. We are currently experiencing the effects of fundamental change on a large scale, at a discomforting pace, and in all spheres of society. South Africa has inherited from its past a heavy burden of violence now mainly expressed in very high levels of criminality. This is the single biggest threat to stability. Tables 1 and 2 give some quantification of serious crimes.
TABLE 1 VIOLENT CRIMES - TRENDS 1987-19945
Type of crime 1987 1988 1989 1990 1991 1992 1993 1994
Assault 120 779 125 571 128 887 124 030 129 626 136 322 144 504 157 315 Murder 9 800 10 631 11 750 15 109 14 693 16 067 19 583 18 312 Public violence 1 973 1 368 3 173 4 756 2 402 2 250 5 695 961 Rape 18 145 19 368 20 458 20 321 22 761 24 360 27 037 32 107
22 TABLE 2 CRIME PER 100 000 - CHANGING RATES 1994-199633
Type of crime 1994 1995 1996 Decrease/increase Murder 66.6 64.6 61.6 ➷ Robbery 210.8 194.1 159.2 ➷ Rape 105.3 115.2 119.5 ➹ Serious assault 521.9 535.8 545.6 ➹ Public violence 3.0 2.4 2.1 ➷ Motor vehicle theft 258.9 245.0 229.0 ➷
The crime rates in South Africa are indicative of social and moral erosion, apart from costing the country R30.3 billion annually.26,34 An expanding network of measures have been initiated in recent years to combat crime and violence (See chapter 24). In addition to formal measures communities are increasingly prepared to combat crime by taking the law into their own hands. Recent trends point to either a decline or a stabilisation in South African crime rates. However, without addressing the root causes, efforts to prevent crime can not succeed. If a large percentage of out-of-school youth are unemployed, crime is the only mechanism whereby they can survive .26 South Africa has entered a period of serious disruption of key social institutions. Particularly noticeable is the breakdown of family and kinship structures. Indications are that South African family life is characterised by high and increasing levels of disintegration among all groups.10,35 The steep rise in divorce rates is an example of this. Also the phenomenon of street children, and the many associated problems, can be ascribed to the destruction of stable family life.36-39 It should be noted that socio-economic development and growth can only take place in a society where social stability prevails. A society characterised by continuous social unrest and conflict due to shortages of basic life-needs, facilities and services, is certainly not supportive of development.10 A quote from Spies captures this: “If the current condition of group conflict, racial conflict, political opportunism, industrial unrest and poor human development continue, the chances are slight that South Africa could ever become competitive within a world context.”11
DEVELOPMENT POLICY IN SOUTH AFRICA Government policies: development and restructuring For the most part, development policy in South Africa was notorious for its authoritarian, top- down and non-consultative approach with the exclusion of civil society and local communities.3,40 State-driven development sacrificed notions of human development as an essential component of development and saw development purely in technocratic and economic terms. Delivery of concrete projects was given priority over qualitative improvements in the living standards. After the 1994 elections - a period of ‘community-driven’ development was inaugurated.40 Since April 1994 our society has embarked on a process of fundamental institutional transformation with far reaching implications for development. This includes the development and institution of new policies and laws; the inauguration of new and different development priorities; the creation of new structures; and the installation of new measures in every sector of society in order to direct, facilitate and control the activities of individuals and communal structures within the reformative framework. In every sector of South African society, people are either led or persuaded to do things in different ways. This is the essence of social transformation and reform. Current reforms in South Africa have one thing in common, viz. to organise, provide and distribute the outcomes of development in a defragmented, equitable, accessible and acceptable manner - features that were not present in the past. In this sense, current social reforms should be seen as an important contributor to sustainable human development strategies. Three years after the 1994 elections, development is still in its early stages. The bulk of the intended reform and restructuring, as well as the implementation of new policies, are still far from accomplished. For the greater part, the reform process is slow, often hampered by a variety of difficulties and constraints, and even deliberately opposed by forces of different ideology and interest. Generally however, this
Health and Development 23 reformative development of the South African society has in the short span since April 1994, been remarkable and fundamental. To date the reform process has focused particularly on the institutional dimensions of development; state policies have been revisited; the entire development sector has been legalised; and new governance and management structures have been established. In many cases these developments have also been accompanied by the installation of new infrastructure to give material content to the reform policies (eg. clinic building programme, the provision of classrooms). However, delivery has been slow and there has been little visible effect on the broader development status of the South African population. The most basic needs are still unmet. The wide inequalities still prevail between sub-sectors and sub-groups of the population, despite the institutional enshrinement of equity and equality in development policies.
The Reconstruction and Development Programme (RDP) The RDP41 was promoted as the development initiative of the post-apartheid government. Five broad programmes were identified to promote the objectives of combating poverty : ➣ the meeting of basic needs ➣ upgrading human resources ➣ strengthening the economy ➣ democratising the state and society ➣ making the state and the public sector more efficient. Health development targets were also specifically spelled out in a number of priority programmes.28,42 Furthermore, twenty-two so-called Presidential Lead Projects were launched to “kick-start” the programme. These included a feeding scheme for primary school children; a free health care programme and building new clinics. The RDP was a widely acclaimed strategy for development. The RDP was the collective product of a prolonged process of consultation. As a result many of the values and principles of the RDP became deeply enshrined in newly established policies and legislation. In particular, health and development policies of the post-apartheid era have been cast in the RDP mould. However, the RDP was symbolic of the new government’s wider inability to deliver on its election promises and development programmes.17, 30 The criticism was aimed specifically at unrealistic goals and shortcomings in the implementation of the RDP. More specific criticisms include the following: ➣ lack of integrated planning ➣ inefficient delivery ➣ lack of capacity ➣ underspending on projects ➣ bureaucratic bottlenecks ➣ protracted and inefficient consultation processes. The RDP Ministry was not able to allocate all the funds at its disposal, and where money had been allocated it had often not been spent. Only 55 per cent of the 1994/95 RDP Fund was allocated and only a small fraction was actually spent.17,20,30 Blumenfeld sketches the demise of the RDP: “Initially, the RDP received virtually universal political support. Within one year, however, this support had begun to erode, and within two years, the separate ministry set up to implement the programme had been abolished, and the RDP thereby severely downgraded”.30 In mid-1996, the government presented its new Growth, Employment and Redistribution Programme (GEAR).43,44 This signalled a significant ideological shift in the ANC’s policies towards development. However, the principles of the RDP remain firmly entrenched in the form of policy documents, legislation and many programmes and projects.
24 Growth, Employment and Redistribution (GEAR) Against the backdrop of failure to reverse the unemployment crisis, inadequate resources for expansion of social services, and insufficient progress toward equitable distribution of wealth and income, GEAR was introduced as an integrated, macro-economic strategy for rebuilding and restructuring the economy. Though GEAR reaffirms commitment to the RDP, the GEAR strategy conveys quite a different message which boils down to economic growth and employment creation. A quote from the policy document: “It is Government’s conviction that we have to mobilise all our energy in a new burst of economic activity”.12,43,45,46 There are references in GEAR to social development; particularly to education, health and welfare services, housing, land reform and infrastructure as key determinants in economic growth and redistribution. However, within the entire context and dominant thrust of GEAR, social development clearly takes a secondary position. Although redistribution is still allocated a prominent place in the GEAR strategy, it seems likely that the intended macro-economic adjustment, and sharp reduction of the budget deficit and curbing of state expenditure may seriously affect many of the RDP programmes. Inevitably such reduction and curbing would result in reprioritisation and cuts in basic-needs spending.47 The main stakeholders in the development of GEAR were strongly driven by economic considerations. But, it is clear that there is some disagreement on basic principles among the main partners, i.e. government, business, labour and the SANCO.45,48,49 At this early stage there are a number of criticisms levelled against GEAR. There is a mystique around the inception of GEAR. The broad-based consultation that preceded the RDP was absent in the generation of GEAR. Secondly economic growth is elevated to the prerequisite for the achievement of virtually all goals. One source comments that the “premise that economic growth is an obligatory precursor to development is false”; instead, “when equitable development is pursued with vigour, economic growth will occur as a consequence”.26 GEAR is also criticised for not being in the interest of the poor, and that it will not solve the problem of crime because the “trickle down” effects of both foreign investment and free market policies could take a long time to materialise. The general argument then is that GEAR will impose additional hardships on the country’s poor rather than alleviating the inequities inherited from apartheid.26,44,47 Also the aura of a structural adjustment programme surrounding GEAR remains a major concern. Elsewhere these programmes have failed to create employment, deepened social inequality and poverty, and thereby increased social instability and disintegration.50,51
Development through non-governmental organisations (NGOs) There are at present more than 50 000 NGOs operating in the country. Of these an estimated 20 000 are developmental in nature. In many cases these organisations have excellent track records in both the health and development spheres.B Many NGOs are faced with the challenge to transform themselves from playing an anti-apartheid role to becoming pro-active development role-players.40,56,57 Barnard55 has urged NGOs to start establishing for themselves a base beyond the political arena in order to become more development-orientated in their agendas. NGOs would in future be expected to do more with less. Macozoma55 summarises the challenges facing South African NGOs: ➣ Regarding the external environment, he emphasised that the transformational capacity of the new state would be limited; that the NGO sector would have to define its relationship with a new state; that the pace with which development policies are being decided would not leave NGOs room to manoeuvre; and that NGOs would be threatened by the recruitment of NGO personnel to the state and private sector. ➣ In terms of their internal organisation, NGOs would need to articulate a sustainable vision of development; to develop measures with which to measure their development impact; to define and establish new funding sources, as well as the priority areas that
B The variety of NGOs involved in the health and development fields in South Africa is extensively noted in different publications, the following giving an overview of the field in recent years: Prodder Newsletters 50,52,53 and The Southern African Development Dictionary.54
Health and Development 25 need to be addressed; and to reach consensus in dividing labour between themselves and the state. ➣ Regarding the communities they address, NGOs would have to deal with both a social fabric that is damaged and the apathy that exists in many communities. Many of these observations appear valid and have placed NGOs at risk. There is increasing competition for funding.51 The government has partly contributed to the demise of many NGOs, through its inability to make donor and RDP funds available in good time.58-60 Some NGOs have contributed to this through abuse and mismanagement of funds.56 Nevertheless, many NGOs make substantial contributions to development. In particular their work is done either where government is weak, or its delivery systems fail, or operating in parallel with government. In fact, the key to the major strengths of NGOs precisely resides in their independence from government and even in their “anti-statist” sentiments serving as “a bulwark against government encroachment on civil society”. As such NGOs are an essential part of the “coping strategies of communities”. NGOs have proven effective in strengthening democracy and in diffusing power, thus helping to widen participation in government’s decision making. This factor is essential to fostering community commitment, rather than resistance to development. The role of NGOs can “best add value to development when they operate freely and autonomously. In that way, they bring their dynamism to development, adding value through innovation and ideas, instead of acting as extensions of the civil service”.46 Moreover, development appears to be one particular area where NGOs have a “comparative advantage over government because of their ability to innovate, their enthusiasm and commitment, their flexibility, and their lack of bureaucracy”.46,51,60 In fact, NGOs can act without undue constraints as pace-makers and innovators in development and transition; they can experiment with alternative means and methods of promoting development, and easily innovate and adapt; they are able to elicit popular participation; they are cost-effective in service delivery; and they have a tendency to focus on and to benefit the deprived, disadvantaged and more vulnerable strata of society.40 The post-apartheid era has seen a wide range of health and development activities in the NGO field.57 Because of scarce resources, co-ordination among NGOs has become important for strengthening their achievements in development. In order to address the immediate funding crisis, a South African NGO Coalition was instrumental in establishing the Transitional National Development Trust. This Trust is an interim development funder and formal link between government and NGOs.59 The strength of NGOs lies in partnerships among themselves and with the other main role- players, viz. government, business and labour. A climate conducive to such partnerships should be created and facilitated. The latest developments envisage legislation by the Department of Welfare aimed at creating an environment in which NGOs could function more effectively with minimum government control. There is the realisation that development can only succeed if government enters into partnership with civil society. Some of the guidelines, for strengthening and extending the role of NGOs in development are:40 ➣ the capacity and skills levels of NGOs should be strengthened and extended ➣ networking of NGOs and information sharing-partnerships need to be established ➣ the availability of more resources to NGOs in order to facilitate the process of development in a ‘bottom-up’ fashion needs addressing ➣ the acquisition of more relevant and up-to-date information databases should be established ➣ partnerships between national, provincial and local government and NGOs should be strengthened and extended ➣ the channel of communication and feedback between the NGO-government partnership and the people at the lowest level (the mandating constituents) should be broadened and extended.
26 CONCLUSION Drawing up a balance sheet on health and development in South Africa is no easy task. On the debit side, there is a lack of education, low economic growth, unemployment, lack of basic services and amenities, high poverty levels, inequalities in life-chances, social instability, crime and violence, and the erosion of key social institutions and values. Superimposed on these are deep inequalities and disparities in most of the health and development indices, accompanied by severe deprivation. The imminent threat of HIV/AIDS is perhaps the most important single factor in the larger health and development game. On the credit side, significant progress has been made in a number of health and development areas including improving literacy rates, rising life-expectancy, falling infant mortality figures and greater immunisation coverage. As a result, South Africa’s performance vis-a-vis the Human Development Index is steadily improving. Most important in this balancing exercise, however, are the remarkable strides that are being made in the institutional reform of South African society. What is most significant in this respect, despite slow progress, sectional resistance and funding constraints, are the meaningful gains in freedom, democracy and equity, accompanied by the systematic eradication of racism, discrimination and injustice. The hope remains that these gains will in time spill over to those areas of health and development which need improvement.
Health and Development 27 28 HEALTH 3 LEGISLATION
INTRODUCTION During 1997, the pace of national health legislation quickened from a trickle to a steady flow. The National Department of Health prioritised ten pieces of legislation for the 1997 Parliamentary session, in marked contrast to 1996, when only one piece of legislation, The Choice on Termination of Pregnancy Act, was introduced in Parliament. Despite noticeable improvements in the volume of legislation, serious problems persist in the legislative restructuring of the health system. This chapter will review the progress of health policy formulation and health legislation during 1997. The formulation of legislation is vital as it forms the legal basis whereby many policies are implemented. Thus, it is very encouraging to note that the Department of Health has accelerated the production of legislation. Up to July 1997, the following pieces of health legislation had been introduced in Parliament: ➣ The Nursing Amendment Bill1 ➣ The Dental Technicians Amendment Bill2 ➣ The Medical, Dental, and Supplementary Health Service Professions Amendment Bill3 ➣ The Medicines and Related Substances Control Amendment Bill4 ➣ The Pharmacy Amendment Bill.5 The absence of a National Health Bill from the above list remains a major concern. In the absence of a national legislative framework, several Provincial Health Departments have taken the initiative and identified legislative reform needed in their respective provinces. This national legislative vacuum has resulted in a disjointed restructuring process amongst provinces. Until a national health legislative framework is finalised, mechanisms to measure the extent of the transformation of the health system will remain inadequate. The National Assembly Portfolio Committee on Health made great efforts to involve the public in health policy and legislation. A greater diversity of people participated in public hearings through means of oral and written submissions than have ever participated previously. In addition, the creation of the National Council of Provinces (NCOP) under the new Constitution should provide greater opportunities for public participation at the provincial level.6,7
Authors: Jane Stuurman-Moleleki, National Progressive Primary Health Care Network Lynette Sait, National Assembly Portfolio Committee on Health Peter Long, National Progressive Primary Health Care Network 29 SPECIFIC NATIONAL HEALTH LEGISLATION To date, the Department has introduced five of the ten health bills scheduled for the year, of which two have been passed by Parliament. The Nursing Amendment Act was passed by the National Assembly on 17 June 1997. The National Assembly also processed the Dental Technicians Amendment Bill. The Medical, Dental and Supplementary Health Services Professions Amendment Bill, Medicines and Related Substance Control Amendment Bill and the Pharmacy Amendment Bill were introduced simultaneously in May 1997. The three Bills dealt with issues relating to the implementation of the National Drug Policy and the reformulation of the Interim National Medical and Dental Council and the Interim Pharmacy Council. Due to concerns raised during the Committee hearings about the three bills, the Minister of Health withdrew them from Parliament. Amended versions have subsequently been presented to the Cabinet and are expected to be tabled after the winter recess.
Choice on Termination of Pregnancy Act The Choice on Termination of Pregnancy Act (Act 92 of 1996) came into effect on 1 February 1997. The amended Choice on Termination of Pregnancy Bill was passed by the National Assembly on 29 October 1996 and the Senate on 5 November 1996. The national policy process around abortion took two full years between the inception of the Ad Hoc Select Committee on Abortion and Sterilisation and the final passage of legislation by Parliament. Despite the lengthy period of consideration for this Act, issues such as implementation strategies, access to services, and support mechanisms for health workers were not fully developed before the final passage of the bill. This resulted in a three month waiting period between the final passage of this legislation and its implementation date. Provinces are slowly moving towards full implementation of the Act. There have been numerous teething problems that are currently being addressed within each province, but this could be expected from any new radical legislation. Lessons should be learned from this implementation process, however, so that the same mistakes are not repeated with future health legislation.
The Nursing Amendment Act The Nursing Amendment Bill was the first piece of legislation introduced by the Ministry of Health during 1997. This bill sought to establish a transformed South African Nursing Council. The Nursing Amendment Bill was passed by the National Assembly in June 1997 and elections for the new Council are currently underway. The Bill gave rise to much controversy among the nursing profession. The Ministry of Health’s initial draft of the Nursing Amendment Bill was informed by recommendations made by the Interim Nursing Council, which first met in August 1995. The recommendations were debated during 1996 within the ranks of the nursing profession. A draft bill (Government Gazette No. 17194 of 24 May 1996) was accepted by part of the organised profession, notably by the Democratic Nursing Organisation of South Africa (DENOSA). Deep divisions, however, emerged among key stakeholders concerning the governance of the Council at hearings on the bill held by the Portfolio Committee on Health on 6 March 1997. After the hearings, the National Assembly Portfolio Committee on Health amended the bill. The Committee increased the numbers of nursing assistants, auxiliary nurses, student nurses and community representatives on the Council. As a result of these amendments, professional nurses would not have the majority of seats on the new Council. The Portfolio Committee’s amendments drew strong reactions from the public in general and the nursing profession in particular. Many professional nurses argued that the role of the Council was to regulate the profession and to maintain professional standards. They argued that enrolled and nursing auxiliaries were not equipped to fulfil this function. DENOSA was particularly unhappy with both the content of these changes and the process by which the bill underwent changes. The
30 National Education Health and Allied Workers’ Union (NEHAWU), on the other hand, supported the changes and challenged the validity of the original consultation co-ordinated by DENOSA. The amended bill was debated in the National Assembly and referred to the NCOP, as it was classified as a bill affecting the provinces. The NCOP amended the bill further to include a medical practitioner and the lawyer on the Council. Although the legislation was eventually passed by the NCOP and the National Assembly, antagonism persists among some nurses about the consultation process, the role of the Minister of Health and the position of nurses in the health system.
Dental Technicians Amendment Bill The Dental Technicians Amendment Bill was published in the Government Gazette in May 1996, but legislation was not introduced until 1997. This bill dealt with the composition and functions of the Dental Technicians’ Council; made technical amendments to recognise dental technologists; and regulated the relationship between dentists and dental technicians. The National Assembly Portfolio Committee on Health recognised that the Dental Technicians’ Council needs to be transformed and has subsequently mandated the Council to report to Parliament in 18 months regarding the transformation of the profession. In May 1997, the Portfolio Committee held public hearings on the bill. As with the Nursing Amendment Bill, the Portfolio Committee introduced community representatives onto the Council. It also increased the number of dental technicians, clinical dental technologists, and dental assistants. As a result of these amendments, dentists no longer form the majority on the Dental Technicians’ Council.
The Medical Dental and Supplementary Health Services Professions Amendment Bill The Medical, Dental and Supplementary Health Service Professions Amendment Bill of 1997 was introduced in Parliament in May 1997. The bill amends the Medical, Dental and Supplementary Health Professions Act of 1974, under which the South African Medical and Dental Council (SAMDC) operates. This Act also provided for control over the training, registration and practice of health professionals. The bill made provision for the establishment of a Health Professions Council of South Africa (HPC), which would be the permanent statutory Council overseeing the health professions. The bill proposed considerable changes to the structure and function of this Council. The change in name (from the SAMDC to the HPC) and the changes in structure indicated a change to a Council which would be more representative of all health professions. Previously, the Council focused primarily on the medical and dental professions. The bill also made provision for the establishment of Professional Boards for all health professions. In addition, community representatives were included on both the Council and Boards. This stipulation was provided in order to make the Council more accountable and accessible to communities. Many functions of the previous SAMDC were to be devolved to these Professional Boards, including exercising authority over training, registration requirements and disciplinary powers. It was envisaged that the HPC would play a co- ordinating and advisory role. One issue which was discussed at length during the National Assembly Portfolio Committee’s hearing on the bill related to the issue of licensing of health professionals in order to dispense medicines. This provision was included in the bill, in order to bring the original Act in line with the National Drug Policy (NDP). The NDP sought to separate the functions of prescribing and dispensing. Medical practitioners were opposed to this limitation being put on their practice. This issue had also been previously debated at length during a special hearing held by the Portfolio Committee in September 1996.8 In addition, the Interim National Medical and Dental Council (INMDC) was opposed to the provision which made the Director-General responsible for this licensing. It also stated its displeasure at not being consulted on the final version of the bill, before it was gazetted. Another issue which stirred up much controversy during the public hearings related to the issue of vocational training. Although this issue was not part of the content of the bill, many people
Health Legislation 31 used the hearings as an opportunity to voice their opinions.9 The INMDC had proposed an additional two-year vocational training period for doctors going into private practice, which was to begin in January 1998. The Medical Association of South Africa, junior doctors, medical interns, and representatives of medical students voiced their opposition to this proposal, and to not being adequately consulted by the INMDC. The Amendment Bill was withdrawn from Parliament after the committee hearings because of the controversy surrounding it. In addition, the proposal for vocational training was put on hold and will be replaced by one year of mandatory community service.
Medicines and Related Substance Control Amendment Bill This Bill was tabled in Parliament in May 1997. This amendment bill was drafted in order to bring the Medicines and Related Substances Control Act of 1965 in line with the National Drug Policy (NDP) of the Ministry of Health. The proposed legislation, which was subsequently withdrawn by the Minister of Health, affected all stakeholders in the pharmaceutical sector, from manufactures and wholesalers to prescribers, dispensers and consumers. Particular attention in the bill was given to parallel importation, generic substitution, and the prohibition of bonusing and sampling. Another major change proposed in the bill was the introduction of licensing of health care professionals to dispense medicines. It was envisaged that this would have a major impact on dispensing doctors and their patients. Other provisions were related to governance and the powers of the Medicines Control Council. The bill sought to allow for the parallel importation of drugs into South Africa. This would be the importation of drugs by a given manufacturer of a medicine already registered with the Medicines Control Council, from a factory of the same manufacturer located in another country. This, together with the authorisation of international tendering, would enable the government to buy medicine at a lower price outside South Africa. It was hoped that these proposals would encourage locally based multi-national pharmaceutical companies to align their prices with those in other countries, in order to win public sector tenders. The bill further attempted to legalise and promote the dispensing of generically equivalent medicines. These are medicines whose active ingredients are the same as those of another medicine, although they may be different in size and colour. The bill required a pharmacist to dispense generically equivalent medicine, except in cases where the patient refuses substitution or when the price of the generic medicine is higher than that of the prescribed medicine. The bill also made allowance for medical practitioners, nurses, and other persons registered under the Medical, Dental and Supplementary Health Profession Act, to dispense if licensed by the Director-General. Specific criteria for the issuing of licences were not stipulated in the bill. Public response to this bill has been mixed. While the National Drug Policy was widely accepted across the pharmaceutical and health sectors, the bill has received criticism from some quarters in terms of the consultation process, the wording of the bill and its content. The Medicines Control Council was particularly concerned about the legality of certain clauses and expressed their disappointment at being consulted late in the legislative process. Other concerns have been raised in the pharmaceutical industry, which sees the proposed legislation, in particular concerning parallel importation, as a threat to the industry. Some dispensing doctors and their clients were also opposed to the proposed licensing system. This section of the bill was debated at length by the National Assembly Portfolio Committee on Health at a special hearing held in September 1996.
Pharmacy Amendment Bill The Pharmacy Amendment Bill of 1997 was also introduced in May 1997. The bill amended the Pharmacy Act of 1974. The bill provided for the establishment of a permanent Pharmacy Council and dealt with issues relating to the practice and rendering of pharmaceutical services. It was withdrawn for further changes. The bill allowed for the ownership of pharmacies to be extended to people other than
32 pharmacists. The Pharmacy Act of 1974 only allowed a pharmacist to own a pharmacy. This bill aims at broadening the scope of ownership beyond pharmacists and included any person who is not registered under the Medical, Dental and Supplementary Health Professions Act (Act 56 of 1974). However, all pharmacies must be under the continuous supervision of a registered pharmacist. The bill further suggested that the supervising pharmacist would be kept liable by the Council for any acts performed by or on behalf of the pharmacy. All pharmacies will have to be licensed under this legislation. The bill proposed significant changes to the present system of pharmaceutical practice. In particular, it provided for improved education and training of pharmaceutical personnel, and established a Council which was more transparent and representative. With respect to the composition of the Pharmacy Council, community representation is not stipulated as a special requirement. This differs significantly from the legislation governing the Health Professions Council and the Nursing Council. During the public hearings, the Interim Pharmacy Council of South Africa objected to licensing becoming the responsibility of the Director-General. They suggested that responsibility should be placed with the Minister of Health, who could then delegate this responsibility. The Interim Pharmaceutical Council also voiced their displeasure at not being consulted before the final draft of the bill was submitted to Parliament.
National Health Act Although significant progress was made during the year, there is still no new National Health Act. Draft 9 of the Health Bill was circulated to stakeholders for comments through the National Consultative Health Forum in November 1996. The Department has indicated that Draft 10 of the Health Bill will be circulated for comments and then be tabled in Parliament, but it has not been publicly released as yet. It is unlikely that the Health Bill will be tabled in Parliament during 1997. It is encouraging to note that on 16 April 1997, the Minister of Health published the White Paper on the Transformation of the Health System in South Africa in the Government Gazette No 17910 of April 1997. 10 It presents the policy objectives and principles upon which a unified health system of South Africa will be based. In addition, the document presents various implementation strategies to meet these objectives. As such, it represents a comprehensive picture of the Department’s vision for the creation of a unified National Health System. It is not clear how these two policy documents relate to one another as Draft 9 of the Health Bill was completed before the White Paper. It is also not clearly stated how the White Paper will be taken forward in relation to the National Health Bill. The White Paper falls short of indicating time frames for the majority of implementation strategies outlined in the document. Some of these strategies are very wide in scope and would be difficult to translate into concrete legislation.
CONSULTATION PROCESS ON HEALTH LEGISLATION Since October 1996, the National Assembly Portfolio Committee on Health has processed six pieces of legislation. For each bill, the Committee held public hearings to elicit input from civil society. For the first time in the history of this country, communities have been consulted about health legislation. It must be acknowledged that, despite some difficulties with the process, communities’ views and values have been taken into account, giving substance to Constitutional objectives to establish a democratic society. The establishment of the NCOP and the demise of the Senate promises a more democratic, participatory, and accountable process of governance that will promote transparency and greater involvement of the provinces in the legislative process. The NCOP was created under the new Constitution, which came into effect on the 3 February 1997. The main objective of the NCOP is to forge more meaningful and structured links between the National Assembly and the nine provinces, and to give effect to the idea of co-operative government. It gives provinces more power to consider national legislation in areas of co-operative
Health Legislation 33 governance. The new system should provide more opportunities for civil society to participate at provincial level by having public hearings closer to more people. Recent experiences with the Nursing Amendment Bill illustrate that greater public consultation comes at a price. Consideration of the bill took much longer than previous bills because of the complex processes of consultation within the NCOP. Public hearings within the provinces also allowed opponents of the bill further opportunities to challenge its content. Process issues kept the bill in the media spotlight. These factors all have the potential to delay and possibly derail progressive legislative initiatives. It is important for democracy, however, that the scope of public debate is widened even if it includes dissonant voices.
PROVINCIAL HEALTH LEGISLATION To date little health legislation has been passed by the provincial legislatures as most provinces are awaiting the passage of a new Health Act. Two pieces of provincial health legislation identified in the 1996 South African Health Review11 have been subsequently passed by the provincial legislatures. Little progress, however, has been made with implementation. In retrospect, it is not clear whether these bills will help the transformation of the health system in the absence of a national legislative framework. The Free State Province passed the Hospital Act of 1996.12 The Free State Hospital Bill was introduced to the provincial legislature in September 1996. It was debated and referred to the Free State Standing Committee on Pensions, Health and Welfare. Public hearings on this bill, were held in October 1996. These hearings were attended by the health professions and representative organisations. The bill was passed by the provincial legislature on the 15 November 1996. One of the major provisions of this Act is to set out policies governing hospital regulations and establishment of more democratic hospital boards. According to this Act, the Provincial Member of Executive Council (MEC) for Health will have the power to establish and abolish hospital boards for all provincial hospitals. Hospital board members will be appointed by the MEC for Health for a period not exceeding two years. The functions of hospital boards are to co-ordinate the management of hospitals and monitor its accomplishments. They should also represent community needs. The board has to oversee hospital performance and be pro-active in the governance of provincial hospitals. The board can also make recommendations on issues referred to them by the MEC for Health, Head of Department of Health or the chief executive officer of provincial hospitals. The North West provincial legislature has passed the Health, Developmental Social Welfare and Hospital Governance Institutions Act, 1997. 13 This Act outlines the framework for the creation of health, development and hospital governance structures in the North West Province. It further outlines the composition, selection, powers and function, authority and payment of these governance structures. The provisions of the North West Act are similar to the Free State legislation with respect to the far reaching powers granted to the MEC. According to the Act, the MEC will have the power to establish community health and development social welfare forums at the district, facility and community levels. The MEC may also determine the number of members for such forums and specify the community for which such forums are constituted. The Governance Bill was introduced in 1996 and public hearings were held in every region of the province. It was passed in March 1997.
SOME CONCLUSIONS In contrast to 1996, this has been an active year for health legislation. The Department has drafted numerous bills on specific health issues to provide legal substance to the transformation of the health system. These efforts are commendable. The most striking aspect of health legislation in 1997, however, was the continued absence of a new Health Bill and the failure of the Department of Health to consult adequately with stakeholders before introducing new Bills to Parliament. In the South African Health Review 1996 concern was expressed that without an enabling
34 legislative framework, it remains unclear on what authority the Department of Health will implement many of its policies. The introduction of a White Paper on Health for the transformation of the health system in the country represents a positive step and will definitely give more direction to the restructuring process, especially at the provincial level. It has now become critical that a National Health Bill be introduced so that Provinces can take the restructuring process forward and introduce their own legislation. As can be expected when dramatic policy changes are being proposed, each piece of health legislation introduced this year has been surrounded by controversy. But of concern is the fact that major stakeholders such as the MCC, INDMC, and the Interim Pharmacy Council complained to the Portfolio Committee that they had not been sufficiently consulted by the Department before legislation was introduced. Since September 1996, the Department has withdrawn proposed regulations on dispensing of medicines, the three amendment bills, and a proposal for additional vocational training for doctors because of technical errors and fierce opposition. These all occurred after the Department made public announcements supporting the proposals and defending the consultation process. Concerted efforts that have been made by the National Assembly Portfolio Committee on Health to increase public involvement in the legislative process should be lauded. Failure to achieve sufficient consensus prior to the submission of draft bills to parliament places unrealistic burdens on the national assembly portfolio committee on health. The Ministry of Health has shown great courage in attempting to tackle the fundamentals of health reform head on. The controversy generated by submission of a number of the bills is testimony to this fact. It is imperative that the success of these submissions is not jeopardised by inadequate communication or consultation.
Health Legislation 35 36 PRIVATE 4 SECTOR
SUMMARY South Africa’s private health care industry is large and highly developed but it is estimated that only 20 to 25% of the population have regular access to this sector. Given its capacity, broadening access to the private sector is recognised to be an important goal in improving the quality of health care available to all South Africans. The private sector is currently facing a number of challenges, including the pressure of rising costs and the changing make-up of the insured population. These challenges threaten to upset the traditional balance in the South African medical scheme industry. Instead of broadening access to the resources of the private sector, they could result in the shifting of private sector patients onto the already over stretched public sector. Well designed regulatory legislation with effective monitoring mechanisms, coupled with initiatives of the private sector, must play an important role in addressing these challenges and harnessing the potential of this important sector. This chapter reviews the activities of the private sector, the challenges which it faces and critically examines its response to these challenges.
INTRODUCTION The cost of health care in South Africa is rapidly escalating to a level that neither the private, nor the public sector can afford. The private sector is utilised by 20 to 25% of the population in South Africa, whilst it is estimated that private sector expenditure exceeds that of the public health sector. Total health care expenditure is difficult to assess, making it equally difficult to state what percentage of this total is spent in the private sector. Table 1 shows estimated health expenditure in the private and public sectors for the year 1995. In this year, medical schemes paid out a total of R14.9 billion.1 In addition to medical scheme pay outs, an estimate must be made for out of pocket expenditure by individuals in order to calculate total private sector expenditure. The most recent estimate for this expenditure, which includes payments by medical scheme members to bridge gaps in their claims, over the counter medicines, GP cash practice, medical insurance and industry expenditure is R5.98 billion for 1992/93.2,6 In table 1 this figure has been increased by a conservative estimate of 10% annually to reach a figure of R7.8 billion for 1995. Note that this figure excludes user fees at public hospitals. The government budget for 1995 was R19.2 billion, although actual expenditure was in excess of this amount. Additional public sector funds for health care also originate from sources such as local authority spending, the public works budget and funds spent by the military and prison services on health care.
Authors: Gustaaf Wolvardt, Medical Association of South Africa Natasha Palmer, Health Systems Trust 37 TABLE 1 ESTIMATED HEALTH EXPENDITURE 1995
Rand (billion) %
Public sector 19.2 45b Budgeted (not actual) expenditure Private sector 22.7 55 Medical Schemes 14.9 35 Out of Pocket Paymentsa 7.8 20 Including exempted schemes, using 10% growth rate since 92/93 Total 41.9 100 a It is stressed that the out of pocket payment figure shown above is simply an estimate for the purposes of illustration. The growth rate chosen of 10% may be considered conservative given the recent trend towards increased co-payments by many schemes and insur- ance funds and the high rate of medical inflation. b The percentage split shown in table 1 is merely for the purposes of illustration, because other sources of public spending exist which are not shown in this table.
FIGURE 1 PRIVATE SECTOR HEALTH EXPENDITURE - BASED ON MEDICAL SCHEME PAYMENTS 1995
Provincial Hospitals 1.8% Private Hospitals 23.2% Medicines 29.4%
Other 7.6%
Dentistry GPs 8.3% 10.4% Medical Specialists 19.2%
Total = 14.42 billion Rand
Source: Registrar of Medical Schemes, 1995
OVERVIEW The private sector is made up of the following groups: ➣ funders: those who pay for private health care services ➣ service providers: those who provide private health care services ➣ suppliers: those who provide equipment and supplies for the private health care industry. Funders The funders of private sector health care delivery include:
Medical Schemes Medical Schemes are the principal financial intermediaries in the private sector, accounting for nearly two-thirds of total private sector health care funding.2 They are non profit associations funded primarily out of contributions from employers and employees. Generally the size of contributions depends on the Members’ income and number of dependants. Medical schemes cover approximately 17% of the population.A
A This is based on a total medical scheme membership of 6 548 187 (Report of the Registrar of Medical Schemes for the year ending 1995) and the recently quoted new census results of a total population of 37.9 million.
38 Individuals Individuals also directly purchase health care by paying for the full cost of services or through co-payments. Direct out of pocket payments by households are the second largest source of private health care finance, accounting for 23% of the total in 1992/1993.2 This category includes medical scheme co-payments, direct payments to doctors and for drugs, user fees at public sector hospitals and spending on over the counter medicines by all categories of patients.
Insurance Companies Health insurance is a small but rapidly growing component of private health financing in South Africa.1 It is offered by both life and short-term insurance companies. Most policies provide cover for major surgical and hospitalisation costs. This mechanism of funding appeals to young and healthy individuals. Costs are usually kept low through exclusion criteria that disqualify elderly or chronically ill people or individual risk rating.
Managed Care Organisations Following amendment of the Medical Schemes Act in 1994 managed care concepts have been introduced to the South African market. A number of companies have been established with a view to expanding this form of healthcare funding and delivery. 7, 8
Medical Savings Accounts Medical savings accounts, a new development in the market, are designed to encourage members to take ownership of health care expenditure. Savings accounts generally appeal to low risk relatively young patients. Typically hospitalisation and chronic medication costs are covered through insurance. Day to day expenses are paid out of a dedicated medical savings account funded through monthly contributions. The member controls the savings account and can utilise it for a wide range of health care as well as long term retirement benefits. However, this new scheme has received criticism due to the excessive individualisation of health risks which it encourages and hence its future remains uncertain.
Providers Health professionals With the exception of nurses, the majority of health professionals now practice in the private sector (See table 2). Health professionals working in the private sector include general and specialist medical practitioners, dental practitioners and other personnel registered with the Interim Medical and Dental Council (IMDC), or other relevant professional councils.
TABLE 2 HEALTH PERSONNEL PRACTISING IN THE PRIVATE SECTOR
Category Total South Africa Number in private sector % in private sector General Practitioners 17 438 10 067 57.7 Specialists 6 342 3 657 57.7 Dentists 3 748 3 330 88.8 Pharmacists 15 794 14 841 94.0 Nurses 119 922 16 586 13.8
Source: Regional Health Information Management Systems (ReHMIS) 1994/5 Representative Association of Medical Schemes (RAMS) 1996
Note: Statistics for doctors are still very unreliable; according to the Medical Association of South Africa (MASA), less than 8000 General Practitioners are in full time private practice.
Private Sector 39 The Private Hospital Industry There are a range of hospitals within the private sector including for profit facilities which provide care on a fee for service basis, non-profit hospitals run by charitable or welfare organisations, and industry specific hospitals. Most private for profit hospitals are located in metropolitan areas, where high income earners live. The private hospital industry employs approximately 50 000 people and admits 1.8 million patients per annum. Over the past 8 years there has been a growth of 113% in the number of private for profit hospital beds available in South Africa. The distribution of private hospital beds by ownership category for 1988 to 1996 is shown in Table 3.
TABLE 3 DISTRIBUTION OF PRIVATE HOSPITAL BEDS BY OWNERSHIP
Type of Hospital Beds 1988 Beds 1996 % (+/-) For profit 9 825 20 991 113 Industrial 9 789 6 687 -31.7 Contractorsa 13 962 14 659 4.9 SANTAb 5 335 4 963 -6.9 Otherc 923 1 529d 65.7
a Private hospitals that are contracted to the State to provide long-term and psychiatric care to indigent patients. b SANTA is a charitable organisation that provides long-term inpatient care for tuberculosis patients. c This category includes hospitals owned by religious and welfare organisations. d The latest figure available is for 1993.
Source: 1988 data from Chetty (1995):10 1996 data from Hospital Association of South Africa
Suppliers The Pharmaceutical Industry The pharmaceutical industry in South Africa contains both local and multi-national firms. In 1996 the total size of the industry was estimated to be between 6 and 6.1 billion Rand. Approximately 25% was drugs sold to the public sector (1.5 billion Rand). Private sector consumption of pharmaceuticals is thus in the order of 4.6 billion Rand. In 1995 3.1 billion Rands worth of pharmaceuticals was prescribed and dispensed to medical scheme beneficiaries, with the balance being made up of out of pocket prescribed and over the counter purchases by individuals.3
Equipment Suppliers There is a growing indigenous equipment industry, but in general the market is still dominated by foreign equipment suppliers.
CHALLENGES TO THE PRIVATE SECTOR The private sector faces a combination of factors which threaten to increase prices and reduce access to private health care for many South Africans. Two key challenges discussed below are spiralling costs for health care treatment and the impact of risk rating on medical scheme membership. The effect of the changing demography of those privately insured is also discussed.
Cost Escalation The cost of private health care in South Africa is spiralling, with increases in medical scheme subscriptions regularly exceeding the consumer price index. Figure 2 demonstrates escalation of medical costs compared to general inflation in South Africa. This trend is influenced by a combination of an increasing cost per average treatment episode, coupled with increasing utilisation rates by patients in the private sector. Specific factors contributing to this trend include: ➣ South Africa’s private sector has for the last few decades operated on a fee for service,
40 third party payment system. This close relationship between volume of work and earnings creates incentives for suppliers to provide as many services as possible, creating a potential for over-demand and over-supply of health services. ➣ This system can be further exacerbated by arrangements such as joint share ownership, incentive schemes created by hospitals for doctors and payment of medical scheme administrators according to the volume of claims which they process.4 Dispensing by doctors and increasing vertical integration in the private sector (e.g. between hospital groups and pharmaceutical interests) further reduces incentives by medical practitioners to contain escalating costs. ➣ Medicine and private hospitals form the two most rapid areas of medical scheme expenditure increase. Whilst medical schemes can negotiate with providers about consultation costs and fees per inpatient day, they are unable to control the rapidly rising unit costs of medicines.4 ➣ The number of private ‘for profit’ hospital beds has increased rapidly over recent years (Table 3). Such institutions tend to have a higher level of more expensive technology, leading to increased cost per diagnosis/intervention in the private sector. Recent investment by the private sector in terms of infrastructure and systems is estimated at R2 billion for the period 1994 to 1997. ➣ Contributing to both increased cost per claim and increased utilisation is the changing demographic composition of the insured population. Increased cost of medical cover is leading to a reduced enrolment by younger, healthier people and therefore proportionally increasing the number of aged within Medical Schemes. In addition to this the general ageing process amongst existing scheme members carries its own costs.
FIGURE 2 COMPARISON OF ESCALATION IN MEDICAL COSTS COMPARED TO GENERAL INFLATION
21% 250
Medical costs
200
12 %
15 0 Inflation Costs (based on 100 in 1990) Costs (based on 100
100 1991 1992 1993 1994 1995 Years Source: MASA 1997
Risk rating The Medical Schemes Act No. 72 of 1967 regulates the funding and operation of medical schemes in South Africa. Prior to 1989, a community rating system was enforced and members’ contributions were calculated only according to income and number of dependants. However, since deregulation, the insurance industry has been able to offer risk rated cover at lower premiums to the young and healthy. Such risk rating has the effect of substantially increasing contributions required from the less healthy. This consequently prices out of private health care those who are most likely to fall ill, causing them to seek care in the public sector. Medical schemes in South Africa have traditionally operated by a cross-subsidy principle which used younger and fitter members’ contributions to subsidise cover for the less healthy. Many of these schemes now face a crisis as their membership becomes increasingly skewed
Private Sector 41 towards older people, as the younger and fitter decline increasingly expensive medical scheme cover. This implies that there are less funds available with which to subsidise older members of the scheme. An associated trend towards the creation of a wider number of distinct coverage options within individual medical schemes which do not cross-subsidise is further fragmenting already fragile risk pools. These developments run directly counter to the challenge to the private sector of broadening access for South Africans to private health insurance. It is estimated that the existing medical schemes industry provides care to just over 6 million South Africans, whilst a further estimated 5 to 7 million in formal employment remain outside of the traditional medical schemes system. Many of these people are at present unable to enter the system because costs are too high.
Regulating the Public /Private Mix Identifying and developing ways in which the private and public health sectors can co-operate and combine their resources is a further key challenge for the health sector. Increased co-operation between the two sectors should increase efficiency and improve the cost-effectiveness of service delivery. This in turn will free up funds for the extension of services. The White Paper5 for the Transformation of the Health System in South Africa envisages co-operation between public and private health sectors in the following areas: ➣ The delivery and management of services ➣ Provision of information to the National Health Information and Audit system ➣ Development of standardised clinical management protocols ➣ Co-ordination of expensive equipment in geographic areas ➣ Service provision to district health authorities by accredited providers ➣ Sessional work by private providers in public facilities ➣ Referral contracts with private practitioners. Other areas for possible co-operation could include: ➣ leasing spare health care capacity in one sector to the other rather than allowing it to stand idle ➣ a programme to attract private patients to public sector hospitals and allow revenue to be retained ➣ utilisation of private sector facilities for the training of medical and administrative staff.
ADDRESSING THE CHALLENGES TO THE PRIVATE SECTOR Response of funders: Cost containment measures There have been several attempts to control cost escalation in the private health sector. These include the introduction of a new fee model for hospitals, the introduction of pharmacy benefit management programmes and the adoption of managed care principles. Medical Schemes have also implemented utilisation review procedures in an attempt to counter excessive utilisation or supplier induced demand. Such review sometimes focuses on the routine review of the prescribing or dispensing patterns and hospitalisation rates of individual medical practitioners. Increasing attention is now also being given to pre-hospitalisation certification and chronic medicine programmes.4 Managed care is a recent phenomenon which promises major changes in the way in which private health care is financed and provided. It attempts to cut costs by controlling access to and use of health facilities without compromising the quality of care. It is seen by its advocates as a solution to the problems generated by South Africa’s unrestricted fee for service, third party payment system in the private sector. The limiting factors which up until now have prevented the rapid introduction of managed care systems include poor relationships between providers and funders, lack of sophisticated information systems, no standardised diagnostic and procedure coding systems and the inability to realign incentives to promote cost-effective behaviour. However, in the last two
42 years several managed care initiatives have been introduced in South Africa. These range from large integrated models down to the introduction of managed care principles by individual medical schemes/administrators (eg.utilisation review, chronic medicine programmes and formularies) and the grouping of doctors into Independent Practitioner Associations (IPAs).
Government response: Legislative and regulatory changes The following amendments to legislation have been proposed by government:
The Medical Schemes Act Proposals to amend this Act as put forward in the recent Department of Health White Paper5 aim to deal with a number of problems that pose a risk of continuing instability in the medical schemes market. These problems include:11 ➣ escalating medical schemes costs ➣ the tendency towards greater individual risk rating ➣ the proliferation of unrealistically low benefit packages that are quickly exhausted ➣ poor governance and administration of many medical schemes. Proposals include: ➣ the re-introduction of community rating principles ➣ making provision for benefits for continuation members ➣ prescribing a minimum set of benefits. It is hoped that these measures will stabilise risk pools and broaden access. Furthermore, all schemes established with the object of doing the business of a medical scheme will be regulated by the Act, bringing health insurance, medical schemes and managed care policies together under one Act for the first time. Current reporting requirements of schemes will be changed to provide for more regular and meaningful reporting. In recognition of its important role, the Office of the Registrar of Medical Schemes is to be strengthened and upgraded to a Directorate. Proposals are under consideration to fund such an upgrade through a levy on medical schemes.
Pharmaceutical regulation Legislative changes in the area of drug policy will have a profound impact on the industry and include: ➣ Generic substitution ➣ No dispensing by doctors (except where there is no access to a pharmacy) ➣ Corporate ownership of pharmacies ➣ Parallel importation of drugs.
Legislation affecting Human Resources A number of legislative changes have the potential to impact on human resources in the private sector. These include: ➣ a new Standard Conditions of Employment Act which no longer grants an exemption to private hospitals to accommodate for their unusual working hours. Costs of staffing and the numbers of staff employed will be affected by this if no exemption is achieved. ➣ a new Labour Relations Act. Previously all nursing services were classified as essential services and therefore for dispute resolution only by compulsory arbitration. The private hospital industry however believes in maintaining a position of full collective bargaining.
The Draft Health Bill This contains regulatory measures regarding the licensing of private hospitals and private practices. The Minister of Health is granted the authority to: ➣ Determine categories of public and private health establishments
Private Sector 43 ➣ Determine whether certain categories may be enlarged, established or modified. ➣ Prescribe a procedure for granting of licences. ➣ Establish minimum standards to be met by any health establishment in terms of staffing, equipment, hygiene, safety and the protection of patients and health workers rights.
KEY AREAS FOR THE FUTURE Controlling costs and broadening access are the main challenges to the private sector in South Africa. Both the government and the private sector have a responsibility to ensure that a combination of regulatory policy and incentive structures enable it to achieve this goal. Vital regulatory functions include strengthening the monitoring of medical schemes and controlling the growth of private hospitals and associated technology.4 A moratorium on the granting of licences to build new private hospitals, or increase the size of existing hospitals has been in place for two years. This moratorium is a stop gap measure to enable the national Health Department to assess the overall supply of hospital beds in South Africa. Mechanisms for controlling the cost spiral in medical schemes are best pursued as a joint effort between key medical scheme players and the state. A change in the current method of remuneration of medical scheme administrators to a system which encourages cost containment would form a useful starting point. Furthermore, changes in reimbursement mechanisms for health care providers may achieve great success in cost containment, alongside the practice of utilisation review which has already been introduced by some schemes. Measures must also be implemented which will address the harmful effects of risk rating. It must be recognised that the long term effects of this practice are to reduce access for those most in need and to shift the cost of their treatment onto an already overburdened public sector. This has obvious negative implications for the Government’s stated policy of improving equity within health service provision. Other developments in the private sector may be complementary to improved regulation. First, an increased role for managed care tools should construct a framework of incentives which ensure that appropriate care is delivered cost-effectively. Second, a well designed policy framework around the public/private mix should provide increasing opportunities to broaden access to the considerable resources of the private sector. It is important to recognise the great potential and capacity of South Africa’s private sector. In return for a relatively small investment in terms of designing an appropriate policy and regulatory environment, this sector has the potential to provide great benefits in terms of improving access to quality health services for all South Africans.
44 PROVINCIAL 5 RESTRUCTURING
OVERVIEW At the time of the 1994 elections, public health services were largely outside of democratic control. Segregation and racial discrimination were institutionalised; services offered to marginalised groups including women, HIV patients and rural blacks were discriminatory and stagnant. Over the past three years, the provincial public health services have moved decisively against fragmentation, domination by special interest groups and discrimination, and positively towards equity, redistribution of resources and affirmative action. A broad consensus on health policy has been achieved and there is substantial public understanding and acceptance of those objectives. There has been a shift towards a district based primary health care approach for public health. The need for more cost effective services and a more inclusive catchment population for health insurance is widely understood and accepted. Despite the extraordinary transformation that has occurred there is a feeling of low morale within the health sector. There is also a widespread public perception that access to health services and quality of care is no better than it was. There are a number of structural problems within the public health sector which threaten to undermine the consensus and the enormous gains that have occurred. The Public Health System is located across national, provincial and local levels of government. These levels are sometimes conflicting and contradictory. These problems demand a fundamental examination of structures, administration, and finance. This chapter looks at the position of the provincial health departments, sandwiched between the national Department of Health and multiple local government health departments. It also examines the challenges that are faced by these provincial health departments as they try to transform the delivery system of health services in South Africa.
ROLE AND FUNCTIONS OF THE PROVINCIAL HEALTH DEPARTMENTS The role of the provincial health departments is defined in the White Paper on the Transformation of the Health System in South Africa. “The mission of a provincial health department, as mandated by the Constitution of South Africa within the framework of national policies, strategies and guidelines, is to promote and monitor the health of the
Authors: David Robb, previously Department of Health and Developmental Welfare, North West Province Marie Annandale de Villiers, Department of Health and Welfare, Northern Province Krish Vallabjee, Department of Health, Western Cape 45 people in the province, and develop and support a caring and effective provincial health system, through the establishment of a province-wide district health system (DHS) based on the principles of primary health care (PHC).”2 “During the period of transition required for the establishment of a DHS, the provincial authorities will perform functions that will be devolved to the newly-established districts at a later stage. During this critical process, sub-provincial structures such as health regions may be established to assist in carrying out these functions.”1
ANALYSIS OF PROBLEMS AT PROVINCIAL LEVEL To evaluate the progress of the Provincial Health Departments in restructuring health care delivery, it is useful to have an understanding of the generic difficulties faced by most provincial departments.
FIGURE 1 STRUCTURE OF PROVINCIAL GOVERNMENT
CABINET PREMIER + 9 MEMBERS OF EXECUTIVE COUNCILS (MECs)
PROVINCIAL DIRECTOR GENERAL
FIGURE 2 LINES OF AUTHORITY AND ACCOUNTABILITY
PROVINCIAL MEC HEALTH MEC FINANCE DIRECTOR-GENERAL
HEAD OF HEALTH HEAD OF FINANCE DEPARTMENT DEPARTMENT
Political Accountability Administrative Accountability
As can be seen in Figure 1, the political responsibility for the running of the province lies with the provincial cabinet consisting of the Premier and usually nine MECs. The responsibilities of the MECs vary by province. Each MEC has responsibility for one or more portfolio such as Health, Education, Sports and Recreation, Public Works, Finance and Administration, Safety and Security, Local Government, Welfare, Transport, Tourism, Environment and Agriculture. Each MEC is the political head of the relevant line department. The administrative head of the province is the Director-General, who is appointed on a five year contract. The Director- General is directly accountable to the provincial cabinet. As can be seen in Figure 2, each head of provincial department such as health, has a dual accountability in that he/she is responsible for the implementation of policy to the MEC, while at the same time being accountable to the Director- General for general administrative functioning. This situation has the potential to lead to a conflict of interests. At best it is likely to lead to inefficiency and at worst it may result in paralysis, with the head of the health department caught between two masters. This provincial government structure, with nine departments of equal status, each with a MEC, is a recipe for misallocation of resources, duplication and bureaucratic snarl ups. It invites a confusion of the political with the administrative function. Rationalisation or co-ordination of the
46 different functions by the Director-General could be interpreted by the nine MECs as political interference. Consequently, the simplest matters may have to be referred to the Premier and his cabinet. There is also great potential for undermining the co-ordinating and supervisory role of the Director-General of the Province. Similarly there is potential for the policy direction of the MEC’s to be undermined by a recalcitrant bureaucracy. There is also potential for administrative confusion in the relationship between the health department and other departments within the province which have the responsibility for supporting the health department. The head of the health department has the responsibility and accountability for the running of the department. However components which are essential for the smooth and effective functioning of the health department, such as personnel, maintenance of buildings and transport, generally fall under the authority of another administrative head. So for example, although the health department pays for the use of provincial vehicles, the head of the health department has little managerial authority over these vehicles. The head of the health department is obliged to pay the transport department for the maintenance of these vehicles, even if they could be maintained more cheaply by private sector organisations. More importantly, inefficiencies in the transport department such as overlong servicing times can lead to inefficiencies in the health department. The frustration of being reliant on another department encourages health departments to allocate scarce posts to perform functions for which funds have been allocated to other departments. So, in many provinces there is duplication of work done on personnel functions by the Health Department and the Administration Department.
Regulatory Framework Provincial government is situated within a regulatory framework inherited from the former regime. This framework is based on a centralised mechanism of decision making and responsibility which is not compatible with the responsibilities for implementation that the provinces have, nor with the health department’s policy of decentralisation of decision making to districts and hospital management. This regulatory framework is concerned with processes and not outcomes. It functions ineffectively and inefficiently in a modern organisation which is trying to set goals based on equity and improvement of health status. There are a number of legislatively determined, standard operating rules and structures which govern the way in which things may be done. These include the PAS (Public Administration Standards), the FAS (Financial Administration Standards), Treasury Instructions, Central Bargaining Chamber, Department of Transport rules, Tender Board regulations, Department of Public Works systems and the Public Service Commission. These rules, regulations and codes of conduct constitute bureaucratic red tape which constrain and hamper the health departments as they set about restructuring themselves to achieve their new mission, goals and objectives. These national systems were designed for the national Ministries and Departments and not for provincial Departments of Health aiming at implementing a primary health care orientated approach based on a decentralised health district system of delivery. The PAS comprises literally hundreds of pages of written instructions to cover virtually any event or eventuality. These lay down rules for everything from the size of a director’s desk to the purchase of rations. Modern hospitals are complex institutions which require continuous high level management decisions to run them. They do not run well when initiative is thwarted by the rule books and decision making is avoided as a result of centralisation of authority.
The Central Bargaining Chamber and the Public Service Commission came into existence as a result of the Nationalist Government’s subversion of the public service to become a mechanism for white job creation and white economic upliftment and control. These structures are the mechanism whereby public servants create rules and conditions of service that are in their own interest, in direct contradiction to the interests of the public who rely on those services. These are major impediments obstructing the attempts of provincial health departments to restructure the health services.
Provincial Restructuring 47 For example the public service commission has a rigid formula specifying how many senior managers there can be in a particular health department; the so-called “Chapter J Formula”. This formula leaves nothing to the initiative of particular health departments. What happens in practice is that intelligent managers spend precious managerial time and efforts finding ways to subvert the formula. One such example is that medical doctors who are specialists, often have better salaries and benefits than senior managers. It is relatively easy to get specialists appointed. So what happens is that specialists are appointed but in reality they are senior managers in everything but name and do managerial work. Another example of employees benefiting rather than the service has been the introduction of Voluntary Severance Packages (VSP) as a tool to rightsize the Public Service. This is an employee driven, blunt instrument with little managerial discretion to direct it to areas requiring rationalisation of services. This has affected all levels of the service and led to huge distortions in human resource provision in the health services. As an example, more than 4000 health workers have been approved to leave on the VSP in the Western Cape. This has not helped rational restructuring of the service.
Delegation Of Authority In order for managers to be able to manage, they need to be given the authority to do the job. The head of health departments themselves do not have the delegated authority to do many things. Until the Director-General of the province, who is the accounting officer for the province as a whole, has delegated functions to the line departments they are dependent on the Director- General for his/her authority. As a result, the appointment of staff, even at the lowest level of unskilled worker, is under the authority of the Director-General until it is further delegated to the health department. Once it is delegated to the head of the health department it can be further delegated. This process of delegation of authority has varied through the provinces but there has been universal frustration with the slowness of the process. This single important delegation; viz the appointment of staff - if not in the hands of the appropriate decision makers - has the ability to thwart the best plans of managers and to make a mockery of well thought through objectives. Simply put, without the right people in place, policies, plans and objectives will not be achieved. This lack of authority makes the process of management cumbersome and slow. For example, in one province the process of authorisation for cars to have a standard 10 000 km service resulted in vehicles being off the road for an average of twenty days; appointment of staff to an authorised and funded post took an average of eight months. In some provinces all delegations for purchasing have been removed and must now go through the Tender Board, thus making it illegal to buy a simple but necessary item from the local supermarket. Disciplinary investigations may only be set up by the Director-General of the province, which means that hospital or district management may not suspend a staff member suspected of, or actually caught committing serious criminal acts. Senior management is understandably reluctant to delegate authority. Under the present regulatory framework they are directly liable and yet do not have the necessary financial and information systems to monitor what is going on. Furthermore, the conditions of employment of the public service make it virtually impossible to remove a manager who is sub-standard, and therefore senior managers protect themselves from the incompetence of their subordinates by insisting that their decisions require head office approval. One of the key recommendations of the National Department of Health commissioned Hospital Strategy Project was decentralised management. The principal has been accepted, but there has been little progress in implementation.
HEALTH DEPARTMENT STRUCTURES AND CAPACITY With the exception of KwaZulu-Natal, Free State, Gauteng and Western Cape, the provinces did not inherit the core administrative units and skills necessary to perform their functions as defined by the regulatory framework. The Eastern Cape, North West, Mpumalanga and Northern Provinces had to absorb large bureaucracies from the homeland regimes. These bureaucracies had
48 different regulations and systems, and were severely compromised by institutionalised corruption and nepotism. The Northern Cape had to set up a management team virtually from scratch. Understandably, the initial priority of the new provincial governments was to achieve equity, representivity, and community participation. These priorities became the criteria for most of the senior administrative appointments. As a result, the departmental structures that were set up and the persons appointed to the posts were often relatively inexperienced. These managers were faced with multiple challenges, including sorting out a system of government that had long since collapsed under its internal contradictions and built-in inefficiencies. They were also faced with a unique managerial situation which required the complete transformation of services. The third unusual challenge required a major movement of staff, either organisationally or else geographically. These challenges were in addition to maintaining the delivery of health services. In many cases this has placed a great stress on new managers who have taken a long time to come to grips with the demands of the situation.
Organisational Structure In the 1996 Annual Review2 the organograms of the provinces were shown. Since then two of the provinces, viz the Free State and the Eastern Cape have split their health and welfare functions. This leaves the Northern Cape, North West, Mpumalanga and Northern Province with joint health and welfare functions whilst the other five have these functions separated. As pointed out in last year’s review, only time will tell which is the better structure. Another aspect of organisational structure raised in the 1996 review relates to “line and programme” functions. With service delivery being pushed to districts, there is anecdotal evidence from many provinces that the lines of communication and authority are not as clear as they should be. Unless the lines of communication are very clear there is a built-in recipe for confusion. There are programme managers at national and provincial level who all wish, naturally enough to do the best for their particular programme. There is also an overall policy of integration of services at the delivery level. The health workers at the point of service delivery can be faced with multiple programme demands that are competing for limited resources and hands to do the job. To illustrate the point : At clinic level, the nurse in charge can be bombarded by the demands of the programme managers for AIDS, TB, Maternal and Child Health, Mental Health, Chronic Diseases, Health Education, Community Development and Human Resource Development. Unless she has a regional and district manager who will support and protect her, and who can channel the flow of demands through themselves, she may well be overwhelmed by competing demands.
LOCAL GOVERNMENT AND DISTRICT LEVEL Theoretically the district based approach to Primary Health Care should result in an administrative simplification and bring local control over service delivery. However, in South Africa this has not yet been the case. In terms of the constitutional principle of co-operative government, provincial and local government are jointly responsible for ensuring that primary care services, including level one hospitalisation, are delivered. However there are still fundamental problems and confusion around this joint responsibility. The principle of long term local government responsibility for delivery of primary care services is accepted. However, at present local government is in a process of restructuring and, in the rural areas particularly, is very fragmented and weak. Consequently, the province is largely stuck with the responsibility for delivery. (See Chapter 6). There is no consensus as to what type of services should be provided at the primary level. It is thus difficult for provinces to negotiate with local governments to transfer funds to them so that they are in a position to implement. Further, the previous history of local government and health service delivery is an unhappy one. There are examples of the health subsidy to local government being used to fund services other than health. There is also the problem of the high salaries paid in the metropolitan areas by local government. This makes the transfer of staff rendering primary care services, from provincial to local government unaffordable.
Provincial Restructuring 49 These issues remain unresolved, largely because they are of a more fundamental nature than any principle of co-operation could be expected to solve.
NATIONAL LEVEL Health services are the responsibility of three ill-defined tiers of government with the provincial health departments in the middle. Theoretically, co-operative governance is supposed to take place but the reality is much more complicated. Although responsible for policy, the National Department has almost no control over implementation. The provincial Health Department is in fact a sub-department of the province which is an independent department with its own Director- General answerable to the Premier of the province. From the current financial year, 1997/1998 the national Department of Health has little say over the allocation of the budget to the provincial health departments. Each province gets a block allocation for all of its functions and health is in competition with the other departments for its share of the cake. In the absence of clearly defined standards of health service delivery, it is difficult for provincial health departments to motivate for their budgets. There is the distinct possibility that different provinces will allocate different amounts per capita to their health departments, and by so doing the fundamental policy objective of equity across the country may be compromised. On the other side of the spectrum, the provincial health department has to communicate through the provincial Department of Local Government with the chief executives of local authorities who are answerable to democratically elected councillors. These local authorities will have their own sources of revenue, some of which could be used for health services. Provinces will in terms of section 156(4) of the Constitution, assign functions “by agreement and subject to any conditions” to a municipality. The provincial Health Departments would continue to play a monitoring and support role and would develop performance contracts to accompany the transfer payments to local authorities. However, the mechanism or formula for these transfer payments is unclear. It is also unclear how provincial Health Departments will exercise authority over local authority health departments that do not deliver according to standard. Because health services are a complex system of referrals of clinical problems from the lower to the higher levels of care, the national health service system needs to be based on a planned, rational, and equitable distribution of those resources. It is clear that health expenditure rules and guidelines need to be spelt out either by legislation or through State Expenditure/Treasury guidelines. They should also specify how level one, two and three care will be paid for; what each level of government must contribute proportionately to infrastructural support, and how cross border charges will be handled. Further broad norms and standards of productivity/cost effectiveness should be developed against which budget proposals may be evaluated.
FINANCIAL PROBLEMS Many provinces are facing serious financial problems as a result of their budgetary allocations being less than they expected. In a situation where making staff redundant is not legally possible, balancing the books can result in crisis management through post freezing and the cutting of capital projects. These two methods of short term budgetary management result in a vicious cycle of undermining the budgetary process for the future in that health workers have no faith in them. The issues of funding inter-provincial referrals, the funding of level three and teaching hospitals, cross border flows, and the funding of local government delivery of district based Primary Care remain unsolved.
50 CONCLUSION Generally, the provincial health restructuring process has resulted in provincial health departments being more equipped to face the challenges demanded. There has been significant progress in making the system more equitable. However, there are a number of structural problems which need to be overcome. ➣ With the emphasis on a district health system, provinces will need to decentralise decision making and authority. This will require fundamental changes to the whole public sector, involving not only the Health Departments. ➣ Methods of de-regulating health care delivery need to be examined. ➣ Managers at all levels need to be given more responsibility and accountability for managing their budgets. ➣ Government bureaucracy and obstacles to a customer-oriented system need to be minimised.
51 52 LOCAL GOVERNMENT 6 IN THE MOVE TO A DISTRICT HEALTH SYSTEM
INTRODUCTION This chapter gives a short overview of the background and legislation regarding health services delivered by local authorities. It then reviews the latest legislative and policy changes regarding the development of a district health system and the role of the municipalities in this system. The last part of the chapter reviews the progress made and challenges to be overcome in moving toward a district health system.
A SHORT HISTORY OF HEALTH CARE AND LOCAL GOVERNMENT 1910 - 1993 Unification in 1910 At the time of unification in 1910, responsibility for health care was transferred from the four colonies to the four provincial administrations, while local authorities simply continued with the tasks previously entrusted to them. In the South Africa Act (1910), there was neither special mention of health services, nor did it repeal the previously fragmented colonial health legislation. While each of the four provincial administrations continued to provide public curative services independently, environmental and preventive health services were still provided by local authorities under the jurisdiction of the Department of Internal Affairs. At unification, there was no question of a separate Department of Health, and there was also marked fragmentation of authority for health matters.
The Public Health Act of 1919 The disastrous influenza epidemic of 1918 which claimed approximately 142 000 lives was directly responsible for a fundamental reorganisation of South Africa’s health care. This epidemic revealed the shortcomings in the organisation and co-ordination of the health services at that time, but also stressed the fact that the State had to assume responsibility for public health, especially where disease threatened society as a whole. A new dispensation with a definite health policy and clearer authority structures came about shortly after this epidemic. Proclamation of the Public Health Act 36 of 1919 reformulated and amended some of the obsolete colonial health acts to establish uniform control of preventive health services. An additional and separate Ministry and Department of Public Health was established at the first tier of the government, responsible for public health services in South Africa and for co-ordinating the network of health services provided by local authorities. The new Department of Public Health was responsible for the following: ➣ aid and advice to provincial and local authorities
Author: Shan Naidoo, Southern Metropolitan Substructure, Johannesburg 53 ➣ responsibility for the control of contagious and other diseases ➣ the advancement of environmental health ➣ extra-institutional services such as district surgeon services ➣ control of institutions for the mentally ill and for tuberculosis and leprosy patients. In terms of this legislation, provincial administrations retained responsibility for the establishment, maintenance and management of general hospitals and charitable institutions. As such, they were regarded as the principal providers of curative services in South Africa. Local authorities were, as agents of the Department of Public Health, made responsible for the control of contagious diseases and for environmental health in their areas of jurisdiction. Costs of these services were recoverable from the Department of Public Health. The original purpose of the 1919 legislation, namely the co-ordinated supply of health care, was lost as provincial administrations continued to have autonomy, exacerbating the polarisation between preventive and curative services. A further critical shortcoming of the Act was that it made no reference to the place and role of the rapidly emerging private health sector. This legislation drew the lasting contours of a highly fragmented health service, the implications of which continue to this day.
The Gluckman Report of 1944 The National Health Services (Gluckman) Commission’s report was the culmination of the reformist thinking in health care. Its brief was to make recommendations regarding the provision of an organised national health service, and the necessary administrative, legislation and financial measures required for this purpose. The Commission recommended the establishment of a national health service for South Africa, and at the same time also formulated a detailed programme to implement such a service. Central to its recommendations was the establishment of a single national health authority responsible for all personal health services and for co-ordinating all non-personal health services. This recommendation of the Gluckman Commission was never implemented.
Health Reform in the 1970’s For nearly sixty years, the 1919 Public Health Act determined the organisational framework of South African health care. It was repealed and replaced by the Health Act 63 of 1977. In essence, the Act reinforced the administrative and functional fragmentation of health care, delegating responsibility for preventive services principally to local government, while retaining provincial control over hospitals. Consequently, local authorities provided a limited range of health services, varying in nature and extent.
Further fragmentation in the 1980’s The shortcomings of the Health Act rapidly became apparent, and a number of plans aimed at streamlining the services were devised (Commission of Inquiry into Health Services 1980, the National Health Services Facilities Plan 1980, and the National Health Plan 1986). However, any efforts at creating a more logical service were stymied by the grand apartheid plan, with further fragmentation due to the homelands policy and the constitutional changes of 1983. The consequence of these policies, evolved over eighty years, was a conglomeration of health providers, each responsible for a limited range of services and with little interaction between them.
HEALTH DISTRICTS AND LOCAL GOVERNMENT The Ministry of Health has committed itself to developing the District Health System (DHS) as its model of implementation. The box below was taken from the White Paper for the Trans- formation of the Health System.1
54 Principles, long-term goals and role of the District Health System1
Principles A national committee established to develop a DHS, comprising representatives of the national and provincial health departments, has agreed unanimously that there are twelve principles with which planners must comply in the development of the DHS. These are: ✧ overcoming fragmentation ✧ equity ✧ comprehensive services ✧ effectiveness ✧ efficiency ✧ quality access to services ✧ local accountability ✧ community participation ✧ decentralisation ✧ developmental and intersectoral approach ✧ sustainability Long-term goals and role of the district ✧ The goal outlined in the RDP is to have a single NHS, based on a district health system that facilitates health promotion, provides universal access to essential health care and allows for the rational planning and appropriate use of resources, including the optimal utilisation of the private health sector resources. ✧ The country will be divided into geographically coherent, functional health districts. In each health district, a team will be responsible for the planning and management of all local health services for a defined population. The team will arrange for the delivery of a comprehensive package of PHC and district hospital services within national and provincial policies and guidelines. In time, all district level staff should be employed on the same salary scales and under the same terms and conditions of employment that apply to the public sector health personnel throughout the country. ✧ In view of the variety of conditions that exist among and within the provinces, it is unlikely that a single system of governance can be implemented throughout the country. Therefore, three governance options are suggested: ✧ The provincial option, i.e. the province is responsible for all district health services through the district health manager. (This option can be exercised where there is insufficient independent capacity and infrastructure at the local level). ✧ The statutory district health authority option, i.e. the province, through legislation, creates a district health authority for each health district. (This option can be exercised in instances where no single local authority has the capacity to render comprehensive services). ✧ The local government option, i.e. a local authority is responsible for all district health services. (This option can be exercised if a local authority, whose boundaries are the same as that of a health district, has the capacity to render comprehensive services.) Implementation strategies ✧ Each province will be subdivided into a number of functional health districts. ✧ This district will serve both as a provider and purchaser of health services, and select the appropriate strategy on the basis of equity, efficiency and assessment of local conditions. ✧ Peri-urban, farming and rural areas will fall within the same health district as the towns with which they have the closest economic and social links. The fragmentation and inequity created by the past practice of separating peri-urban and rural health services from the adjacent municipal health services must be eradicated. ✧ There will be parity in salaries and conditions of services for all public sector health personnel throughout the country, which include appropriate incentives to encourage people to work in underserved areas. This is essential in order to rationalise services, overcome fragmentation and promote equity, particularly between metropolitan, urban and rural areas. ✧ Financing mechanisms or formulae will be devised, to ensure that district level health services are financed in an equitable and sustainable manner. The establishment of the DHS is at the core of the entire health strategy, and its rapid implementation, therefore, is of the highest priority.
Local Government in the move to a District Health System 55 International experience has shown that the boundaries of a health district should not cross the boundaries of other administrative sectors, or of local governments i.e. they should be coterminous with these other boundaries. As the Green Paper for restructuring local government has recommended significant changes to local authorities, district boundaries may change. The health district needs to be large enough to have the financial and management capacity to provide comprehensive primary health care including emergency services and first level hospital care. The Constitution of the Republic of South Africa (1996),2 the Local Government Transition Act of 1993, and its second amendment in 19963 give substantial legal powers to Local Government to render a range of services, including health services. In terms of the Local Government Transition Act, health services historically the responsibility of local government were deemed to be a competency of local councils. The Interim Constitution of the Republic of South Africa of 1993 described the following functions as that of Local Governments: “A local government shall, to the extent determined in any applicable law, make provision for access by all persons residing within its area of jurisdiction to water, sanitation, transportation facilities, electricity, primary health care services and amenities that can be rendered in a sustainable manner and are financially and physically practicable.” The final constitution reflected the political battle between unionists and federalists, and the compromise benefited local governments substantially. In terms of Chapter 7: Local Government, the Constitution2 describes the objects of Local Government (s152) as: 1 a) to provide democratic and accountable government for local communities; b) to ensure the provision of services to communities in a sustainable manner; c) to promote social and economic development; d) to promote a safe and healthy environment; and e) to encourage the involvement of communities and community organisations in the matters of local government. 2 A municipality must strive, within its financial and administrative capacity, to achieve the objects set out in subsection 1. Also s153 describes the Developmental duties of municipalities as :- A Municipality must a) structure and manage its administration and budgeting and planning processes to give priority to the basic needs of the community, and to promote the social and economic development of the community; and b) participate in national and provincial development. The chapter also deals with the co-operative governance between the different tiers of government, emphasising the supportive role of national and provincial tiers to the well functioning and success of local governments. Amongst the local government matters described in Schedule 4, which outlines the Functional Areas of Concurrent National and Provincial Legislative Competence, is municipal health services. The definition of such health services has been subject to interpretation and has not yet been finalised.
56 CHALLENGES IN MOVING TOWARDS LOCAL GOVERNMENT CONTROL Despite a legal framework which supports local government control of primary health services, there are a number of problems facing local government in South Africa. These mitigate against wholesale transfer of provincial responsibilities to local government in the short to medium term.
Limited revenue The legacy of both significant underfunding by the apartheid state and the rent boycott have severely constrained the revenue of many local authorities. Most local governments have an insufficient rates base to render basic services and, in particular, the “softer” services such as health face increasingly restrictive budgets. These services rely on provincial subsidies to carry out their basic functions. Despite the agreement to write off domestic arrears in January 1994, there has not been the envisaged support for the Masakhane campaign, aimed at encouraging the resumption of payment for services.
Limited infrastructure The second problem facing local governments in the main is poor infrastructure, both capital and human. To develop sufficient capacity, the new Local Governments elected in November 1995 have had to push resources into historically neglected areas and simultaneously implement stringent credit control measures to gain income. This process is in itself time consuming and complex - and even now there are a very few local governments that are financially viable. Intergovernmental grants have declined substantially and both provinces and local governments are battling to meet community demands.
Incongruent boundaries A fundamental problem is that many Local Governments are not structured on the basis of geographically coherent districts congruent with most of the proposed health districts. The Local Government Transition Act and subsequent amendments make provision for local councils in urban areas, and rural councils in rural areas. The local councils and the rural councils nominate representatives on a proportional basis to a District Council. The District Councils are responsible for service delivery in the rural areas and may provide services where requested on behalf of the urban local councils. In metropolitan areas, there are a number of metropolitan local councils who will nominate members to the metropolitan council in addition to directly elected members. These various structures of local governments have implications for the successful implementation of district health systems. In the Gauteng Province, the metropolitan local councils are regarded as districts and the provincial health departments are working together with local councils to establish district health systems. But in rural areas, smaller municipalities surrounded by district council areas result in a Swiss-Cheese phenomenon. This flies in the face of logical health service organisation.
Factors constraining integration of services A number of factors prevent logical integration of primary health services, whether under local government or provincial control. These include persistent differences in conditions of services and salaries of health workers employed by different authorities, difficulties in merging two distinct hierarchies, and protection of empires. There is a lack of skilled managerial capacity to manage these districts. The relationship and communication channels between vertical programme managers at provincial and national level and district line managers have not been clarified. Programme managers all want the best for their programme, understandably, but at the point of service delivery all programmes need to be integrated and each programme will have to shed something in the pursuit of equity and fairness. How will these decisions be made? The core package of services to be offered at primary level has not been agreed upon. This is fundamental to many of the issues relating to equitable health service delivery. Proposals for a core package of PHC services are currently under discussion.
Local Government in the move to a District Health System 57 FUTURE OPTIONS Most local governments, as they restructure, see a continued role in PHC delivery. There is grassroot demand for health and social services at local level. It is the ward councillor who is first called on a range of health and social issues. The challenge therefore is for the Provincial and National government to assist local governments to meet the developmental needs of communities. National policy proposals suggest a phased approach to the delegation of responsibilities to local government. Three models for governance of health districts have been proposed (see above). Bringing decisions closer to where the services are delivered is likely to result in more appropriate implementation of national policies. It will also result in a management which is more accountable to the needs of the community/district. This will translate into greater equity in improved service delivery.
IMPLEMENTATION OF THE DHS Table 1 shows the progress made towards the creation of districts in the various provinces. With the exception of KwaZulu-Natal, all the provinces have drawn district boundaries. The Northern Cape, because of its large geographical area and small population has only regions. The average number of people per district is around 200 000 but there is considerable variation between provinces. Between the two urbanised provinces, Western Cape and Gauteng, there is a two fold difference with Gauteng having nearly 300 000 people per district and the Western Cape close to 150 000. In the more rural provinces there is a similar scale of difference between Mpumalanga and Eastern Cape Provinces. It would be illuminating to know on what basis the decision was made to have districts with such wide differences in population size. It will also be useful to monitor the effect these large differences have on management structures and ultimately on the decentralisation of decision making.
TABLE 1 DEVELOPMENT OF DISTRICTS4
Province District Development Districts - Population per Regions - number number District Northern Cape 6 (6) 124 000 Free State 6 14 197 000 Mpumalanga 3 21 143 000 North West 5 18 188 000 Western Cape 4 25 149 000 Northern Province 6 25 216 000 Eastern Cape 5 21 308 000 Gauteng 5 25 282 000 KwaZulu-Natal 8 - - South Africa 48 155 ± 200 000
CONCLUSION Although there has been strong political will and commitment to the creation of a decentralised health system based on districts there has not been the same commitment to overcoming the obstacles that impede implementation of this system. Because districts are where service delivery happens, they are the cogs around which many of the wheels to real equity turn. Quality of care issues have not received the necessary attention and services at primary level need considerable improvement.
58 HOSPITAL 7 RESTRUCTURING
INTRODUCTION The public hospital sector is currently confronted with two major tasks: ➣ halting the decline in the service ➣ restructuring the services Generally hospital services are characterised by vastly differing conditions. These differences are dependent on factors including: ➣ academic linkages ➣ previous racial orientation There is reasonable service provision in traditionally ‘white’ hospitals especially in those attached to universities. Conversely, non-academic regional hospitals have generally not been able to offer services of a high standard of care. However, during the eighties and nineties, it appears as if conditions in all of these hospitals declined. The reasons for this decline included: ➣ budgetary constraints (exaggerated for hospitals whose equipment is imported - where Rand prices increased rapidly) ➣ exodus of medical staff to the private sector and to other countries. The current state of each hospital is thus a reflection of the past heights achieved and the subsequent rates of decline. Clearly, the first challenge is to reverse this decline. Secondly, health sector reform has concentrated on the development of a District Health System (DHS). Initially there was little emphasis on hospital restructuring and reform in public health sector policies. However, since most of available funding is tied up in hospitals, (and in a climate of static or even shrinking budgets for health care) it has increasingly been evident that the DHS development is integrally linked to successfully reforming the hospital sector. For hospitals this implies: ➣ less health expenditure in hospitals ➣ a simultaneous improvement in the clinical care ➣ addressing the racial and geographical inequities in care. Also pushing the need for reform was a widespread perception of hospitals: ➣ being excessively concentrated in metropolitan areas ➣ relatively over-funded ➣ inefficient and wasteful ➣ not sufficiently addressing the newly identified health priorities. One of the forces mitigating against such reform, was the existing managerial process, including managers and systems. The existing health governance structures at national, provincial and hospital level, were traditionally concerned with day to day routine issues.
Author: Brian Ruff, Department of Health, Gauteng 59 Hospital managers were not trained or prepared for undertaking fundamental reform, nor were they overly concerned with cost effectiveness and efficiency. After the 1994 elections new managers were appointed who were more reflective of the political transformation taking place in the country. They were well aware of the need for health restructuring. However, many were inexperienced with little detailed knowledge of the systems they were charged with managing. They also often did not have the capacity required to support a process of fundamental structural change. In many provinces these new managers faced, in addition to hospital restructuring, the difficult task of restructuring the whole provincial system. Many of the essential elements for hospital reform were absent. Some of these are summarised in the box below.A Next to each, are the requirements for reform.
Absent Elements needed for Reform Requirements for Reform Lack of Useful information: Develop: ✧ absence of a needs analysis; no hospital service ✧ Service planning norms planning norms / guidelines ✧ unreliable and unhelpful routine hospital data; ✧ Health Information Systems - none regarding single clinical departments as reflective of Functional Units functional units or cost centres within large, and Cost Centres complex hospitals Distorted Referral System Rationalise, upgrade and develop ✧ badly placed (white suburbia), under-utilised ✧ district hospitals district /community hospitals ✧ an undersupply of regional hospitals; those few ✧ regional hospitals in a poor state of functioning and of repair, especially in black townships ✧ excessively resourced academic hospitals, with ✧ rationalise and downsize, cap unsustainable amounts of Level 3 development tertiary spending and sub-speciality training ✧ disperse the good service effects of academic involvement ✧ difficult to keep or attract quality staff in non - ✧ staff incentives for under- academic public hospitals, or anywhere outside resourced hospitals of the metropolitan areas ✧ little formal clinical referral or communication ✧ referral mechanisms and between levels of the service, resulting in obligations duplication of effort and wasteful practice Human Resource Planning Develop ✧ little uniformity in staffing levels between hospitals ✧ staffing norms per service at all and between provinces levels of care ✧ existing staffing norms are unaffordable ✧ affordable norms Capital Development Develop ✧ maldistribution of beds with oversupply in some ✧ capital assessment and areas and undersupply in others development programmes ✧ poor state of many facilities and their equipment ✧ facility assessment and upgrading programmes Financing Develop ✧ lack of financial data by levels of care and by ✧ costed and capitated service clinical service and staff norm proposals ✧ lack of credible financial targets for provinces ✧ realistic targets and timeframes and for hospitals for change ✧ unavailability of ‘bridging’ funding ✧ find alternative sources of hospital funds ✧ lack of a framework within which to manage ✧ public / private interface interaction between the private sector (medical proposal for a regulatory aid and other paying patients, private framework practitioners, private facilities) and public hospital services - to their mutual advantage
This chapter will assess the progress made in addressing these problems.
A from Hospital Strategy Project (HSP): Restructuring Referral Hospitals1
60 THE ROLE OF THE DEPARTMENT OF HEALTH (DOH) IN HOSPITAL REFORM Hospital Strategy Project In recognition of these problems, the DoH and the European Union commissioned and funded a Hospital Strategy Project (HSP)1 to study the serious problems of inefficiency and inequity of the hospital system. The project worked from June ’95 until June ’96. Its findings included an analysis of problems, strategic recommendations, guidelines and targets. The HSP process principles included: ➣ a participatory and consultative approach to policy making and strategy development ➣ continuous integration of project findings with the policy making process, in order to facilitate early action ➣ development of internal capacity in the DoH and the Provincial Health Departments. The HSP developed a number of modules, which are elaborated on later in this chapter. A number of specific strategies were recommended. These include:
Ensure adequate funding for the public hospital system ➣ HSP recommended 2.64 beds /1000, whereas National Facilities Audit showed current beds to be 2.3 beds /1000. Current levels of funding, using optimal staffing levels, can fund 1.83 beds /1000 (using lower realistic levels 2.18 beds / 1000 can be funded) ➣ Based on the DoH Medium Term Expenditure Framework, (see below), which assumes additional funds for hospitals, the 2.64 /1000 would be affordable, even with optimal staffing ➣ If additional funds are not forthcoming, various compromises will need to be made. (These involve skills mix and numbers of staff, numbers of beds and the division of resources between PHC and hospitals)
Rationalise and reallocate hospital resources ➣ Develop detailed nationally acceptable and affordable guidelines, including beds to population and staff to workload ratios ➣ Implement in a slow and controlled fashion
Restructure the hospital system ➣ develop a consistent classification of hospitals, and referral arrangements between them
Develop a system for rational planning of future resource allocation ➣ develop guidelines based on objective criteria ➣ capital development guidelines
Ensure efficient resource use at hospital level ➣ strengthen management capacity, structures and systems ➣ detail clinical guidelines for district, regional and tertiary hospitals
Develop efficient and accountable hospital management ➣ Implement the national Policy on Decentralised Hospital Management. This includes: - delegation of substantial powers over personnel, finances and procurement - shift the role of Provincial Health Departments from line management to one of policy and guideline setting - modern management structures and systems - recruit and develop skilled hospital managers
Ensure efficient labour relations policy and management
Hospital Restructuring 61 Create an effective public/private interface which contributes positively to the public hospital system ➣ Control expansion of private sector beds so as to minimise impact on public sector ➣ compete with private sector for paying patients; bring these patients and practitioners back into the public hospitals ➣ create partnerships
The HSP also suggested a number of Critical Implementation Steps ➣ Develop consensus, at provincial and national level, and with key stakeholders, on the HSP goals and strategies ➣ Ensure that hospital policy issues are high on the agenda of the public health sector ➣ Develop an appropriate timetable for hospital reform ➣ Develop detailed systemic implementation plans A number of modules, with detailed mechanisms and tools, were developed by the HSP, in order to promote hospital restructuring. These modules with some of the highlights are listed below.B
Module 1: National Affordability Guidelines for Hospital Service Delivery: ➣ Definitions and Classification of Hospitals. ➣ Indicators of Service Provision - with beds guideline per 1000 population
Level III 0.3 Level II 1 Level I 2 Chronic 0.4 All hospitals 3.7 Public only 3
➣ Guidelines for the provision of Level I, II, III services were proposed ➣ Human Resources Planning Guidelines: There is a need to resolve a number of questions: - extent of budget shift to PHC - expansion of private sector - strengthening of regional hospitals - separation of levels of care in hospitals - decentralised management - minimum package of essential services - use of mid level workers - use of multi purpose assistants in patient care units ➣ Essential Performance Indicators ➣ Improving the Quality of Care - introduce Continuous Quality Improvement programmes ➣ Clinical and Referral Guidelines ➣ Planning Facility Development and Maintenance Module 2: Strengthening Hospital Management
B Each of these modules represents a substantial piece of work. These are available from the national DOH and provincial Health Departments.1
62 Module 3: Cost Recovery and Contracting Out ➣ Limit expansion of Private Sector ➣ Real and Perceived Quality of Care in the public sector hospitals should be improved ➣ Open private wards in selected public hospitals, with better ‘hotel facilities but not clinical care - it was the HSP view that this step was absolutely central to improved cost recovery. ➣ Allow hospitals to retain revenue to create incentives for efficient collection ➣ Address problems in the current user fee schedule and in its implementation ➣ Improve the accuracy of patient classification on admission, accuracy of procedures performed and bills sent out ➣ Improve billing relationships with insurers ➣ Critically evaluate all existing contracted out relationships, and terminate or renegotiate those that are inappropriate
Module 4: Labour Relations The Future of the Hospital Strategy Project The ultimate question regarding the HSP regards its usefulness at the implementation level i.e. what was its role in helping to achieve real structural change in the public hospital sector? The documents of the HSP are both detailed and sophisticated. While some of the work is immensely practical and of immediate use, much of it can only be implemented if and when the capacity of the public hospital system develops. The DoH is currently planning a follow up project, which will very practically ‘roll out’ the suggestions to the provinces and hospitals, using pilot projects and direct support. The remainder of this chapter deals with different aspects of hospital policy and implementation and should be read with the recommendations of the HSP in mind.
NATIONAL HOSPITAL CO-ORDINATING COMMITTEE A national committee was formed in 1995, initially to consider the work of the HSP, and to disseminate its product to relevant levels of the provincial hospital systems. However its mandate has broadened to consider all the issues arising from public hospitals and develop plans for their resolution. This committee meets regularly, under the chair of Dr Tim Wilson, Chief Director: Academic Health Centres and Hospitals at the DoH, and is a mechanism for cross fertilisation of ideas, as well as for developing joint policy initiatives. These have included: ➣ the standardisation and application of hospital definitions to all public hospitals, including the recognition of basic ‘level of care’ provision within these hospitals. This is a fundamental pre-requisite towards meaningful assessment and planning of hospitals. ➣ developing an agreed list of “Highly Specialised Services” such as transplantation (of various kinds), open heart surgery, in vitro fertilisation, complex oncotherapy, highly infectious disease units and renal dialysis. ➣ There has been consideration of a national DoH proposal regarding the academic hospitals. Recognising that these hospitals were a national asset which should be equally accessible to all, the initial proposals were for central co-ordination in their planning and funding. This was fairly uncontroversial. The proposals have, more recently, evolved towards suggesting an incremental process whereby the hospitals would eventually also be managed by the DoH i.e. separated largely from the provincial departments. This latter proposal is controversial and appears to have been rejected. ➣ The committee has also spent significant time in detailed planning and co-ordination of the proposed “Post Graduate Vocational Training” process, ensuring that provinces have capacity and systems in place to guarantee the success of the initiative.
Hospital Restructuring 63 CENTRAL BARGAINING CHAMBER Functionaries of the DoH negotiate on behalf of the State, including Provinces, regarding a whole range of issues effecting the staff of hospitals. These include salaries, overtime payments and incentives. This process largely ensures standardisation of conditions of service for all staff around the country. However, real conditions on the ground vary considerably between provinces and between categories of staff. These factors are not easily dealt with by this centralised process, leading to a lack of flexibility, which has serious practical consequences. A classical example of this is the removal, by the Chamber, of some financially insignificant incentives from intensive care unit (ICU) nurses. Many ICU nurses have moved to the private sector, attracted by better packages available to them. Their loss from public hospitals has exacerbated the existing shortage of these nurses. This is a problem which bedevils all provinces. If understaffed provinces are ever going to be able to attract doctors to their hospitals, they will need to provide attractive packages which include housing, vehicles, educational and monetary incentives, outside of the strictures of standard conditions of services.
HUMAN RESOURCE DEVELOPMENT ➣ The DoH is working towards policy guidelines for Human Resources Development (HRD). These guidelines have not yet specified the level of service per population or norms of staff per hospital service. ➣ The Hospitals Directorate (DoH) recently held a national workshop for HR planning. This focused on the ‘Hospital Establishment Review’ process being undertaken for a number of provinces as an extension of the HSP work. This review is based on clinical utilisation and not on population based ratios. Therefore, its prime usage is for institutional review rather than overall planning. ➣ Foreign doctors and the Cuban contract: Many rural and small town hospitals are now dependant on contract Cuban doctors. This has come about because of the loss of other foreign doctors (appointed as ‘free agents’) because of the 1994 national moratorium on appointing new foreign doctors. Few South African doctors are settling outside of the metropoles. As a result, this moratorium appears to have had a devastating impact on the availability of doctors in certain under-served provinces, where the overall medical stock has declined since 19942 ➣ Cuban DoctorsDoctors: These doctors are trained to work in a very different health system to the South African one. Generally, their system has them working as components of a substantial team. It follows that for them to be usefully deployed, they must be kept together and deployed as a team i.e. at a large rural or regional hospital, practising at specialist level. Not many can be usefully deployed in small numbers in small hospitals. This contract represents a ‘stop-gap’ measure, and should not be regarded as a sustainable resource. ➣ The rural or general specialist: The question of appropriately trained local practitioners for rural and regional hospitals remains unresolved. ➣ Compulsory Community Service / Vocational training - While many provinces will welcome the extra pairs of hands made available in this way, the potential usefulness of these very junior doctors unsupervised in the periphery is in doubt. The real need is for mid level doctors with some experience of general medical practice.
MANAGEMENT SYSTEMS Decentralisation of Management Authority It is widely perceived that many public sector hospitals are run inefficiently. One of the key factors is the fact that managers of public hospitals have very little decision making power and authority. The Hospital Strategy Project recommended decentralisation of management authority as a key to the improvement of efficiency. The National Department of Health has proposed implementation of decentralised management within 10 academic hospitals as the first phase of the implementation of
64 decentralisation. Funding has been requested from the European Union and the target date for implementation is January 1998. The plan is to appoint Chief Executive Officers within institutions to initiate a change in management process. Sufficient finance, personnel and procurement delegations as well as vastly increased authority over public works and transport will be handed to these managers. Ability to generate and retain revenue and the implementation of large scale management training will be important additional changes. A second phase of decentralisation will involve 5 regional hospitals and is intended to commence in July 1998. The process is envisaged to be very similar to that of the academic hospitals. The process of decentralisation faces major challenges of which the most important are: ➣ Department of Finance who foresee the potential for abuse due to lack of adequate controls ➣ Public and provincial service commissions who are unconvinced that adequate capacity is present in individual departments to ensure transformation of the public service ➣ Lack of information systems ➣ The complex web of legislation and regulations eg. Public Sector Act ➣ Central bargaining with labour unions within the public sector.
FINANCE Details of the Budget Allocation are in Chapter 8. Because of the national policy of prioritising District development, as well as the enormous difficulties associated with the rationalising of academic hospitals, there has been an overall shrinkage in the budget of regional and district hospitals of nearly 9% in real terms (96/7 to 97/8). The DoH has now developed a Medium Term Expenditure Framework (MTEF) for the public sector, which proposes a framework for expenditure until 2000. The MTEF indicates that it is affordable to provide basic health care for all South Africans within 10 years, providing minimal growth (1.3%) to academic hospital services; slow growth for provincial and district hospitals (2 - 3%); and significant growth in PHC expenditure (9%) until PHC constitutes 26% of the annual budget. In 95/96 the PHC share of the budget was 19.7%. The MTEF, however, assumes real growth of 3.6% of the whole Health budget. This is not assured. The MTEF has 3 provisos: ➣ that there is redistribution geographically and by level of care ➣ that additional funds be mobilised for public hospital service - these to be found by increasing public hospital revenue by: - partial fee retention by hospitals - introducing ‘Social Health Insurance. This would require all formal sector employees, who do not have medical aid cover, to be insured for the costs of treatment of them- selves and their dependants, within public hospitals - ensuring available resources are used more efficiently, partially by a resource reallocation strategy. This strategy would promote district services; right size hospitals; and build capacity in operational planning, financial management and health economic evaluation at all levels. There are two major unknowns regarding the future strategy of the MTEF: ➣ Firstly the DoH is no longer in a position to allocate funds. Since the 1997/8 financial year the allocation of funds falls to each province. In the absence of statutory norms and conditional or “ringed’ grants, hospital budgets cannot be guaranteed to grow at a predictable rate. ➣ Secondly the concept of social health insurance has not yet been accepted by all relevant stake-holders.
Hospital Restructuring 65 THE PUBLIC / PRIVATE INTERFACE The Public/Private interface is, as will be seen from the appendices to this chapter, a key area of possible opportunities for reform, particularly with the advent of Managed Care. However, it is also an enormously complex area. At the heart of the problem, are issues for the DoH to resolve: ➣ Should the State be both regulator and provider, or should it move towards greater regulation and less provision? The previous pattern of private sector delivery does not make such a shift easy for the DoH. ➣ Is the State prepared to partially enter the health ‘market place”, i.e. compete for private patients in order to increase revenue and cross subsidise indigent patients. This might entail differential care (eg. ‘hotel” care) for patients and possibly differential conditions of service for staff.
PUBLIC SERVICE COMMISSION The Voluntary Severance Package process has had unfortunate consequences for the Health and, in particular, the hospital sector. Generally, the skilled staff (highly qualified nurses - ICU, theatre, allied professionals and senior administrators) required by the services, have taken the packages, while unskilled staff currently in over supply, have not.
DEPARTMENT OF EDUCATION Because there are many instances of joint service and training functions occurring side-by- side in hospitals (nurse, doctor, allied professional) and teaching institutions receiving direct and indirect budgets from both Health and Education budgets, co-ordination between the two sectors is critical. The perception exists that co-ordination could be strengthened, so that critical issues do not fall into the gap of responsibility between the two departments. An extremely important example of this is the determination of how many specialists and sub specialists are trained. Co-ordination with the Interim National Medical and Dental Council is also necessary in this regard, as it is the responsible body for controlling specialists in training.
PROVINCIAL PROGRESS The issues faced by the Provinces could be seen as the “tale of two provinces”, where most are underdeveloped and need substantial growth, while a few are well developed, but for the sake of equity and efficiency need to downsize and spend less. Those in need of substantial development of their hospital services include North West, Northern, Mpumalanga, Eastern Cape and Northern Cape Provinces. Key features of their work include: ➣ attempting to develop regional and district hospitals; experiencing considerable difficulties ➣ using academic links where possible ➣ critical shortage of medical specialist staff ➣ major dependency on foreign and Cuban doctors ➣ referral systems gradually becoming better structured (especially Northern Cape) ➣ little managerial reform possible (except Northern Province) ➣ at provincial treasury level health development budgets enjoy less priority than supporting current commitments and infrastructure, and funding is largely being held at current levels ➣ considerable reliance on local private sector - not seen as problematic ➣ extensive facility upgrading and expenditure Those needing to “trim down” include Gauteng, the Western Cape and to a minor extent, Free State. This is not to say that they do not also require significant internal restructuring and relocation of services.
66 Key features of their work include: ➣ rationalisation and downsizing of tertiary/academic hospitals staff establishments is critical; enormously complicated by Academic Faculty involvement ➣ regional hospital development is seen as the cornerstone of reform ➣ there is mounting financial pressure, making rationalising imperative but more difficult to achieve; moratoria on staff appointments. ➣ rules governing access to tertiary services are critical ➣ management systems planning ongoing, not yet implemented ➣ private sector co-ordination could be much increased if policy framework was clearer ➣ extensive facility planning and upgrading KwaZulu-Natal is usually at the average. Detailed provincial profiles are attached in Appendix 1.
CONCLUSION There is significant progress towards hospital restructuring in the South African public sector. There is enormous energy and great volumes of work, mostly productive, and a sense of uniformity of progress is evident. However, it is unavoidably patchy, with different provinces and processes reaching different points without much co-ordination. In a way, this is an advantage, almost as if there are 9 ‘experiments’ going on, each with slightly differing approaches. However, to be advantageous, the successful features of each need to be recognised by other provinces and used, as appropriate. There is little evidence to suggest that this is happening adequately. There is also the danger that, in the absence of better co-ordination and leadership, the whole system could gradually decline. This is especially necessary in the face of the potentially divisive financing system now in place. The entire public hospital sector needs to rapidly set some common service and staffing norms. There need to be common planning processes regarding service provision, referral arrangements and decentralised delegations. This will greatly assist each provincial health department to fulfil its mandate as well as form the basis for motivation for adequate funding to develop or protect their service. An unavoidable, but healthy tension, should therefore exist between the Provinces and the DoH. The DoH needs to play the role of resource centre, co-ordinator and regulator. It should provide tools for hospital development and evaluate and support implementation. Though allowing flexibility where required, it should firmly insist on co-operation and standardisation where it is essential. Where provinces are weak, it should provide protection and support. The nine Provincial Health Departments should realise the benefits of co-operation and the dangers of antagonism between themselves. Despite the ‘federal’ nature of the country, the public health and hospital system is a single system, in which all should be enabled to play their appropriate part.
Hospital Restructuring 67 APPENDIX 1 Provincial Profiles: Eastern Cape 1. Functional Restructuring
a) Staff and Services ✧ Upgrading of Umtata hospital and development of (planning: norms/ role UNITRA definition / population / ✧ post graduate resource centres being developed in checks & balances / P.E., E.L. and Queenstown Regional hospital crisis) i) Medical Staff ✧ shortage of specialists especially Radiology, Anaesthetics, ENT, Opthalmology ii) Nurses ✧ ICU, theatre trained nurses in short supply iii) Allied Professionals ✧ Physiotherapists, Dieticians, O.Ts in short supply b) Referral Chain & Systems i) specific incentives / ✧ Hospitals all categorised mechanisms to develop ✧ District Managers tasked to promote correct referral regional / rural hospitals - patterns from clinics to hospitals progress ✧ Major facility upgrading programme underway for district hospitals (see below) ✧ Constraints: ✧ ambulance services not fully integrated ✧ shortage of doctors in District hospitals (despite rural allowance of about R 19 000 per annum) - results in unnecessary referrals ii) access guarantee mechanisms c) Management and Administration i) Data systems - financial, clinical/societal interest, cost centre budgeting & accounting ii) Achieving Efficiency - ✧ Patient Charter distributed authority, autonomy, ✧ considering implementing HSP recommendations on decentralisation, decentralising management, possibly as a pilot rewards etc project
iii) Financial arrangements - ✧ Uitenhage model: GPs given beds in empty wards, in public/private interface return for which the state gets revenue and assistance from private sector doctors ✧ purchase certain services from private sector eg. MRI, laser therapy ✧ negotiating contracts with Lifecare, SANTA as well as catering and laundry services 2. Structural
a) New hospitals and ✧ process of identifying a hospital per district to Upgrading existing upgrade or relocate - using the National Facilities hospitals Audit and money consequently made available by national DoH. ✧ upgrading of casualties at Livingstone, Frere, Cecelia Makiwane ✧ Wards at Cecelia Makiwane ✧ Upgrading Umtata hospital ✧ Upgrading Frontier hospital to a regional hospital ✧ Major facility upgrading programme underway for district hospitals ✧ Presidential task team looking to upgrade water, electricity to institutions in former Transkei ✧ Problems: regarding the cessation of fund “roll over” - little funding available 97/8 b) Equipment Information supplied by: Dr Rank (Acting Director Hospitals)
68 Provincial Profile: Mpumalanga
1. Functional Changes
a) Staff and Services (planning: norms/ role definition / population / checks & balances / Regional hospital crisis) i) Effect on: - Medical Staff - Nurses - Allied Professionals b) Referral Chain & Systems i) specific incentives / ✧ Highveld region joint establishments and process mechanisms to develop with University of Pretoria for Witbank hospital regional / rural hospitals - ✧ joint establishments and process with MEDUNSA progress for Philadelphia hospital ✧ includes specialists, allied professionals ✧ includes equipment upgrade ✧ Universities assisting with management and planning of both hospitals ✧ Eastern Highveld ✧ Bethal and Ermelo hospitals ✧ Lowveld ✧ Tonga and Rob Ferreira hospitals ii) access guarantee mechanisms c) Management and Administration i) Data systems - financial, clinical, cost centre budgeting & accounting ii) Achieving Efficiency - ✧ management structures of hospitals broadened from authority, autonomy, traditional 3 heads to 3 plus heads of sections decentralisation, according to principles of representivity and rewards etc affirmative action ✧ Universities asked to help in revising structures of management of district and regional hospitals iii) Financial arrangements - ✧ Extending links with private specialists on a sessional public/private interface basis 2. Structural a) New hospitals and Upgrading existing hospitals b) Equipment
Information supplied by: Dr A Verburgh (Director, Information and Research)
Hospital Restructuring 69 Provincial Profile: Northern Cape
1. Functional Restructuring a) Staff and Services ✧ beds and resources allocated with equity and (planning: norms/ role affordability in mind - resulted in authorised beds definition / population / at less than current occupancy levels (i.e. real checks & balances / cut in service). Staff allocations done according to Regional hospital crisis) authorised beds and have been absorbed according to the revised, rationalised establishments. i) Medical Staff ii) Nurses iii) Allied Professionals b) Referral Chain & Systems ✧ being implemented with regional managers ✧ Kimberley only referral hospital on eastern border, very limited secondary care at Upington hospital ✧ some towns nearer W Cape referral centres than those within province ✧ no tertiary facilities, with cost implication for inter- provincial referrals and national vagueness on budget allocations and cost recovery process i) specific incentives / ✧ district hospital development inhibited by: mechanisms to develop ✧ lack of economies of scale regional / rural hospitals - ✧ no policy decision on subsidised Provincial progress Aided Hospitals ✧ Apartheid physical structures ✧ recruitment of qualified staff to platteland problematic ii) access guarantee ✧ secondary level: elective patients only referred intra- mechanisms provincially, after being assessed by a ‘flying specialist team’. Referral to another province must have regional manager approval. Emergencies to nearest secondary centre. ✧ tertiary referral: referred only via Upington and Kimberley to Bloemfontein but some cases to Cape Peninsula. c) Management and Administration i) Data systems - financial, clinical/societal interest, cost centre budgeting & accounting ii) Achieving Efficiency - ✧ combination of revised approved bed number, staff authority, autonomy, establishment and prevention of ‘upward’ dumping of decentralisation, patients results in a higher turnover of patients (and rewards etc greater cost efficiency). ✧ rather than decentralising, the N Cape is centralising or rationalising management processes because of ‘economies of scale’. iii) Financial arrangements - public/private interface 2. Structural a) New hospitals and ✧ IDT funded facilities audit performed at all provincial Upgrading existing hospitals. Architect visits also. Plans being developed hospitals to eradicate apartheid structures and in line with authorised beds. Currently costing and prioritising being done - will be scheduled depending on fund availability for capital projects. b) Equipment
Information supplied by: Dr P Erasmus (Director: Regional Development)
70 Provincial Profile: Northern Province
1. Functional a) Staff and Services ✧ review of staff establishment has begun (planning: norms/ role definition / population / checks & balances / Regional hospital crisis) i) Medical Staff ii) Nurses iii) Allied Professionals b) Referral Chain & Systems ✧ 6 regional hospitals and two tertiary hospitals (Pietersburg / Mankweng in a “complex” ) have been designated. ✧ Contract with MEDUNSA to establish satellite at this tertiary site, with some departments already sending registrars and students. Some secondary and community hospitals are also used as teaching sites. ✧ specialist clinics now functioning in the province with very significant decrease in referrals to Gauteng (70% in Orthopaedics) ✧ limiting factors - availability of doctors and accommodation at certain centres - both being addressed ✧ progress good but will take time i) specific incentives / ✧ decided to concentrate on district development (25 mechanisms to develop districts) prior to hospitals, under district management regional / rural hospitals ✧ 6 regions with 6 regional hospitals, and the provincial - progress hospital complex with 3 special hospitals ii) access guarantee mechanisms c) Management and Administration i) Data systems - financial, ✧ computerised HIS being installed presently clinical/societal interest, ✧ district and hospital budgets constructed as cost cost centre budgeting centres, designed for local insight and control & accounting ii) Achieving Efficiency - ✧ quality assurance programme implemented authority, autonomy, ✧ regular courses for administrators - on personnel decentralisation, assessment, budgeting, expenditure control rewards etc ✧ personnel and financial delegations to management levels being prepared iii) Financial arrangements - public/private interface 2. Structural a) New hospitals and ✧ capital works programme in 2nd year - all hospitals Upgrading existing looking neater and have basic facilities hospitals ✧ facilities audit completed ✧ 95/6 R170 million work - basic eg. roads, electricity, water, gas, sewerage ✧ 96/7 R 190 million upgrading currently underway ✧ 97/8 R 190 million again - R 650 million work identified with specifications ✧ four new hospitals under construction and four more replacements of existing hospitals b) Equipment ✧ purchased /ordered in order to provide greater technology capacity higher in the referral hierarchy
Information supplied by: Dr N Crisp, (Superintendent - General)
Hospital Restructuring 71 Provincial Profile: North West
1. Functional Restructuring a) Staff and Services ✧ A ‘Hospital Establishment Review’ was performed for (planning: norms/ role all staff, guided by Dr Rodion Krause, a private definition / population / Consultant. This was done for all hospitals between checks & balances / May 96 and January 97, resulting in NW Provincial Regional hospital crisis) Service Commission approval. The process resulted in equitable staffing establishments relative to case/workload, by facility. It included the development of increased capacity to upgrade Bopolong and Rustenberg hospitals to enable these hospitals to play a full regional referral hospital role (eg. Rustenberg would increase from 200 to 500 beds); as well as consolidating Klerksdorp hospital at Regional ‘plus’ level i.e. mostly Level II and some Level III services i.e. as the “kingpin” hospital in the province. The intention is that no patient would then be referred to a hospital service in another province, except from these three hospitals. ✧ However, a freeze has subsequently been placed on all appointments owing to the overall (not health specific) provincial overspend, resulting in serious delays to the process. The result of the above (amongst other) difficulties, is that there remain huge gaps in the actual filled versus newly approved staff establishments. i) Medical Staff ✧ Those specialists that are employed by the province, are mostly on a part time basis. There has been a small increase (about 3 full time specialists) because of the policy of offering posts at a Principle Specialist rank at Bopolong, Rustenberg and Klerksdorp. The freeze on appointments has prevented this strategy from being further pursued. ii) Nurses ✧ Professional nurses are one of the categories of staff most affected by the ‘Hospital Establishment Review’. The intention is to move them from clinics, where they are currently inappropriately deployed, to CHC level. iii) Allied Professionals ✧ These staff are generally in low supply. There has been little development at the level of the clinical assistant; village or community health worker. iv) Support staff ✧ General assistants numbers are oversupplied by a significant number in the wrong places. b) Referral Chain & Systems ✧ See comments above re 3 referral hospitals. ✧ Uncertainties regarding funding and financial arrangements between provinces has retarded the development of formal and properly structured interprovincial referral. New proposals for the re- introduction of a “top-slice” may help resolve this situation. i) specific incentives / ✧ The establishment of Principal Specialist posts at mechanisms to develop Regional hospitals. regional / rural hospitals - ✧ Other incentive developments are non existent. A progress perception exists that their development is being inhibited at a national level. For example, the national DoH agreements at the Central Bargaining Chamber regarding overtime payments for doctors and nurses was not strategic - prescriptive and rigid and rather than being perceived as an incentive, had the effect of engendering staff resentment. ✧ The existing rural incentive fund is also very inflexible and too small to be really useful.
72 ✧ The requirement is for a flexible package - offering (as needed) housing, motor vehicles, children’s education funding, additional leave and, ultimately, financial reward. ii) access guarantee ✧ cannot refer to other provinces except via a small mechanisms number of hospitals - regional hospitals and from Odi region c) Management and Administration i) Data systems - financial, ✧ less than adequate at this time clinical / societal interest, cost centre budgeting & accounting ii) Achieving Efficiency - ✧ nil decentralisation process in place authority, autonomy, ✧ Continuous quality assurance programme - Council decentralisation, on Hospital Accreditation of SA (COHSASA) rewards etc The process involves assessing clinical techniques and protocols eg. for the giving of an anaesthetic, infection control; as well as control of pharma- ceuticals and supplies. The work is technical and developed in a participative manner - working with local clinicians, support staff and managers. ✧ The process has been successful at morale boosting amongst medical and nursing staff - and has resulted in basic improvements in theatre protocols, infection control. It probably needs to run for 2 -3 years more, until a stage is reached where OPD protocols and similar detailed work can also be examined. iii) Financial arrangements - ✧ Sessional doctors are critical to the service. public/private interface ✧ At Victoria hospital, a curative hospital in Mafikeng - the province has negotiated with Lifecare for delivering certain acute services; and a possible second such arrangement is being considered in Mabopane. ✧ Extensive usage is made of private sector services in Klerksdorp and Rustenberg. However, the services available are limited and do not replace the need to refer to Gauteng academic hospitals. 2. Structural a) New hospitals and ✧ Concentration has been on renovating the referral Upgrading existing hospitals, and not on building any new hospitals. hospitals b) Equipment ✧ There has been significant spending on equipment, but not within a structured framework. Much has been paid for by RDP funding. ✧ This has not included large capital equipment such as CT scans - this type of service is more cost effectively purchased by private sector contract.
Information supplied by: Mr D Robb, (Former Chief Director, health) Dr H Gosnell, (Chief Director, health)
Hospital Restructuring 73 Provincial Profile: Free State
1. Functional Restructuring a) Staff and Services ✧ Renewal of Staff establishments: Team established (planning: norms / role August 96. Using computer modelling, have definition / population / established base staff establishment of hospitals, checks & balances / which are then actively discussed with hospitals as to Regional hospital crisis) their sufficiency, or to cater for the special needs of the hospital. This has been completed for Regional and District hospitals, as well as for inappropriate Levels I and II at academic hospitals. ✧ The remainder of academic hospitals will be done next. Problems encountered include: ✧ determining actual beds needed at Level III ✧ motivating the Faculty to be involved in the process ✧ instability created by the process ✧ Process has been far quicker than traditional management advisory services approach, and has been very rewarding for the Department. Difficulties are obviously encountered where reductions in staff are required. i) Medical Staff ii) Nurses iii) Allied Professionals b) Referral Chain & Systems i) specific incentives/ ✧ Separation of secondary and tertiary services (under mechanisms to develop Provincial Health Authority) from District Health System, regional / rural hospitals - including District hospitals (under District Health progress Authority). District development phase now operating. A separate research project for the referral system is underway to maximise benefit for both Provincial and District systems. ii) access guarantee ✧ formal referral criteria/arrangements at each level. mechanisms ✧ Level II / referral hospital per each of 3 regions - Eastern, Northern and South Western Free State. ✧ Services at Universitas referral for 3 regional hospitals above, as well as for the Kimberley complex (Northern Cape Province) and Lesotho. c) Management and Administration i) Data systems - financial, ✧ Early stages of planning for cost centres, to which the clinical/societal interest, Department is committed. Very complex. Also has cost centre budgeting completed an evaluation of a Tender for & accounting implementation of a Patient Master Index, Admissions, Billing and Laboratory systems for Universitas, Pelonomi and National hospitals. Implementation in August 97, completed in 9 months. Will roll out Health Information Systems in all hospitals over 3 years. ii) Achieving Efficiency - ✧ COHSASA accreditation programme being authority, autonomy, implemented in 3 pilot sites (Hoopstad, Virginia and decentralisation, Boitumelo hospitals). Started May 97, intention to rewards etc roll out to other hospitals. ✧ District hospitals < 60 beds managed by District Office ✧ Significant decision making powers will be delegated to District Offices and Hospitals, regarding staffing, personnel management, procurement and financial management. iii) Financial arrangements - ✧ Lifecare psychiatry and TB now decreasing public/private interface ✧ exploration only - /hiring out unused wards/buildings to the private sector
74 2. Structural a) New hospitals and ✧ Upgrading of Bethlehem and Boitumelo hospitals to Upgrading existing 400 bed hospitals, and Jagersfontein to 60 beds, hospitals being planned, ✧ Functional upgrading of Pelonomi, Zastron, Heilbron, Bothaville, Harrismith, Smithfield, Elizabeth Ross, Monapo, Thaba Nchu hospitals ✧ Creation of a new OPD for Universitas under way b) Equipment
Information supplied by: Dr Ron Chapman (Director, Information and Research)
Provincial Profile: Western Cape
1. Functional Restructuring a) Staff and Services (planning: norms/ role definition / population / checks & balances / Regional hospital crisis) i) Rationalising Academic ✧ JIMS (Joint Implementation Management Scheme) is hospitals a process of considering the merits of the duplicated specialist services between the academic hospitals and proposing rationalising of these. A full time team is in place to support this process, who have collecting huge amounts of data, service by service, which will now be used to make decisions. The recommendations of the Kings Fund consultants will accelerate the process. ✧ Kings Fund report - March 97 - recommended - 3 critical steps: 1. enhance Management capacity of academic hospitals, under a CEO, as single entity - with substantial decentralisation, empowered leadership. Includes separation of hospital functions from that of the Medical Schools, with finite budgets. 2. Retain two (2) undergraduate medical schools - UCT and Stellenbosch; but 3. create a single, common post graduate school, built on the best aspects of both schools ✧ many workshops held, at very high level - included the MEC, and Vice-Chancellors of Universities. There is largely agreement - Cabinet approval expected soon. ✧ will require new agreements with 3 schools (including University of Western Cape) re access to teaching ✧ Financial Crisis/MTEF proposals ✧ Measures: recently closed 500 beds between GSH/Tygerberg - secondary and tertiary beds - across all the main disciplines ✧ lost 2 750 staff through voluntary severance packages (VSPs) from academic hospitals ✧ MTEF 98/99 to 2000/1 proposes major shift from Programme 4 (academic hospitals) to Programmes 3 (Provincial hospitals) and Programme 2 (District Services). These are budget shifts, which cannot yet be fully implemented because of the national moratorium on retrenchment % of budget: 94/5 97/8 ✧ Prog 4: 66% 38%
Hospital Restructuring 75 ✧ 1997/8 - Prog 2: increase by R150 million ✧ 1997/8 - Prog 3: increase by R 80 million (Some invested in newly commissioned regional hospitals eg. Karl Bremer, GF Jooste) ✧ Some modelling performed to analyse the effects of this budget shift on staff, based mostly on the Birmingham hospital model - this shows mostly would affect a significant reduction on medical staff and on general support staff; and not nurses (their is a major shortage of qualified ICU staff etc) nor administrative staff. (This depends on the VSP requests; which mostly have been taken by senior nurses and admin staff!) The model has not yet been widely discussed. ✧ The effect would be to open up posts in Programmes 2 and 3, and freeze those in Programme 4, diminishing these as quickly as possible until a projected deficit of between R363 million (97/8) is addressed. ✧ Current Measures: ✧ effective moratorium on all posts on & off for 3 years, with few exceptions ✧ also on computer and equipment purchases ✧ greater centralisation has been the results i.e. loss of delegations from Health department to other Provincial departments ✧ in the past few months, all proposed new appointments in the whole Province go to the DG for approval, most of which are being refused. ii) Medical Staff ✧ salary increases have resulted in 30 - 40 doctors joining primary (CHC/district hosp) and secondary hospitals - from private sector and outside ✧ There has been some shift of medical staff from academic to regional - posts, rather than people and some other resources. ✧ There has been a process of shifting whole units away from academic hospitals: ✧ eg.1: Red Cross casualty is now closed to off the street referrals (was 75% of work) and the medical staff were transferred to Primary care units. ✧ eg.2: the medical casualty from Groote Schuur Hospital has been transferred to GF Jooste hospital iii) Nurses ✧ college intake decreased by 50% because of lack of funds iv) Allied Professionals ✧ losing Physios and others b) Referral Chain & Systems i) Specific incentives / ✧ Held a metropole regional workshop in November mechanisms to develop 1996, at which the role of regional hospitals was regional / district defined, which allowed clear operational objectives hospitals - progress: and strategies to be developed ✧ Plans for a 7th new regional hospital in the metropole, built from scratch ✧ Plan to deploy significant number of registrars to regional hospitals within the metropole level, limiting factor is presence of full time specialists. Will change character of regional hospitals and referral patterns ✧ Prof David Power is undertaking a review of 8 regional hospitals in metro - clinical role, referral, support and teaching potential v provincial plan and HSP
76 suggestions, towards successful transfer of services and staff. Includes detail of shifts eg. if one can’t have full radiology in every regional hospital, alternatives are movable regional radiology centres or a couple of centre of excellence. In addition, the links between interdependent services and specialists eg. internal medicine & radiology (like a “Rubiks cube”!). ✧ rationalising orthopaedic satellite units eg. Lady Michealis Hospital closed ✧ Internal reorganisation of Mowbray maternity, which was in Programme 4, is now attached to Programme 3 services ✧ There is a process of rationalising Psychiatric services and hospitals - proposal to close an acute hospital (from 4 to 3) and to reduce size of all. Also to specify roles of the remaining 3 eg. forensics, medical handicap, regional referral, metro referral. ii) access guarantee ✧ zoning system just introduced, publicised, clear who mechanisms goes where - designated district hospital, regional, central - assumes support between hospitals within system ✧ Groote Schuur Hospital: 4 regional hospitals + own secondary region ✧ Tygerberg 3 regional hospitals + own secondary region ✧ at tertiary hospitals, walk in patients from outside zone are treated and referred to their own area, except emergencies. The effect of all of the above measures at academic hospitals are much smaller OPDs, closed wards, reduced radiology services etc - i.e. a vast diminishing of their load. eg. emergency medical 4500 cases /month at GSH, now 2 000. i.e. 2 500 to GF Jooste at 1/3 the unit cost. c) Management and Administration i) Data systems - financial, ✧ out to tender for HIS for academic hosp - upgrade of clinical, cost centre current system - Management and admin system, budgeting & accounting patient billing - can be extended to secondary and district hospitals (37 hospitals + 60 CHCs) ✧ MAP project at GSH - considering ‘roll out’ to other hospitals ✧ Head Office new directorate - Information Management : provides monthly data eg. hospital occupancy, staff expenditure - per institution, with exception reporting ✧ surveillance systems: process and use data regionally ii) Achieving Efficiency - ✧ delegations from Finance/PSC to Health department - authority, autonomy, danger will be re-centralised in current climate decentralisation, ✧ centralisation of IT/HR out of Health Dept to Province rewards etc ✧ Regional Directorates have lot of influence but not as much delegated authority ✧ They experience frustration re appointing staff Overall disappointed re level of decentralisation ✧ decentralisation/delegation to local government, possible district services will eventually move to this level iii) Financial arrangements ✧ current contracts with Lifecare, District Surgeons - public/private ✧ Considering addition contracting options for certain interface services ✧ Regarding possible joint private sector clinical services ventures, 3 options being discussed: ✧ UCT Proposal - attracting private patients into academic hospital, treated in currently closed beds, on a ‘not for profit’ basis. Many issues
Hospital Restructuring 77 including LPP type issues - in principle agreement but not yet on the mechanisms ✧ lease vacant wards/hospitals to private sector ✧ establish hospitals/services with attractive “hotel” type facilities but staff with own medical staff 2. Structural a) New hospitals and ✧ Moratorium on licensing new private facilities Upgrading existing ✧ re-commissioned and upgraded 2 hospitals (as hospitals above), also upgraded other regional hospitals eg. Ceres, George, Oudtshoorn and others - cost of about R 100 million ✧ planning a new regional hospital in the metropole b) Equipment ✧ moratorium on equipment
Information supplied by: Dr F Abdullah, (Chief Director- Health services) Mr Barnard, (Deputy Director Admin, Supra Regional services) Dr Loubscher, (Deputy Director Metro Region) Prof D Power, (Department of Paediatrics, Red Cross Hospital)
Provincial Profile: Gauteng
1. Functional Restructuring a) Staff and Services Structural Transformation Plan 9 (STP) tabled Oct 96 (planning: norms/ role ✧ closure of 3 hospitals nearing completion (2 small definition / population / district and one chronic), staff seconded, with checks & balances / patients, to functional sites. Regional hospital crisis) ✧ conversion of 6 others to Community Health Centres (CHCs), will occur around October 97. ✧ defined staff/workload ratios for each category of staff at each category of hospital / Level of Care (all hospitals categorised as to level/role). This has the effect of diminishing staff levels at central/academic hospitals (Programme 4), and vastly improving staff levels at regional hospitals (Programme 3), as well as making posts/staff available for District development (Programme 2). Formal transfers of (non-medical) staff will occur from October 97. ✧ PDEs (patient day equivalents) used i.e. activity based planing, but a Geographic Information System is being developed to allow population to become a factor considered i) Medical Staff ✧ a small amount of “outreach” from academic to regional hospitals, mostly registrars, is in place. ✧ the vast majority of medical staff, especially specialists, are concentrated in central academic hospitals. Because of the complexity of the services which they support, a process of “Clinical Fora” is underway, utilising large amounts of GHD resources. Medical organograms, service rationalisation and service and staff shifts, and, eventually, clinical guidelines, will be produced. Target - Feb 98. ✧ an initial (additional) movement of FTE (full time equivalent) specialist and Registrar is being negotiated. ii) Nurses ✧ The STP process recognises that there is a substantial global deficit of nurses, in all but a handful of hospitals. There will be gains for most hospitals, largely from the closures and conversions, and not at the current level of funding, from outside the system. If increased
78 funding becomes available, the STP will guide the employment of new staff. ✧ There is a particular lack of ICU and theatre nurses. ✧ Significant loss of skilled nurses to VSPs (Voluntary severance packages). iii) Allied Professionals ✧ In general, allied professionals are in short supply, and hardly exist at regional and district hospital level. Although the original intention of the STP was to substantially improve this situation, by transfers from central and new posts, the current funds will allow only a minor increase. iv) Admin Staff ✧ Significant loss of skilled administrators to VSPs. v) General Assistants ✧ there is a vast oversupply of this category of staff, who must be held and paid as supernumerary until retrenchment is permitted. This situation places limits on improving the situation of nursing and allied professionals. ✧ Few VSP requests at this level, but up to 20% may have potential for retraining as nurse assistants or clerks. b) Referral Chain & Systems i) specific incentives / ✧ as for STP mechanisms to develop ✧ Despite much planning, little real change yet at this regional / rural hospitals - level progress ii) access guarantee ✧ difficult to even discuss zoning until after STP i.e. better mechanisms resourced regional hospital/district services. ✧ clinical fora process will define clinical role by level of care and thus referral criteria c) Management and Administration i) Data systems - financial, ✧ large tender for new Health Information System in clinical/societal interest, place, includes ability to begin cost centre analysis cost centre budgeting & accounting ✧ spontaneous management-led cost centre projects at Baragwanath, Pretoria Academic and Ga Rankuwa (all central hospitals) ii) Achieving Efficiency - ✧ workshop held, proposed certain delegations, but authority, autonomy, many are not general Health Department decentralisation, competencies to delegate. Being rewards etc investigated. iii) Financial arrangements - ✧ detailed proposal on public/private interface, public/private interface evaluating 20 proposals from private sector - pilot projects being considered ✧ note the need for a national policy 2. Structural a) New hospitals and ✧ Facility implications of STP i.e. conversions of hospitals Upgrading existing to CHCs hospitals ✧ intention to sell 2 closed hospitals ✧ major clinic building programme ongoing b) Equipment ✧ equipment audit at closures, standard template of equipment per service and per level of care being prepared, with clinical fora.
Information supplied by: Brian Ruff (Special adviser, Hospital Restructuring)
Hospital Restructuring 79 Provincial Profile: KwaZulu-Natal
Criteria: Hospital Restructuring 1. Functional Changes a) Staff and Services ✧ Lack of funds make progress very difficult (planning: norms/ role ✧ No specific detailed plan has yet been implemented. definition / population / A number of initiatives are being undertaken to checks & balances / amalgamate certain hospitals. Regional hospital crisis)
i) Medical Staff ✧ Some medical posts have been moved from urban to rural areas. ii) Nurses ✧ No significant movement has taken place iii Allied Professionals ✧ No significant movement has taken place b) Referral Chain & Systems ✧ Regional systems are taking shape but still require a lot of restructuring i) specific incentives / ✧ Lack of incentives and bureaucratic mechanisms mechanisms to develop place a burden on progress in the shifts taking place. regional / rural hospitals - However significant progress with clinics have been progress made which has reduced the burden on some hospitals ii) access guarantee ✧ All hospitals are open to all persons mechanisms c) Management and ✧ Management posts are being filled at present. The Administration training of managers still requires a lot of attention i) Data systems - financial, ✧ The data systems in the province is 80% decentralised clinical/societal interest, and information is becoming more reliable. The cost centre budgeting & capacity to run these systems is however, lacking. accounting ✧ Cost centre budgetting has been introduced to include outpatients/inpatients/clinics. ✧ Lack of capacity will make it very difficult to introduce detailed cost centres. ii) Achieving Efficiency - ✧ Most of the powers in regards to staff and tenders authority, autonomy, have not been delegated to the Department hence decentralisation, no progress can be made in decentralisation. rewards etc iii Financial arrangements - (Nil) public/private interface 2. Structural a) New hospitals and ✧ Presently New Durban Academic Hospital is being Upgrading existing built. Plans to replace King Edward VIII and hospitals King George V. Major upgrading. Lack of funds hamper implementation of upgrading plans. b) Equipment ✧ Replacement of obsolete equipment has taken place at all hospitals.
Information supplied by: Mr H. Conradie, Chief Director, KwaZulu-Natal Department of Health
80 HEALTH CARE 8 FINANCING
INTRODUCTION Changes to the financing of health care services in South Africa in the public and private sectors are widespread. These appear to be occurring both within and outside an explicit policy framework developed by government. Within the public sector changes relate to: ➣ the introduction of the new Constitution defining a new set of inter-governmental relationships including changes to the budgetary system from 1997/8 fiscal year ➣ the establishment of the District Health System (DHS). Within the private sector, a rapid restructuring is occurring after the amendments to the Medical Schemes Act in 1989 and 1994. Risk selection, a phenomenon which occurs in commercial markets for medical schemes and health insurance, is now well established. Risk selection occurs when schemes select people who have a low risk of claiming, in an attempt to control costs and keep premiums affordable for low risk members. It both increases the average cost of schemes which do not behave in this way and ultimately shifts costs onto the public sector by excluding those most likely to seek health care.
BROAD FEATURES AND CONCERNS RELATING TO THE HEALTH SYSTEM AS A WHOLE The South African health system is characterised by strong public and private sectors with multiple sources of revenue. The purchase of private sector cover is income-related, with higher income groups choosing to make contributions to medical schemes (Table 1). According to the 1995 October Household Survey, around 18 percent of the total population have some form of private cover. At a broad structural level the South African health system lacks coherent linkages between the private and public sectors. It also exhibits a high degree of cross subsidisation whereby those who are more able to pay for health care (or less likely to fall ill) subsidise those less able to pay or more likely to fall ill.
Authors: A.M. van den Heever, Centre for Health Policy, University of the Witwatersrand Vishal Brijlal, Centre for Health Policy, University of the Witwatersrand 81 Medical Scheme Membership
TABLE 1 CATCHMENT POPULATIONS FOR BOTH THE PUBLIC AND PRIVATE SECTORS
Population Medical scheme membership
Income ranges 1995 % Covered % Not covered % % of total of total of total covered Not employed 32 825 430 79.0 4 394 856 58.4 28 430 573 83.6 13.4 R0 - R7 999 2 189 255 5.3 96 286 1.3 2 092 969 6.2 4.4 R8 000 - R12 499 713 143 1.7 127 324 1.7 585 818 1.7 17.6 R12 500 - R14 999 853 119 2.1 166 074 2.2 687 045 2.0 19.8 R15 000 - R59 999 4 336 051 10.4 2 222 332 29.5 2 113 718 6.2 51.3 R60 000 - R79 999 244 834 0.6 196 806 2.6 48 028 0.1 80.4 R80 000 - R99 999 131 673 0.3 110 013 1.5 21 660 0.1 83.6 R100 000 + 246 705 0.6 217 828 2.9 28 876 0.1 88.3 Total 41 540 209 100.0 7 531 520 100.0 34 008 689 100.0 18.1
Source: Based on an evaluation of the 1995 October Household Survey
If both the expenditure of the public sector and medical schemes (not including out-of- pocket payments and health insurance) are taken together, people who are members of medical schemes contribute 19.4 percent of remuneration on average to the health system whilst people who are not members contribute 5.8 percent (See table 2). Medical scheme members effectively contribute twice for their health care. Once through taxation, which goes to pay for public health services, and once through medical scheme contributions. However, this is moderated by two factors: firstly a tax subsidy is allowed for employer contributions and is currently of the order of R4 to R5 billion,1 and secondly the public sector is not fully funded for the entire population.
TABLE 2 ESTIMATED EXPENDITURE ON THE SOUTH AFRICAN HEALTH SYSTEM IN 1995, INCLUDING BOTH THE PUBLIC AND PRIVATE SECTORS, BY INCOME (R’000) (1995 PRICES)
Income ranges Total % of Covered % of Not covered % of Expenditure Remuneration (R000’s) Remuneration (R000’s) Remuneration (R000’s) Not employed 0 0.0 0 0.0 0 0.0 R0 - R7 999 752 908 6.1 101 394 18.5 651 514 5.5 R8 000 - R12 444 533 785 7.9 232 343 18.5 301 442 5.5 R12 500 - R14 999 923 792 8.1 417 187 18.5 506 604 5.5 R15 000 - R59 999 18 138 067 13.5 14 973 652 19.0 3 164 416 5.7 R60 000 - R79 999 3 037 539 17.1 2 809 463 19.6 228 076 6.6 R80 000 - R99 999 2 029 103 17.6 1 900 904 19.8 128 199 6.8 R100 000 + 6 854 915 18.7 6 558 098 20.2 296 817 7.1 Total 32 270 108 14.0 26 993 042 19.4 5 277 067 5.8
Over the past 10 years costs within the private sector have grown substantially, at around 9.6 percent per annum on a real per capita basis (Figure 1). Consequently, access to the private sector has been limited to those earning a fairly high income. These cost increases have weakened the cross-subsidy system inherent in the medical schemes. By excluding those at greatest risk, who would normally be subsidised by other members, medical schemes and health insurers are able to keep the contributions required from lower risk members at a reasonable level.2 Higher risk individuals are therefore increasingly dependent on public sector services. The net result is increased pressure on public sector services without a corresponding increase in resources. At the primary care level, the creation of a free primary health care service for all makes it difficult to prevent cost-shifting from the private sector, especially for chronic care medication.
82 FIGURE 1 REAL INCREASE IN PER CAPITA EXPENDITURE BY MEDICAL SCHEMES FROM 1983 TO 1993 (1995 PRICES)
2500 Real increase = 9.6% pa (compound) 2000
1500 Real per capita increase 1000
500 Change if at CPI
0 1982 83 84 85 86 87 88 89 90 91 92 93
Source: Annual Report of the Registrar of Medical Schemes deflated using the Consumer Price Index
It is likely that over the next few years, a pool of uninsurables will grow, consisting of people who previously had some form of private cover. This group will be considerably less healthy than the average population and extremely costly to cover. Consequently, future government strategies should consider how to protect cover for this group within the private sector, as well as to provide some mechanism by which lower income groups can insure for their use of public sector hospital facilities.
FIGURE 2 PUBLIC SECTOR / PRIVATE SECTOR ACCESS
Public sector Private sector
Income earners with Access on Access on no access to affordable basis of basis of health care in either low-risk means test private and public sector of claiming
THE PUBLIC SECTOR Central issues At a broad level of discussion the following financial issues are important: ➣ Equity, (both inter- and intra-provincial) within the context of the new provincial budgeting system and the evolution of medium-term budgeting ➣ The definition of and funding of supra-regional and teaching functions ➣ The norms and standards of service for both hospital and primary health care services ➣ The development of a functioning district health system ➣ The development of an effective public/private interface in respect of services and financing.
Changes to the budgeting system for the 1997/98 fiscal year and beyond The 1997/98 national budget allocates a global amount to each province, which then has the responsibility to develop its own budget. This is the first year in which allocations have been made on this basis. The Budget Council co-ordinates this process and is made up of the nine MECs of Finance, the Minister and Deputy Minister of Finance, and officials from the Departments of Finance and State Expenditure, and the Provincial Treasuries. The Financial and Fiscal Commission (FFC) attends as an observer. The Budget Council recommends to Cabinet the shares that each province should receive after taking into account the national priorities and proposals of the provinces.
Health Care Financing 83 EVALUATION OF THE 1997/98 HEALTH BUDGET Provincial budgets General issues The derived total budget allocation to provincial health departments comes to R18.9 billion for 1997/98, which is equivalent to a 4.25 percent real increase in the budget. However, this increase includes: ➣ the inclusion within the provincial budgets of amounts formerly allocated as transfers from the national Department of Health ➣ the inclusion of bridging finance allocations which were formerly not part of the provincial budgets for Gauteng, Western Cape and Free State ➣ significant improvements in conditions of service approved by the national bargaining chamber ➣ provincial decisions to correct the allocations in relation to actual expenditure where this had become distorted, i.e. Gauteng. As a consequence of the above, the increase is more apparent than real. Transparency has been substantially aided through the introduction of inter-provincial budget standardisation at the programme and sub-programme levels.
Equity The ability of the public health system to achieve its objective of a just, fair and equitable health system is potentially compromised by the introduction of the new provincial budgeting system. A clear and easy method for progress towards equity is not apparent through this new system. Given that the achievement of equity is regarded as a cornerstone of health policy both internationally and in South Africa, this represents a major concern. The 1997/98 budget allocations indicates that there have been improvements over the past three years. When the 1994/95 budget is compared to the 1997/98 budget (national and supra- regional functions excluded) substantial real improvements have occurred in the Eastern Cape, Mpumalanga, and Northern Province (see Table 3). Traditionally over-funded Provinces show negative or moderate real growth. Nevertheless, the current relative equity position in 1997/98 shows that enormous disparities still exist. Gauteng is around 65 percent above the national average in per capita spending, with Western Cape at around 51 percent. Mpumalanga and Northern province are the worst off provinces at 44 and 34 percent below average respectively. When the budgets for the two periods are related to population increases by province, all provinces appear to have become worse off in 1997 than they were in 1994. A real decline of 5.7 percent overall is indicated.
TABLE 3 ESTIMATED CHANGES IN PROVINCIAL HEALTH EXPENDITURE FROM 1994/95 TO 1997/98 (Excluding estimates of level 3 services and teaching and associated functions) (1997 Constant prices)
Provinces 94/95 97/98 % change per capita per capita % change % over/ (97 prices) (97 prices) 94/95 1994/95a 1997/98a 94/95 to under (‘000 Rands) (‘000 Rands) to 97/98 97/98 (1997/98) Western Cape 2 157 140 1 960 777 -9.1 749 707 -5.6 50.9 Eastern Cape 2 253 130 2 764 803 22.7 466 444 -4.8 -5.2 Northern Cape 239 551 318 910 33.1 544 543 -0.2 16.0 Free State 1 144 086 1 202 736 5.1 536 510 -4.7 9.0 KwaZulu-Natal 3 164 280 3 301 220 4.3 442 418 -5.3 -10.7 Mpumalanga 630 773 790 801 25.4 281 263 -6.4 -43.7 Gauteng 3 281 982 3 419 531 4.2 830 773 -6.8 65.2 North West 1 038 839 1 135 600 9.3 446 417 -6.4 -10.8 Northern Province 1 355 452 1 660 084 22.5 331 309 -6.8 -34.0 South Africa 15 265 232 16 554 462 8.5 496 468 -5.7 0.0 a Population estimates are based on the 1995 October Household Survey, Central Statistical Services. The populations were adjusted for those covered by some form of private medical scheme. The 1994 and 1997 populations were generated using the provincial population growth rates provided by the Centre for Development Enterprises.
84 Supra-regional and national functions provided within provinces Supra-regional services serve catchment populations beyond the boundaries of the province in which they are situated. Other national functions are teaching and research. The budget does not provide any exact information on these. Total expenditure is estimated at roughly R2.4 billion, 12.5 percent of the total provincial budget, (Table 4) with R758 million associated with teaching and R1.6 billion with level 3 and unique services. These services represent a substantial percentage of the total provincial health budget. Unless they are in some way accounted for in the provincial allocations, provinces providing these services will be unfairly treated in terms of provincial bloc grants, and may unilaterally decide to reduce expenditure on these services.
TABLE 4 ESTIMATED EXPENDITURE ON NATIONAL AND SUPRA-REGIONAL FUNCTIONS BASED ON THE 1997/98 BUDGET
Provinces Level 3 (000’s Rands) A Teaching (000’s Rands) B Total (000’s Rands) Western Cape 334 123 178 764 512 887 Eastern Cape 41 813 35 185 76 998 Northern Cape 0 4 713 4 713 Free State 121 460 84 575 206 036 KwaZulu-Natal 189 104 120 123 309 226 Mpumalanga 0 0 0 Gauteng 913 210 288 318 1 201 528 North West 0 22 500 22 500 Northern Province 544 24 268 24 812 South Africa 1 600 254 758 446 2 358 700
The national Department of Health recently proposed that this problem be resolved through making all academic hospitals national functions.3 A simpler and more acceptable alternative may be to agree upon valid interim estimation methods of the amounts involved, and to allocate them to provinces as a top-slice, on condition of the appropriate funding of the relevant institutions. This is broadly similar to the FFC recommendation for the 1997/98 fiscal year.4 In the medium to long term the budgeting and financial management system can be adapted to identify these factors more explicitly.
Structural changes in the budgets Redirecting public sector resources towards high priority areas is an important concern in the current policy framework of government. However, it is at present difficult to ascertain whether the required shifts in budget are following policy. In previous years a lack of budget standardisation between provinces and a lack of actual expenditure information hindered any such exercise. The new budget structure permits some assessment of these trends for the 1996/97 and 1997/98 budgets, with some reservations.C Unfortunately, expenditure data are still not routinely available on a national basis. Table 5 shows that there appears to be a reprioritisation away from hospital services (-8.0%) and health sciences (-12.1%) in the budget, with a reprioritisation toward District Health Services expenditure (+10.7%). In 1997/98 the latter amounted to 42.2 percent of the total provincial budget, up from 39.7 percent in 1996/97.C
A This is estimated using the level of care cost per bed and utilisation norm used by the Hospital Strategy Project. The resulting ratios were extrapolated onto the total hospital services budget for 1997/198, including all district hospitals. The resulting total for level 3 services was allocated to those provinces with academic hospitals equivalent to their percentage of total academic hospital expenditure.
B Total “teaching” is based on an evaluation of the total teaching, training, and research costs of Gauteng. All defined expenditures on “health sciences” are allocated to provinces according to their budgets. The remainder is based on the Gauteng costs. These latter were divided by the number of enrolled medical students, including interns. This is then multiplied by the number of equivalent medical students in each relevant province.
C In some cases shifts in spending between programmes reflect the reclassification of facilities rather than a reprioritisation of expendi- ture. A problem also exists with allocations to the programme health facilities where some provinces do not have a separate pro- gramme for this allocation. Consequently, the budgets are not strictly comparable between years and provinces as yet. An example of this is in the fact that in some provinces, district hospital budgets in 96/97 were classified as hospital services yet in the 97/98 budget were classified as district health services.
Health Care Financing 85 Academic hospital services show a surprising increase of 10 percent which amounts to 20.7 percent of total. However, much of this is likely to be due to the correction in the Gauteng budget mentioned above.
TABLE 5 STRUCTURAL CHANGE IN THE TOTAL PROVINCIAL HEALTH BUDGET BETWEEN 1996/97 AND 1997/ 98 (1997 PRICES)
TOTAL (1997 prices) % of total per capita expenditure (1997 prices)
Programme 1996/97 1997/98 % 1996/97 1997/98 1996/97 1997/98 % (‘000 Rands) (‘000 Rands) change change Administration 739 286 761 238 3.0 4.1 4.0 21 22 0.9 District Health 7 204 040 7 973 888 10.7 39.7 42.2 208 226 8.5 Hospital Services 5 176 747 4 764 760 -8.0 28.5 25.2 149 135 -9.8 Academic Hospital 3 561 741 3 922 226 10.1 19.6 20.7 103 111 8.0 Health Sciences 353 358 310 697 -12.1 21.0 1.6 10 9 -13.8 Health care support 397 236 424 799 7.0 2.2 2.3 11 12 4.8 Health facilities 709 336 755 554 6.6 3.9 4.0 20 21 4.4 Total 18 141 743 18 913 162 4.3 100.0 100.0 523 535 2.2
District financing The development of a clear, coherent and transparent approach for funding health districts is a process currently co-ordinated by the national Department of Health. However, many problems remain unresolved. Some of these are: ➣ There is no effective authority at the district level that can accept accountability for a budget financing all primary health care services (PHC). ➣ In the past, budget allocations and the tracking of actual expenditure have not taken place on a geographical basis. Consequently, neither the financial management system, nor the budgeting process identify appropriate cost centres for achieving such allocations. ➣ Local government health subsidies, budgets, and actual expenditure are not centrally available, and nor are any national standard minimum reporting criteria set. This makes the task of generating routine consolidated district expenditure difficult and complex. ➣ No minimum norms and standards of primary health care provision, linked to the budgeting process, have been defined. Consequently, it is not possible to set a uniform national standard of service to which all provinces and local authorities must comply, irrespective of the revenue source. ➣ At the district level no mechanism exists for dealing with cross-boundary flows. Once district budgets are allocated only for the populations within their demarcated boundaries, this could create difficulties for the recipients of these flows.
Medium-term expenditure framework Unlike incremental budgeting, which essentially focuses on changes to the previous year’s budget, multi-year budgets are more interested in evaluating allocations relative to a base-line allocation, which is an extrapolation of revenue and spending trends assuming no change in budget policy. South Africa is currently in the process of introducing a medium-term expenditure framework (MTEF) into its budgeting system. The precise nature of this process within a fiscal federal system is currently unclear. However, the Department of Finance has placed a major emphasis on identifying “cost-drivers” within the current budget process, suggesting that financial control rather than improving planning processes may be the primary objective. It is also not clear how this process relates to inter-provincial equity in the allocations of public health services, to norms and standards of service, and to health policy priorities.
86 Norms and standards and the basic package Mechanisms and tools for implementing national policy are provided for in the final constitution. They provide for areas that cannot be regulated effectively through legislation enacted by individual provinces, or where “uniformity across the nation” is required through the establishment of “norms and standards, frameworks or national policies.”5 In essence norms and standards relate to the package of services to be made available by the state in one form or another. These services essentially create the basis for measuring equity, assessing service priorities, access and entitlements. They also establish the official distinction between what can be regarded as essential and discretionary health services. Currently there is little consistency of approach emanating from the Department of Health, or the provinces, as to how norms and standards are to be developed and used, despite a fair amount of research having occurred in this area and concerns raised in parliament.6-11
Public/private interface This area of policy is evolving slowly. The public/private interface can take various forms, (see Chapter 4) such as: ➣ private sector providers operating out of spare facilities in the public sector ➣ medical schemes contracting with public providers at special fee-for-service rates ➣ provincial administrations contracting with private providers for the delivery of specific services to public sector patients ➣ contracts for sessional work ➣ conversion of arrangements with provincial-aided hospitals into formal contracts. Irrespective of the nature of the interaction, a requirement is placed on the province to manage contracts, and to negotiate arrangements in a competent manner. Development of the required management skills may take time in some provinces and most hospitals. Indications are that pressure is building up to offer low-cost medical scheme cover which uses state facilities as the preferred provider for hospital care. However, medical schemes are finding it difficult to negotiate appropriate arrangements with provincial governments. Where these arrangements have been successfully concluded, public hospitals frequently do not bill the relevant medical schemes.12 This appears to be an incentive problem, as neither the hospital, nor the health department presently retain the additional revenue raised.
Private Sector financing General issues on the private sector The combined effect of cost increases and competitive pressure is undermining the ability of the private sector to perform a useful social function. The policy response of government is to intervene in two areas. The first is in relation to the regulation of the private sector, while the second relates to the introduction of a public hospital insurance fund. Regulation is intended to prevent arbitrary cost-shifting onto the state, whilst a public hospital insurance fund aims to ensure that non-members of medical schemes pre-fund in some way for their expected utilisation of public hospitals.13
Regulation of medical schemes Proposed changes to medical schemes legislation aim to address increased cost shifting onto state services. The essence of the changes are as follows: ➣ Medical schemes may not exclude an individual on the basis of health risk. Contribution rates for the full package of benefits can be differentiated only on the basis of income and number of dependants. ➣ Medical schemes are obliged to continue providing health benefits to continuation members (i.e. pensioners, widows, and widowers).
Health Care Financing 87 ➣ All medical schemes will be required to provide a set of prescribed minimum benefits to be defined in terms of conditions/diagnoses and related treatments/procedures. These benefits will have to be covered in full, irrespective of whether the service is obtained from the public or private sector provider system. The benefits so covered will relate to essential medical conditions and procedures. The intention is to prevent schemes from applying arbitrary financial limits which result in ineffective coverage for those who need it. An important element of the reform process is also to ensure that the regulatory authority, the Office of the Registrar of Medical Schemes, is able to effectively oversee the relevant Act. Weaknesses in this particular authority have been noted on numerous occasions.14-16 The Department of Health is recommending that the Office become a statutory body, reporting to the Minister of Health and accountable to Parliament, which will be levy funded by medical schemes. By shifting the Office out of the public service it will be able to fund itself appropriately and attract the high level staff required to achieve its objectives.17
Social Health Insurance Any attempt to protect a community rated environment has to include mandatory medical scheme membership for people above a particular income group, or for companies above a minimum employment level. Without this, instability is generated through the voluntary nature of the market, making risk selection more widespread. It appears very likely that this mandatory environment will emerge through the requirement for non-members of medical schemes to join a public hospital insurance fund, rather than through regulation coming out of the Medical Schemes Act as was originally proposed.18 A social health insurance fund in the form of a public hospital insurance fund potentially fills the missing piece of the puzzle in the reform of the South African health system. The primary objectives for such a fund would be to: ➣ Prevent free-riding on the public hospital system ➣ Generate a mandatory contributory environment for all people earning a sufficient income to contribute toward their own health care ➣ Share the burden of the income cross-subsidy to the public health system more fairly ➣ Generate competitive pressures within the health funding and provider markets ➣ Strengthen the public sector provider system to ensure its long-term viability as a safety net for the country as a whole. However, taking such a route requires the following to be addressed: ➣ issues regarding administration of the fund ➣ revenue collection ➣ specific entitlements of contributors and dependants, i.e. benefits ➣ relationship of the fund to existing medical schemes ➣ methods of reimbursement ➣ ensuring that the budget is reduced correspondingly for any additional revenue raised ➣ ensuring compatibility with the provincial budgeting system ➣ ensuring an equitable allocation of the health budget for public hospitals is going to the indigent. The fact that public hospitals cannot cope at present suggests that much work needs to be done in the public sector before such a fund will succeed, no matter how appropriate the intervention.
Status of health financing reform From the above analysis it is not clear that government policy with regard to health financing is fully developed or objectives clearly prioritised. The achievement of inter-provincial equity appears to be slipping down the agenda despite constitutional means and a political obligation to achieve this fundamental goal. The inter-provincial allocations for 1997/98 reveal that substantial levels of
88 inequity in funding of health services remain. These discrepancies will clearly prove indefensible from a policy perspective if allowed to persist. Related to the issue of equity are norms and standards of service. These are important in defining the prioritised services to be provided in the public sector, any social health insurance fund entitlements, and prescribed minimum benefits to be contained in a medical scheme. The Department of Health has, as yet, established no identifiable process capable of taking this policy issue forward. The Department needs to develop an effective and simple method for protecting provinces with national and supra-regional services. Interventions with respect to revenue retention and hospital autonomy suggested by the Hospital Strategy Project have not been implemented as yet. Private sector policies appear to be moving forward. These involve regulating medical schemes and setting up a social health insurance fund. A positive feature of this is the increasing recognition of the critical linkages between the public and private funding and provider sectors.
Health Care Financing 89 90 HUMAN RESOURCE 9 DEVELOPMENT FOR HEALTH
INTRODUCTION This chapter provides an analysis and critical review of progress in policy development and programme implementation in human resource development (HRD) in the public health sector. The past year has been characterised by major debates and conflicts in policies affecting future HRD. There has also been uneven progress in the implementation of HRD policies at all levels. In the attempt to re-shape an urban-centred, hospital-based and doctor dominated human resource profile, activities have fallen into three linked areas: ➣ policy formulation ➣ consolidating provincial structures for HRD ➣ implementing policies through re-distribution and training initiatives. Policy initiatives have centred around control over health professionals, their training and on mechanisms to redistribute public sector health personnel. The development of national and provincial HRD structures has proceeded. Some provinces have established regional capacity. Strategies are being developed to retrain and re-distribute personnel, and training activities have been accelerated, albeit in an uncoordinated way, to broaden the skills base of health personnel at different levels. DEVELOPMENTS IN POLICY-MAKING The past year has seen the release of major documents by the Departments of Health and Education which impact on human resources in the health sector. The chapter on human resources in the White Paper for the Transformation of the Health System in South Africa,1 the draft National Human Resource Development Policy Document,2 and the Audit of Health Care Personnel for South Africa3 form the major documents of the Department of Health. The Report of the National Commission on Higher Education4 and the draft White Paper on Higher Education have been released by the Department of Education.5 The statutory councils, such as the Interim National Medical and Dental Council (INMDC)6 and Interim Nursing Council South Africa (INCSA)7 most notably, have contributed to Bills which will impact on policy and implementation of health personnel education programmes. At the time of writing the Nursing Amendment Act of 1997 had been passed by Parliament. Pressure to redress staffing inequities and reshape the health personnel pyramid has manifested itself in policy development in two main areas: ➣ the control over health professions and the nature of their education ➣ policies for retention and re-distribution. Authors: Robert Van Niekerk, Centre for Health Human Resources, University of the Western Cape David Sanders, Centre for Health Human Resources, University of the Western Cape 91 One of the main issues in health personnel education policy is where responsibility should reside - in the Department of Health or the Department of Education or the INMDC or a combination of these and other stakeholders. Additional debate relates to the issue of vocational training and whether it is the best means to both address the deficit in PHC knowledge and clinical skills of new medical graduates, and to effect a re-distribution of new medical graduates to undeserved areas. Improving conditions of service to prevent attrition of staff to the private sector, and the achievement of equity across employing authorities, through salary review and salary parity studies respectively, have also been major policy concerns.
Health Department Proposals The Department of Health’s policy document5 on human resources contains several recommendations regarding: ➣ the redistribution of personnel ➣ the composition of the PHC and referral teams at district level ➣ upgrading the skills of mid-level health workers ➣ appropriate systems of health management and education and training. The Department proposes the establishment of Human Resource Development Units at national and provincial levels to co-ordinate policy, planning, production and management of human resources. It is recommended that the proposed National Unit should convene a centralised Co-ordinating Education Committee (CEC) for all health care education and training programmes to address selection of trainees and professionals, curriculum review, continuing education and community based education. This policy document also recommends: ➣ a review of salaries of all public sector health personnel to achieve equity ➣ mechanisms to improve the efficiency and effectiveness of the service ➣ mechanisms to ensure a more compassionate and caring service through developing career guidelines as well as a Charter of Patient Rights ➣ the development of institutional capacity for human resource planning, budgeting, management and evaluation. This would include capacity to co-ordinate training and educational institutions, establish a human resource data-base and information system and set standards and norms for the selection and appointment of health professionals. The profile of human resources and skills/competencies required to render services for the new health system must also be clearly determined. The consolidation of these policies by the Department of Health represents a significant step forward in HRD policy. There are however, a number of concerns relating to these policies. The issue of the control and governance of health personnel education is still unresolved.
Control and Governance of Health Personnel Education The National Commission on Higher Education (NCHE)8 and the White Paper on Higher Education5 both recommend that there should be close co-operation between the Departments of Health and Education for the efficient and effective training of health professionals, and that an appropriate co-ordinating body be established between the two departments. The Department of Health’s proposal, that a Co-ordinating Education Committee (CEC) falls under its auspices appears to ignore the fact that statutory responsibility for education and training of health professionals, other than nurses enrolled in colleges and post-graduate clinical trainees, rests with the Department of Education. Also involved in the policy area is the INMDC,9 which argues that it should have statutory responsibility for determining not only the exit standards of medical and dental graduates, but also the curriculum content and teaching methods to be followed. In contrast, the NCHE has recommended a separation of the accrediting of exit standards (licensing of practitioners) from the
92 accrediting of academic programmes which in its view should be jointly determined by the education and health sectors.10 The South African Qualifications Authority has statutory responsibility for the determination of all standards in the education sector, including health sciences education and is therefore a key player in this debate. The draft policies of both the Health Department and the INMDC10 therefore potentially conflict with those of the Department of Education. Clearly this issue requires resolution.
Nursing Education The majority view amongst nurse educators is that nursing education, including the Nursing Colleges which presently fall under Provincial Health Departments, should be wholly relocated to the Department of Education. This view is endorsed by the Education Department in its White Paper.5 At issue is the perceived erosion of the education function, which is subordinated to the service imperatives of the Department of Health. The counter argument is that nursing education under the Health Department allows previously disadvantaged, mainly female, students the opportunity of a professional career which guarantees a salary whilst in training. It is also argued that the relocation of nursing into the education department will severely erode present capacity for the delivery of health services.
Vocational Training The INMDC’s proposal on vocational training for medical doctors has aroused strong debate.11 In terms of this proposal, two more years of post-graduate vocational training should be added to the six years basic training and internship year of doctors. This, it is argued, will help develop the knowledge, skills and behaviour patterns required by doctors to work in primary care settings. This is to be achieved by rotation through primary level practice settings. While generally accepting the underlying principle of the need for more relevant training for primary health care oriented clinical service in undeserved areas, medical students and junior doctors have opposed the extension in training, deeming it to be covertly enforced compulsory service. Their own proposal is that a public service component is necessary but should follow the existing seven years of training and should be voluntary and incentive driven if it is to be sustainable and effective.11 The Deans of the Medical Schools have supported the proposal for postgraduate vocational training, agreeing that medical doctors are clinically underprepared to work in primary care settings after completing their basic training. They support an additional two years of vocational training as being necessary, but propose that it be integrated with the six year basic training programme, resulting in an eight year medical training programme, with an alternative of five years of basic training and three years of vocational training. The Deans have proposed that implementation of this scheme be deferred for a year as logistics, infrastructure and academic support will not allow its implementation by 1998.12 An interim proposal for one year of community service for doctors completing their intern year in 1997 has recently been announced by the Minister of Health. This will commence in 1998 if the legislation is passed by Parliament.
Restructuring of Professional Councils and Boards The Medical, Dental and Supplementary Health Service Professions Amendment Bill proposes that the five interim Councils (Medical and Dental; Nursing; Pharmacy; Chiropractors, Homeopaths and Allied Health Professions; and Dental Technicians) and seventeen interim Professional Boards should fall under the jurisdiction of an overarching Health Professions Council13 The Council will perform an overall co-ordinating role with executive power in policy and budgeting. Because of controversy14 surrounding this Bill it has been withdrawn temporarily.
Human Resource Development for Health 93 IMPLEMENTATION: PROGRESS AND OBSTACLES ON MAJOR POLICY ISSUES There are a number of factors responsible for slow implementation of policy in the provinces. Structural factors include poor co-ordination between national and provincial level, delays in establishing provincial HRD structures and the ambiguity concerning which chief directorate at national level should have responsibility for the human resource concerns of the academic health centres.
Creation of HRD structures Ambiguity as to where responsibility for human resources in academic health centres lies is exacerbated by the existence of two structures, namely the HRD Directorate within the Chief Directorate: Health Resource Planning, and the Academic Hospitals Directorate in the Chief Directorate: Academic Health Centre and Hospital Development. The Portfolio Committee on Health commented in relation to this problem in its Report on the 1996/97 Health Budget Vote that “...there is clearly an overlap of functions here, and it is not certain how the various aspects of a human resource strategy would be divided between these two directorates, even if such a division were desirable”.15 The establishment of new HRD structures at provincial level has also been slow - and their activity limited. In Gauteng the organisational structure is still incomplete and capacity for policy development and HRD information are all still weak.16 In the Eastern Cape Province HRD organograms have not been fully developed.16 In KwaZulu-Natal it was reported that there was no HRD directorate by the end of 1996 because the Public Service Commission had not approved it, and in the Western Cape the HRD directorate remains significantly understaffed.16
Planning The process of planning at national level has begun with the production of the National Audit of Health Human Resources. The audit data, gathered from ReHMIS, RAMS, the Interim Councils and MASA describes a distribution of personnel which remains substantially the same as that reported in last year’s Review.
TABLE 1 TOTAL NUMBERS OF REGISTERED HEALTH PERSONNEL PER CATEGORY
Category Number All Nurses 190 000 Doctors 18 926 Supplementary Health Professionals 35 400 Pharmacists 11 500 Medical Specialists 5 541 Dentists 4 102
TABLE 2 NUMBER OF REGISTERED HEALTH PERSONNEL PER 10 000 POPULATION
Category Ratio Nurses 36.8 Doctors 4.4 Pharmacists 4.1 Dentists 1
The Audit also reports that there are 17 728 practising doctors of whom 10 067 are in the private sector and 7 665 in the public sector. It notes that “…it would appear that there are an adequate number of doctors and nurses in South Africa but that the major problem is maldistribution” and that “... unless drastic measures are introduced to correct the maldistribution with its urban bias, education and training more health personnel from these categories will not necessarily solve but may even further exacerbate the problem.”17
94 The situation in provinces remains depressingly similar to that a year ago. For example in the North West Province 97% of health personnel in Potchefstroom are employed in hospitals.18 In the Free State the main conclusions arrived at on the state of human resources was that “...the provision of public sector health personnel tends to be concentrated in provincial, and particularly in the academic and regional hospitals and “...that this was the main reason why the reallocation of the budget to PHC is so problematic.”19
Re-distribution Formal health personnel At a provincial level redistribution strategies include the shifting of posts and personnel. The implementation of these strategies has been uneven. The devolution of posts, has proceeded apace in some of the “new” provinces but encountered major obstacles and resistance in others. The Voluntary Severance Package Programme (VSPP) has resulted in some unplanned redistribution. Central government has sought to reduce the number of civil servants by 100 000 per year, but ad hoc implementation of the VSPP has significantly diminished existing capacity by facilitating the departure of some of the best equipped and experienced management and clinical personnel.20 Another contributing problem is the failure to develop financial incentive schemes (such as salary increases, rural allowances) and non-financial incentives (such as accommodation for health personnel and loans for refresher courses) which could encourage improved staffing in rural and underserved areas. As an interim strategy to redress the imbalances in access to rural and undeserved areas the Department of Health has recruited 300 Cuban doctors. They were all selected by the INMDC who assessed and approved their clinical and language skills. Generally the doctors have received a very positive reception. They fill a much needed gap in many rural areas which otherwise would have had no doctor.
Community Health Workers Many practitioners with experience of working at primary care level advocate the greater use of community-based health workers (CHW’s) to extend access to basic health care. Although significant numbers of CHW’s have been trained by health NGO’s and continue to operate, especially in undeserved communities, their use has not been promoted by new policies. The White Paper states “..further incorporation of community health workers into the public service should not occur at present”.5 However many government and non-government professionals continue to motivate their utilisation and expansion as a cadre.21
Production Strengthening the capacity of health personnel to implement and manage the proposed PHC-based system requires attention from both the health and education sectors. The knowledge and skills of personnel currently employed in both the public and private health sectors must be broadened and deepened. Those presently undergoing formal training in health science institutions must achieve appropriate and significant competencies in PHC. Research sponsored by the Health Systems Trust and undertaken by the University of the Western Cape has revealed that recently graduated nurses and doctors exhibit significant weaknesses in their knowledge of PHC and related skills.22
Formal training programmes A number of training institutions have recently introduced or significantly increased the component of community-based education at different points in the academic programme. These include notably the University of Pretoria Medical School which is developing significant capacity for student instruction in rural district settings, as well as the University of Durban Westville, where student placements at community and primary level obligatorily include teaching staff from the
Human Resource Development for Health 95 academic centre. The South African Community Partnerships in Health Personnel Education has attempted to create “models” of appropriate health personnel education.
Community Partnerships in Health Personnel Education: a Model for Transforming Health Personnel Education, Research and Service
Community Partnerships in Health Personnel Education (CP-HPE), initiated in South Africa during 1992, is a model for transforming health personnel education, research and service. The aim of CP-HPE is to develop socially accountable models for health personnel education, research and service through partnerships between communities, academic institutions and health service authorities. To date the CP-HPE projects have collectively established twelve academic/service PHC sites including numerous community development projects and seven PHC Clinics/ Community Health Centres (CHC) each treating on average 6 000 patients per month. Since 1996 the academic/service PHC sites have begun to make an impact upon health personnel education within participating academic institutions in terms of: ✧ student selection ✧ interdisciplinary education ✧ academic staff development ✧ curricular transformation. More than 200 students are selected from (and often by) participating communities to study health sciences within participating academic institutions. Many students are provided with bursaries and academic support programmes to enable them to complete their studies successfully. Some students are contracted to provide health services to their community during their term of study and for a stipulated period thereafter. The sites are being utilised as community-based learning sites for a wide range of disciplines. The sites are also making an impact upon staff development within participating academic institutions. Academics who previously hardly set foot beyond the confines of the tertiary institution are brought face to face with the needs of communities at the PHC level. Several universities with separate faculties for the different health sciences are creating single unified faculties in recognition of, and to give effect to, a greater component of interdisciplinary learning. Such re-structuring, together with initiatives such as the CP-HPE, will facilitate the establishment and operation of PHC teams.
In-service training Improved knowledge and skills development in PHC, especially for the district health system, essentially involves three areas: ➣ general orientation to PHC and its implementation ➣ programme-related training ➣ management training. Such in-service training (mainly in the form of short courses) is provided in part by provincial and local authority health departments and in part by academic institutions and NGO’s. Some are offered by National Units (eg STD and AIDS training,) or by Provincial Directorates in preparation for the introduction of specific programmes eg. the Choice on the Termination of Pregnancy Act. Others are provided by consortia of training institutions eg. the Transvaal School of Public Health and the Western Cape Committee on Public Health Education (COPHE). Training in management occurs in a number of programmes such as the University of Cape Town’s Oliver Tambo Fellowship Programme directed at senior managers, and the UWC-COPHE and the Natal CHESS (Centre for Health and Social Studies) initiatives directed at district level and programme (sub-district level) managers. The Minister of Health in agreement with the nine provincial education MEC’s has agreed to the establishment of a single National School of Public Health in addition to the three regional initiatives which will still continue to operate. The National School of Public Health is intended to be a “school without walls”, marshalling the financial capacity and human resources of the various
96 initiatives in public health training throughout the country. Discussions are under way with the Department of Education on the details of such a School.
Quality of Care The Department of Health has proposed a wide-ranging campaign to improve the quality of care and provide a more caring and compassionate service. Elements of the proposed campaign include a Charter of Community and Patient Rights, a campaign to engender a “culture of caring” throughout the health service, encouragement of competence in the major South African languages, and recognition for mentors who demonstrate and promote caring and compassion.
RECOMMENDATIONS Policies Early decisions are required concerning the location of statutory responsibility for health professionals’ education. Co-operative governance involving major stakeholders such as the Departments of Health and Education as well as the statutory professional councils appears to be the most inclusive and rational option and accords with international experience. The proposal by the draft White Paper in Higher Education for the future location of nursing education with the Education Department has important ramifications. The establishment of an inter-ministerial task group to address these is of great importance.
Strengthening Structures Rationalisation of structures for HRD at national level is required to overcome unnecessary duplication. Specific attention should be given to the overlap of functions between the two responsible chief directorates and their relationship to provincial level health structures and to the Education Department and tertiary educational institutions. At provincial level the capacity of HRD structures needs to be enhanced through strengthened relationships to draw on the institutional capacity resident in universities, technikons and non- governmental organisations.
Implementation Redistribution The uncontrolled application of the Voluntary Severance Package which is resulting in skills loss and unplanned redistribution should be urgently reviewed. Financial and non-financial incentives to encourage redistribution of health personnel need to be urgently put in place.
Production Acceleration of the revision of funding arrangements and creation of new joint agreements between the Department of Health and tertiary training institutions needs to occur. Such joint agreements should encompass lower level facilities, including first-level hospitals, health centres and clinics, thus restructuring academic health centres. The mechanism of subsidisation by the Department of Education of tertiary training institutions needs to be reviewed regarding the funding of non-certificated short courses. Partnerships between the health services, health-related sectors, academic institutions and communities should be created and strengthened to develop models of primary health care practice which can serve as sites for student learning and staff and teacher capacity development.
Human Resource Development for Health 97 CONCLUSION The translation of South Africa’s innovative and widely consulted health policies into a de- centralised, integrated system providing accessible, comprehensive and caring services is proving difficult. In no other area of the health sector is the need for progress more urgent than in the field of human resources. Innovative approaches to re-distribution and education and training must be developed for appropriate capacity to be effectively located throughout the health sector. Such approaches will require the confronting of entrenched social interests and the forging of new alliances within government and also between government and other institutions and communities. A further imperative is the creation of practical models of a future health system which can serve as sites for learning. Without the capacity of its human resources to implement proposed programmes and manage decentralised systems, South Africa’s bold health policies will, as in many other countries, remain mere statements of intent.
98 DRUG 10 POLICY
INTRODUCTION The National Drug Policy (NDP) is the South African Government’s macro plan for the rational and economic use of drugs in the country.1 If carefully and appropriately implemented the NDP will assist in the improvement in the health status of the population of South Africa.
A glance at the 1996 Review The 1996 Review addressed the key issues of both the NDP and the South African Drug Action Programme (SADAP).2 This programme (SADAP) was envisaged to ensure the implementation of the NDP over the next four years through three phases: ➣ Phase one would comprise those aspects for which no regulatory or legislative alterations were necessary, such as the preparation of essential drugs lists. ➣ Phase two would involve the amendment of regulations issued in terms of current legislation (eg. proposed regulation R.1150 of 12 July 1996) ➣ Phase three would be the major changes to legislation such as to the Pharmacy Act and the Medicines and Related Substances Control Act. This chapter will focus on six key areas of the NDP and will assess the degree to which the policy has been implemented, and consider the success of the phased approach.
LEGISLATION AND REGULATION Policy directives The aim of ensuring that drugs reaching patients are safe, effective and meet approved standards and specifications entails amendment of two areas of legislation and their attendant regulations. The Medicines and Related Substances Control Act, No 101 of 1965 requires strengthening in order to aid the Medicines Control Council in its regulatory role. In addition, a number of Acts governing the dispensing of drugs by various service providers require consolidation (eg. Nursing Act).
Progress to date The proposed regulation R.1150 dealing with, amongst other things the labelling of medicines, licensing and the use of non-proprietary name-prescribing, was published for comment in the Government Gazette in July 1996. After inputs from many interested parties, this regulation was withdrawn for further technical attention. Inputs were also gathered by the Parliamentary Portfolio Committee on Health.3 Most of the inputs were
Authors: Andy Gray, Department of Pharmacy, University of Durban- Westville Peter Eagles, Department of Pharmacy, University of the Western Cape 99 subjective in nature and were concerned with issues around the proposed further training of health professionals (such as dispensing doctors) for licensing purposes. A sub-committee was convened by the portfolio committee and briefed with the task of investigating pertinent case studies dealing with dispensing and trading doctors, their interaction with the public and financial analysis. The study has to date not delivered a report and some key players have effectively withdrawn. The Medicines and Related Substances Amendment Bill was withdrawn following its First Reading in Parliament. In particular, Government’s intention to allow for the possible parallel importation of medicines has provoked vigorous response in the press from the pharmaceutical manufacturing sector, even though the intention was clear in the policy and had been reported widely.4,5 (See chapter 3 on legislation). Considerable progress has been made with regard to the amendment of the Pharmacy Act. The Amendment Bill, which was tabled in Parliament in early May 1997, provides for a new composition of the Pharmacy Council, taking into account the impact of the Forum for Statutory Health Councils and the need to have more representation from provincially employed pharmacists who provide pharmaceutical services to some 80% of the population.6 The imperatives of the National Qualifications Framework have also been accommodated in the Bill, but these may still be affected by developments in Education policy. The Bill sets out to enable the Pharmacy Council to introduce lay ownership of retail pharmacies, in support of the NDP. Specifically, allowance is made for multi-professional practices for private hospital pharmacies, and for the licensing of all pharmacies by the Department of Health. This Bill was also withdrawn. It is envisaged that both Bills, after minor technical revisions will be resubmitted to Parliament in the second half of 1997.
DRUG PRICING Policy directives The NDP plans to curb the increase in drug acquisition costs by rationalising drug pricing and by promoting the use of generic drugs. In terms of rationalising pricing, the policy suggests replacement of the wholesale and retail mark-up system with one based on a professional fee. A Pricing Committee was suggested at a national level to monitor and regulate drug prices and to introduce transparency into the pricing process in the private pharmaceutical sector.
Progress to date The Department of Health has taken a very significant step in the provision of health care where drugs are now supplied free of charge to patients at the primary health care (PHC) level. It is policy that in time all of these drugs will comply with the Essential Drugs List (EDL). In late January 1997 agreement was reached between the Pharmaceutical Society of South Africa and the Representative Association of Medical Schemes on a new pricing structure for retail pharmacy. This would be based on an acquisition cost (a disclosed non-discriminatory net unit price ex-manufacturer to which distribution fees, inventory-related costs and practice costs would be added) and a professional fee (based on a tariff per hour, with unit times for specific procedures). Following a meeting of the National Consultative Drug Policy Forum, an implementation date of 1 April 1997 was agreed upon.7 This system has, however, been attacked in the press by the Pharmaceutical Manufacturers Association (PMA)8 and was not implemented on the agreed date. The implementation of generic and/or therapeutic substitution, is dealt with in the Amendment Bill to the Medicines and Related Substances Control Act. International experience has shown that these measures, combined with efficient logistics and a degree of international tendering can reduce drug costs. Such a system was shown to reduce unit costs by more than 50% in its first procurement cycle in a group of nine Eastern Caribbean countries.9
100 DRUG SELECTION Policy directives The NDP endorses the application of the Essential Drug concept and proposes an Essential Drug List (EDL) Committee and a three-tier set of EDLs.
Progress to date The first Standard Treatment Guidelines and EDL for Primary Care was released in March 1996.10 However, application of the list has been patchy. Some provincial and local authorities have had problems with the availability of some drugs on the list. A lack of input from primary care practitioners was also noted. Providers of primary care training programmes lamented the disease orientation of the list, preferring a syndromic or presenting problem approach. This list is currently being reviewed, and a second list is expected before the end of 1997.11 The process being followed with the preparation of the secondary and tertiary EDLs is quite different. A list of “systems”, with disease states within each system has been drawn up.12 Each section has been allocated to a recognised specialist in that field. However, progress on this “hospital list” has been slow.
PROCUREMENT AND DISTRIBUTION Policy directives The NDP suggests measures to improve the cost-effectiveness of public sector distribution facilities and to use private sector facilities where applicable. The public sector co-ordinating body for procurement (COMED) was to have been strengthened.
Progress to date Attention is being given to increasing the efficiency of COMED. COMED has obtained prices substantially lower than those of the private sector but they are still 23% higher than the international generic market. Also COMED continues to have no say over the selection or the quantities of drugs bought by the Provinces. There has been a hint of Provinces taking over their own “COMED” activities. Development of information and accounting systems is slow. As a result there is an absence of exact data of drug expenditure at national level. The Northern Province and Mpumalanga no longer have access to centralised pharmaceutical stores as a result of boundary changes and have used private sector suppliers. An innovative system has been developed in the Free State, where private pharmacies have been supplied with state medicines, via a private wholesaler, for dispensing to District Surgeons’ patients.13 While successful in that setting, the high cost of this system militates against its introduction in many other areas. Private sector initiatives in drug distribution are on the increase. The impact of managed care will be felt in the private sector, with many schemes adopting similar tender processes to those used by the State, in an attempt to reduce expenditure on drugs. For example, in February 1997, the South African Managed Care Coalition (SAMCC) persuaded 50 pharmaceutical manufacturers to tender for supply of medicines at significantly lower prices on the basis of a formulary prepared by SAMCC members.14 In an effort to control shrinkage, the DoH included in regulation R.1150 its intention to implement a Central Mark Control System for all medicines. Implementation is awaited of this system whereby each medicine pack will be labelled with an unique bar code identifying its origins. Another area addressed by the policy was that of the promotion of local manufacture of drugs. To address this issue, the Department of Trade and Industry has established an initiative for the pharmaceutical sector. This attempts to bring together all relevant stakeholders in order to devise strategies for the strengthening of this sector of the economy. In an effort to encourage local industry, local tenders are considered even if up to 15% higher than the lowest tender of international companies.
Drug Policy 101 RATIONAL DRUG USE Policy directives This policy aims to promote rational prescribing, dispensing and use of drugs by all health workers and the public. Emphasis is placed on education and training, on the provision of drug information and on appropriate prescribing and dispensing. The body entrusted with this task is the South African Drug Action Programme (SADAP), which has received external funding for a period of 4 years after which the essential programmes it develops will be institutionalised within the Department of Health.
Progress to date In November 1996, the Co-ordinating Committee for the Training of Prescribing Personnel in the Effective Use of Medication at the Primary Health Care Level arranged a workshop in Pretoria.15 This workshop can be seen as the first evidence of the SADAP process which officially appointed its Director, Dr Wilbert Bannenberg, on a full-time basis from January 1997. Another area of development has been the appointment of Provincial Essential Drugs Co-ordinators (PEDCOs) who are to form the link between SADAP and the Provincial authorities. For example, in the North West Province the PEDCO was able to already claim some progress, in that a trainer pharmacist post for the Province had been approved.16
HUMAN RESOURCE DEVELOPMENT Policy directives The National Drug Policy (NDP) emphasises the need for strengthening drug supply management skills. Two aspects can be delineated: the efforts to bring health professional curricula into line with the NDP and the changes to provincial organograms to support implementation.
Progress to date On the curriculum front, some progress has been made in defining a new approach to the training of pharmacists and pharmacy support personnel. A training system which complies with the National Qualifications Framework is being developed. Initial documents on the competencies of entry-level pharmacists and support personnel are in the final stages of validation.17 SADAP has confirmed the need to define the competencies of all personnel involved in drug prescribing and management and to co-ordinate training efforts in this regard.
New drug training projects and courses
The Rational Drug Prescribing Training Project of the Universities of Durban-Westville and UCT. This project has produced a training manual for primary level prescribers and initiated a regional drug information centre.18,19 The WHO Collaborating Centre on Drug Policy, Information and Safety Monitoring at the University of the Western Cape (UWC, School of Pharmacy) and UCT (Department of Pharmacology) runs short courses such as The Essential Drugs course for a District Health Care System. A series of training courses promoting Aspects of Rational Drug Use are offered by MEDUNSA, both alone and in collaboration with the Boston-based consultancy Management Sciences for Health (MSH).
Almost all provincial Health Departments are understaffed with pharmaceutical personnel. Exact figures on the number of active pharmacists or support personnel posts are unknown. The scale of the challenge can be seen in the figures from the Free State (Figure 1). In January 1997, only 35% of a total of 148 pharmacist posts in the Province were filled. Notably, only 1 of 8 Chief Pharmacist posts was filled. Efforts have been made to improve the human resources situation in some provinces and Mpumalanga has approved a position for a district pharmacist in each District Health Management Team.20 However approval of a position does not mean the post will be filled!
102 Attempts to draw pharmacists to provincial services are seriously hampered by flawed appointment measures, which do not allow for starting salaries commensurate with prior experience. No incentives to work in rural areas have been developed.
FIGURE 1 PHARMACY STAFFING IN THE FREE STATE DEPARTMENT OF HEALTH (AS AT JANUARY 1997)
Vacant Filled Total Chief Pharmacist
Principal Pharmacist
Senior Pharmacist
Pharmacist
02010 30 40 50 60 70 80 90 100
Number of posts
Source: H Marais, Head: Pharmaceutical Services
A recent Health Systems Trust publication has reported on a large scale evaluation of pharmaceutical services in the Northern Province.21 The authors advocate intensive training for all staff in drug supply management and rational prescribing. The study demonstrated a number of areas of concern. These included: ➣ no clinic staff were aware of the NDP ➣ only 60% of hospitals had at least one qualified pharmacist ➣ 55% of all clinic attenders received at least one antibiotic ➣ only 50% of hospitals had a thermometer in the refrigerator used to store vaccines (no hospitals recorded fridge temperatures).
SUMMARY Implementation of the NDP has been slow over the last year which is directly related to the lack of legislative support. In terms of phase one implementation, not all the essential drugs lists have been compiled. The Primary Health Care List is being reviewed, and cannot really be regarded as having been implemented. Initiation of phase two implementation has met with opposition and has resulted in delays while the regulations are being rewritten or the Acts which will enable promulgation of such regulations are being amended. Phase three implementation is dependent on the parliamentary timetable, and the amendment bills of relevance to the NDP are among the legislation which need to be enacted in the 1997 session if significant progress is to be made. SADAP, now fully operational with adequate funding and staffing, is expected to impact significantly on the implementation process. The 1996 Review chapter ended with the following observation: “the degree of opposition by vested interests to the implementation of such progressive policies cannot be overemphasised”.1 It remains to be seen in 1997 whether new legislation will be enough to significantly speed up the implementation of the NDP against this background of continued opposition based on vested interests.
Drug Policy 103 It is crucial that significant changes to the drug policy arena be implemented before the political capital of the change of government is lost. This effect was elegantly demonstrated in the political handling of drug policy reform after the Aquino government came to power in the Philippines.22 Failure to achieve fundamental drug policy changes might result in considerable expenditure on infrastructural development without the wherewithal to supply essential drugs.23 This challenge was well put by the Minister of Health, Dr Zuma: “There were problems in the development process and I’m sure there are going to be problems in implementation. In fact, there are going to be problems all the time”.5
104 HEALTH 11 INFORMATION SYSTEMS
INTRODUCTION The development of health information systems during 1995 and 1996 was mainly dominated by the activities of the National Health Information Systems Committee (NHIS/ SA) and its subcommittees. It was noted in the 1996 Review that the most important initiative in health informatics during 1995/6 was taken by the Department of Health with its plan for a National Health Information System for South Africa.1 Since the latter part of 1996 several initiatives at provincial and district level have gained momentum. This chapter will focus on describing developments in the area of health information systems at provincial and district level. The main issues from the 1996 review relating to NHIS/SA were:
Tender for the National Health Care/Management Information System The tender process for the purchase of a single National Health Care/Management Information System (NHC/MIS) was changed in the middle of 1996 to a process where provinces proceeded with their own tenders for their NHC/MIS. This system aims in the first instance to provide individual patient information as well as information relevant to billing and management. The provincial tenders published to date are specifically for hospitals. All but two of the provinces do not intend to include clinics in their tenders. The NHC/MIS is a priority component of the total Health Information System. However, it is only one component. Other components include surveillance systems, and management systems such as financial and personnel.
Demographic and Health Survey The national Department of Health has commissioned this survey which aims at providing detailed demographic and health indicator information. Pilot surveys were conducted in selected provinces during 1996, but the national survey scheduled for 1997 is now planned for early 1998.
ReHMIS (Regional Health Management Information System) Although an update of ReHMIS was planned for 1996, this survey did not take place. Although ReHMIS played a significant part in health services planning, it is questionable whether it should be updated annually. On the one hand the availability of the ReHMIS dataset could have been useful to quantify changes over time in health services development such as the provision of facilities and personnel. On the other hand the information required for health management decision making is now much more extensive than the limited approach taken by ReHMIS. The decentralisation of decision- making requires operational systems with a broader base at regional and district level.
Authors: Kobus Herbst, Department of Community Health, MEDUNSA and Northern Province Health and Welfare Department Caesar Vundule, Department of Health and Developmental Welfare, North West Province 105 Health Goals, Objectives and Indicators The national Health Goals, Objectives and Indicators remain in draft format, with the latest draft published in June 1997. However, it is not clear how these national objectives and indicators relate to the process of setting objectives at provincial and district level and their implications for the development of district health information systems.
CURRENT STATUS OF HEALTH INFORMATION SYSTEMS AT PROVINCIAL LEVEL Sources of information A questionnaire was developed and distributed to all provincial health information managers in May 1997. The purpose of the questionnaire was to: ➣ review information technology, policy and planning at provincial level ➣ determine the progress made by provinces with regard to the acquisition of the National Health Care / Management Information System ➣ review progress towards the development of district health information systems ➣ review the availability of health information personnel in the provinces.
Information technology policy and planning at provincial level For an organisation to realise maximum benefit from investments in information technology (IT), the development of a strategic (master) information technology plan (MITP) is essential.2,3 The components of such an MITP include: ➣ an inventory of existing systems ➣ master system architecture (including workstation hardware and software specifications, network architecture and the preferred application operating environment) ➣ application development and/or acquisition priorities ➣ IT policy making and management structures such as IT committees and system management committees. Table 1 summarises the current situation regarding the presence of key components of a MITP at provincial level.
TABLE 1 PRESENCE OF MITP COMPONENTS IN PROVINCIAL HEALTH DEPARTMENTS DURING 1997
Province Inventory of Master systems Application IT policy making existing systems architecture development priorities & management structures Eastern Cape No No No Yes Free State Yes Yes Yes Yes Gauteng Yes Yes No Yes KwaZulu-Natal No No No Yes Mpumalanga Yes Yes No Yes Northern Cape Yes Yes No Yes Northern Province Yes Yes Yes Yes North West Yes No No Yes Western Cape Yes Yes No Yes
Provincial departments of health do not function totally independently with regard to information technology deployment. Their flexibility in acquiring and using information technology is often constrained by provincial IT sections and regulations. Table 2 summarises the responsibility for various components of IT deployment. There are wide differences among the provinces and in some provinces even the purchase of office computers has to be done in conjunction with the provincial IT department.
106 TABLE 2 INFORMATION TECHNOLOGY RESPONSIBILITIES IN PROVINCES
Province Workstation Office Workstation LAN LAN WAN acquisition automation and office installation administration management automation support Eastern Cape D D D P J P Free State D D D D D P Gauteng D D D D D P KwaZulu-Natal D D D D D P Mpumalanga D J J D D D Northern Cape J J J J J J Northern Province J J D D D P North West J D J P P P Western Cape D D D P P P
D - Provincial Department of Health P - Provincial IT section J - Joint responsibility LAN = Local Area Network WAN = Wide Area Network
Progress in the acquisition of a National Health Care/ Management Information System (NHC/MIS) in the provinces Seven provinces intend to replace their existing hospital information systems, either completely (Free State, Gauteng, Mpumalanga, Northern Province, North West) or partially (KwaZulu-Natal, Western Cape). The Northern Cape province plans to retain its existing system whereas the Eastern Cape is still undecided. Table 3 shows the planned scope of the NHC/MIS in the different provinces.
TABLE 3 SCOPE OF THE PROPOSED NHC/MIS IN THE DIFFERENT PROVINCES
Province Hospitals Clinics and health centres Eastern Cape All All Free State Academic and regional - Gauteng All (initially 6) All (initially 6) KwaZulu-Natal Selected hospitals depending on funding - Mpumalangaga All hospitals - Northern Cape Regional hospitals - Northern Province All - North West District and Regional - Western Cape All hospitals -
Regarding the acquisition of the NHC/MIS, the North West, Mpumalanga, KwaZulu-Natal and Eastern Cape provinces have not yet embarked on the tendering process. The Northern Cape province plans to extend the system already in use at one hospital to other hospitals. The Western Cape and Gauteng provinces have developed their tender specifications. The Western Cape tender relates to 3 academic hospitals only as the other hospitals are already partially provided for via an existing system. The Free State is in the process of evaluating the tender submissions for academic hospitals. The Northern Province has started with the process of implementing the hospital information system.
Health Information Systems 107 TABLE 4 THE STATUS OF THE TENDER DEVELOPMENT PROCESS IN PROVINCES
Province Develop and publish Use / Modify Use / Modify Use tender own specifications NHIS/SA other provinces’ awarded to specifications specifications other province Eastern Cape - - Yes - Free State Yes - - - Gauteng Yes Yes - - KwaZulu-Natal - - Yes - Mpumalanga Yes - - - Northern Cape - Yes - - Northern Province Yes - - - North West - - Yes - Western Cape - Yes - -
Current status of routine data collection at primary health care level The Free State is the only province where a standard format of routine data collection at primary health care level is in use throughout the province. In the Western Cape, a standard format has been developed and is currently being implemented in 3 pilot sites. In the remaining provinces, a standard format of routine data collection has yet to be developed.
Structures for health information personnel at provincial level Staff establishments for health information have been developed for most provincial and regional offices and provinces are currently in the process of approving them or filling the posts. However, most provinces are still developing their district health information structures. (See Table 5)
TABLE 5 STATUS OF HEALTH INFORMATION STAFF ESTABLISHMENTS IN PROVINCES
Province Provincial office Region District Hospital Eastern Cape Being filled Being filled Being filled - Free State Filled Being filled Being approved Being approved Gauteng Being filled Being filled Being developed Being developed KwaZulu-Natal Being developed Being developed Being developed Being developed Mpumalanga Being filled Being filled Being filled Being filled Northern Cape Being filled Being developed No structure No structure Northern Province Filled Filled Being developed Being developed North West Filled approved No structure Being filled Filled Western Cape Being filled Being filled Being developed Partially Filled
Table 6 shows the number of approved and filled posts for selected categories of posts which are key in the development of health information systems. In five provinces, only two or less of the seven selected categories of health information personnel are filled.
TABLE 6 NUMBER OF APPROVED (AND FILLED) POSTS FOR KEY HEALTH INFORMATION COMPONENTS AT PROVINCIAL OFFICES
Province Director Deputy Assistant Specialist Network Programmer Bio- Director Director (Epidemiology) controller statistician Eastern Cape 0 1 (1) 0 1 (1) 0 1 (0) 0 Free State 0 1 (1) 1 (0) 0 7 (7) 3 (3) 3 (2) Gauteng 1 (0) 3 (3) 1 (1) 2 (0) 1 (1) 1 (1) 1 (?) KwaZulu-Natal 0 1 (1) 1 (1) 0 9 (8) 0 1 (1) Mpumalanga 0 0 2 (0) 1 (0) 0 0 1 (0) Norhter Cape 0 0 1 (1) 0 2 (1) 0 1 (0) Northern Province 0 2 (2) 3 (3) 0 1 (0) 1 (0) 0 North West 0 1 (0) 1 (0) 1(1) 0 0 2 (1) Western Cape 1 (1) 2 (2) 2 (2) 2 (2) 1 1 1
NB: Figures in brackets show the number of filled posts
108 Discussion All provinces have established policy-making structures dealing with information technology (Table 1). Although the majority of provinces have developed master systems architectures, most provinces still have to determine their application development or acquisition priorities. With the exception of the Free State and the Northern Province, no province has all the components of a MITP in place. Table 2 shows the diversity between provinces with regard to the acquisition and support of the basic information technology infrastructure. The implication of the diversity is that provinces will require different approaches and face different constraints in the implementation of health information systems. Provinces are taking a cautious approach to the acquisition of the NHC/MIS. Only two provinces intend to implement the system at both hospitals and clinics and four provinces are limiting their implementation to selected hospitals. This cautious approach is further exemplified by the fact that only one province (Northern) has started with implementation, one province (Free State) is evaluating tender responses and two provinces (Gauteng and Western Cape) are at an advanced stage in the development of their tenders for the NHC/MIS. Routine data collection at primary health care level in most parts of the country is still fragmented, with only the Free State having a uniform province-wide system. This is a very disturbing situation because most provinces and districts cannot determine or monitor many of the basic indicators of health status. For information to support rational decision making at district level, district information systems must be developed. However, it is encouraging that some provinces have started pilot projects aimed at developing a district health information system. At a higher level, a major challenge is the identification of essential information needs at national level. Such national essential information needs will ensure that certain core data is available for all parts of the country, and is also likely to guide the development of district information systems. The successful development and implementation of a national health information system will largely depend on the availability of skilled personnel at all levels. At present, most provinces have not started appointing district level information personnel. Whereas this may reflect the current status in the development of districts, there is a need to have personnel to support decision making at this level since district health services will form the basis of the reformed South African health care system.
OTHER DEVELOPMENTS IN HEALTH INFORMATION Vital registration Significant progress has been made in the development of new birth and death registration systems. New birth and death registration forms are being finalised. There will be closer co- operation between the Departments of Health and Home Affairs in vital event registration process.
Health information use in the private sector Information system use in the private health care sector has long been more extensive than in the public sector, due mostly to the need for detailed financial information. With the continued introduction of managed care concepts into the country over the past year, the requirements for information has grown to be even more extensive. This has resulted in more sophisticated systems with greater clinical content and analytical capacity being introduced in the private sector. The electronic linkage of systems has also increased, first as a result of the electronic interchange of billing information, but more lately ambitious networks linking providers, funders and employers are being planned.
Health Information Systems 109 Pilot project on the development and implementation of an evaluation process for district health information systems This project, conducted by the Medical Research Council has developed a set of criteria and a draft instrument for evaluating the effectiveness of district health information systems.4
ACTIVITIES TOWARDS DEVELOPING DISTRICT INFORMATION SYSTEMS Health Information Systems Pilot Project in the Western Cape The Health Information Systems Pilot Project (HISPP) is a Western Cape based pilot project which seeks to develop a district based health and management information system and is funded by the Norwegian Government. The purpose of the project is to support health authorities in developing a sustainable, collaborative process for the local use of information to improve coverage and quality of health care delivery and management systems. The participants in the project are: ➣ communities, through health committees and the wider community ➣ health workers in institutions and in the community ➣ managers at facility, district, regional and provincial level ➣ planners and policy makers at local authority, provincial and national level ➣ funders The time frame of the project is from April 1996 to June 1998. The HISPP project is currently being implemented in the Mitchell’s Plain, Khayelitsha and Atlantis districts. Funds are being sought to expand the project to other regions of the Western Cape and to Free State, Mpumalanga, North West and Eastern Cape provinces.
PHC/INFO project in the Free State The PHC/INFO project was started in 1994 in order to address the urgent need for an efficient information system for the management of primary health care in the Free State province. The development of an effective system of routine data collection at clinic level was identified as a core element of this. As a result of the project, a new system of routine data collection was implemented throughout the Free State province. The system is based on a one page scanner- readable tick sheet that is completed for each client. The filled tick sheets are then sent to the provincial level where they are scanned. This system has the advantage that errors of data capture are eliminated. However there is potential for major logistical problems of distributing forms to all the clinics and shipping them to a central point where they are scanned.
National Task Team A task team, under the leadership of the Directorate: Information, National Department of Health is busy compiling a handbook to guide the development of district information systems. This handbook should be finalised before the end of 1997.
CONCLUSION Following are the main challenges (policy issues) for the development of health information systems in South Africa: ➣ the identification of essential information needs at national level ➣ effective vital registration system ➣ standardised routine data collection systems at primary health care facilities and district level ➣ the implementation of hospital information systems ➣ the publication and use of health data security and confidentiality guidelines and legislation ➣ the development of health system surveillance systems ➣ strengthening infectious disease surveillance systems to country-wide coverage
110 ➣ staff establishments at all levels of health care delivery responsible for data collection, analysis and presentation ➣ the promotion of health informatics education and training It is clear that not enough progress has been made over the past year and tremendous challenges lie ahead in the development of an effective health information system in South Africa.
Health Information Systems 111 112 12 RESEARCH
INTRODUCTION The whole science system, including health research, is in a process of restructuring. Health research needs to change its approach and should be focused on addressing the country’s major health problems. Funding should support such agendas. Research areas need to be prioritised. Skills need to be developed to ensure that rigorous and appropriate research methods are applied to these priorities. Health services, historically disadvantaged institutions and black researchers who were largely excluded from the research process in the past, need to be financially and technically supported to build their research skills and capacity within priority health research areas. Finally mechanisms need to be developed to monitor research activities and flow of funds. These issues are the essence of the international thrust known as Essential National Health Research (ENHR). ENHR is an integrated strategy for organising and managing research; the goal of which is to promote health and development on the basis of equity and social justice. This chapter will review developments within the key pillars of ENHR: ➣ promotion and advocacy, ➣ priority setting, ➣ financing, ➣ capacity building, ➣ networking and information dissemination, ➣ evaluation. The national Department of Health has taken a clear stand in ensuring that ENHR is high on the research agenda through the coordination and leadership role of the Chief Directorate: Health Information, Evaluation and Research.
PROGRESS IN KEY COMPONENTS OF ENHR Promotion and Advocacy South Africa has a poor history in addressing its own priority issues. To make substantial changes in research agendas requires a change in mind-set. Ensuring that health research is focused on priority health issues and impacts on policy decisions requires an active process of promotion and advocacy. This involves the researchers and funders of health research. The Ministry of Health supports the development of an ENHR1 approach.
Author: Jane Edwards-Miller, Health Systems Trust 113 WHITE PAPER FOR THE TRANSFORMATION OF THE HEALTH SYSTEM IN SOUTH AFRICA. CHAPTER 5 - ESSENTIAL NATIONAL HEALTH RESEARCH
Principles
✧ The research agenda should be developed to address the country’s major health problems and initiate a process involving scientist decision-makers and population representatives as equal, inclusive partners. ✧ Health problems should be addressed by means of a full range of methodologies including epidemiology, social and behavioural, clinical and biomedical, health systems and policy analysis. Priorities should be set by the stakeholders involved. ✧ Research should be relevant to health needs and aimed at informing health planning, effective delivery, management and policy development.
In November 1996, the Department of Health took forward its plans to restructure health research in South Africa according to the ENHR philosophy through a national prioritisation congress.2 This was attended by delegates representing universities, government departments, non- governmental organisations, professional bodies and the science councils. The aim of the exercise was to identify health research areas that address priority health problems; develop a process for consensus building; and facilitate the establishment of an ENHR committee. At the time of writing, this committee has yet to be appointed by the Minister of Health. Some research organisations, (eg. Medical Research Council [MRC], Health Systems Trust [HST]) have given their commitment to ENHR. But it is essential that the Department of Education, which is the largest public funder of research within universities, and the universities themselves are committed to addressing priority health issues. Some academics remain wary of ENHR, fearing that its implementation will diminish their resources and stifle research options. Great sensitivity will be required in the implementation of South Africa’s ENHR, to ensure that the country’s health priorities are addressed, while at the same time sustaining and strengthening the research capacity and expertise which has already been developed. International agencies and governments, and the private sector, particularly the pharmaceutical industry, are important funders of health research and must be acknowledged as influential in setting health research priorities. The pharmaceutical industry’s investment in research is likely to be more than all other sources put together. In reality, research priorities are determined not only by the agenda of researchers but by what the funding agents will finance. These groups thus need to be an important target for promotion and advocacy.
Priority Setting Priority setting needs to be based on a mixture of information relating to: ➣ burden of disease and health profiles ➣ cost-effectiveness of interventions ➣ institutional human resource availability to implement interventions at the community level ➣ health priorities that reflect communities needs. Because, there are fragmented and incomplete health information relating to most of the above, it is difficult to set priorities other than at a fairly crude level. Trends of diseases and distribution of disease burden have been determined from available data. Some of these data were used in the prioritisation exercise of the ENHR congress, held by the national Department of Health in November 1996.2
114 Top ten health priorities identified at ENHR Congress
✧ injury/violence, ✧ tuberculosis, ✧ nutrition, ✧ HIV/AIDS, STD’s, ✧ cancers, ✧ diarrhoea, ✧ respiratory infections, ✧ mental health (excluding substance abuse) ✧ malaria.
At this congress 45 priority health problems were identified. The main surprise is the presence of malaria and the absence of perinatal conditions within the top ten. This possibly reflects the process of prioritisation which based the ranking on the perceptions of participants as well as the burden of disease. The congress agreed that this priority list would need further refinement.
Prioritisation of Research Approaches - A case for Health Systems Research Not only do health problems need to be prioritised, but also research approaches. Health systems research is one such priority approach. Health Systems Research focuses on issues related to the delivery of health care and it therefore cuts across the various health problems. It aims to provide information which will improve the functioning of the health system, by providing policy options and practical information. In the past research has focused almost exclusively on basic and bioclinical research. Research into the delivery of health care has been neglected and funding for this type of research remains negligible. A well-structured health systems research programme is essential to future health policy and to adequate monitoring of the national investment in health services.
Financing One of the strategies of ENHR is to ensure that funding follows the identified priorities and is focused on improving health and promoting equity in health. Information and monitoring of funding sources and its distribution is an essential part of ENHR. Little progress has been made in this area over the past year. In particular, information is needed on the distribution of funding geographically as well as institutionally. The major consumer of public funds are the universities and the Department of Health needs to monitor their spending on current research activity.
Capacity Building In terms of the ENHR approach South Africa needs to develop its research capacity. This increase in capacity is needed to analyse its health problems and to respond to new challenges and to develop better interventions. Little is known about the overall picture of capacity building, as information is neither being collected nor co-ordinated. All that can be done is to describe individual efforts. The MRC has continued to develop its capacity and skills development effort. In the past year the MRC has allocated R1.9 million for scholarships and bursaries to researchers from disadvantaged backgrounds for ‘fast tracking’ of black scientists.3 The HST has an explicit commitment to capacity building and skills development. This includes an internship programme, and support for short courses. The HST also provides methodological support for individual researchers. Around 10 interns per year are fully funded and are placed at institutions where they will be adequately supervised. Other research organisations, such as the Centre for Health Policy, also fund and train interns. The national Department of Health runs in-house short courses on epidemiology. Interested national and provincial Health Department employees have attended these courses.
Research 115 International funding has also been vitally important in developing research capacity. One such initiative is the AIDS International Training and Research Programme, which is funded by the Fogarty International Centre based at the National Institute for Health in Washington. This programme provides training in epidemiology to researchers from Southern Africa to enhance research skills and improve the use of research for AIDS programme planning. To date, eight South Africans have been trained to the masters level and three doctoral level. More than a hundred others have been sponsored to attend short-courses. Investment in South African medical research by foreign agencies (eg. Wellcome Trust, National Institutes of Health), governments (eg. Department for International Development, European Union and USAID) and foreign companies (eg. Glaxo-Wellcome, Schering, Eli Lilly) have also helped build individual and institutional capacity mainly in the field of bio-medical research. Another aspect of capacity building is the shifting of resources to centres which traditionally have not carried out much research. An example of this is the development of the MRC research site at Hlabisa in KwaZulu-Natal. In 1996 the HST funded more projects in “disadvantaged” institutions than it did in total in the previous three years.4
Networking And Information Dissemination Networking and information dissemination are important strategies within an ENHR mechanism. Sharing of knowledge helps co-ordinate research and avoids unnecessary duplication. The growth of e-mail and the Internet in South Africa, offers an important opportunity to improve networking and information sharing. HealthLink, a project of the HST, has been important in developing such activities. It has linked up many rural areas to e-mail and the Internet, and developed Internet web sitesA for many health-related organisations. The MRC has recently established a Web server for ENHR in South Africa, as part of the Science Councils’ collaboration in health research.B This site provides updated information on funding opportunities, organisations involved in ENHR as well as sources of information on South African health research.
Monitoring And Evaluation Information is needed on current health research activities and its funding, as well as institutional and geographical distribution of research and funding. This needs to include all sources of funding. Private sector investment in research, particularly from the pharmaceutical industry, is known to be substantial, yet little is known about this. As has been illustrated in this chapter, South Africa continues to have incomplete and fragmented information on most aspects of its health research. However, the national Department of Health, has begun to compile a database of ongoing research in the country. It is also important to monitor and evaluate capacity building efforts within the historically disadvantaged institutions and health services. Opportunities provided for previously marginalised groups within the historically white universities and science councils should also be included.
ADDRESSING PROVINCIAL PRIORITIES Provincial co-ordination of research offers the opportunity for research to be reviewed, evaluated and commissioned in the light of provincial priorities. The provincial organisation of research varies but in most provinces it has become the responsibility of the information directorates. Some provinces have established research committees; others are planning them and in one province the committee has been disbanded. Very few have specific budgets for research and are therefore unable to pro-actively commission research to ensure that research activities address their needs. Many provinces do not currently have the time, staff or skills to adequately co-ordinate and direct
A http://www.healthlink.org.za/hst B http://www.mrc.ac.za/enhr/enhr.htm
116 provincial research. These issues need to be addressed if provincial co-ordination of research is to become a reality. This will be enhanced by active support from the National Department of Health and closer linkages with academic institutions.
IMPORTANT RESEARCH EVENTS AND DEVELOPMENTS Science and Technology White Paper The Science and Technology White Paper was published in December 1996 entitled ‘Preparing for the 21st Century’.5 It sets out a proposed new structure for the governance and funding of science and technology by the Government. The paper has quite fundamental implications for the science councils including the Medical Research Council. This involves the proposed separation of the functions of the funding and the carrying out of research. These changes are still under discussion. The white paper proposes the establishment of a National Research Foundation which will be responsible for funding research within the higher education sector. This Foundation is envisaged to have four divisions, with a health sciences division to encompass the medical and health components of the current FRD (Foundation for Research Development) and the HSRC (Human Sciences Research Council). It is not clear whether it will take over grant funding function of the MRC.
Wellcome Trust Centre for Population Studies and Reproductive Health The Wellcome Trust (UK) is about to establish a R42 million international research centre for populations studies and reproductive health in KwaZulu-Natal. This centre is a consortium including the MRC, University of Natal and the University of Durban-Westville. The guiding philosophy of the centre is to ensure excellence in the performance of multi- disciplinary research and in the provision of research training that emphasises population and reproductive health priorities in sub-Saharan Africa. The research programme is built on a foundation of continuous socio-demographic surveillance of about 75 000 people in the rural health district of Hlabisa in KwaZulu-Natal.
South African Cochrane Centre Assessing the effectiveness of health care has become an urgent priority as South African introduces multiple new health care programmes. Given this, the South African Cochrane Centre for systematic review was formally established during 1996 with the goal of being a national resource for researchers, clinicians and planners by conducting systematic reviews of the effectiveness of clinical, public health and organisational interventions.
HIV Network Early in 1997, the US National Institutes of Health released a request for proposals to set up HIV vaccine trial sites. Three groups from South Africa have applied to become HIV network (HIVNET) sites situated in Cape Town, Johannesburg and KwaZulu-Natal. HIVNET sites are expected to set up cohorts for HIV prevention trials (eg. microbiocide trials, vertical transmission trials) until such time as an AIDS vaccine is available for efficacy trials. A decision on the HIVNET sites will be made in September 1997.
South African Journal of Public Health (SAJPH) The South African Journal of Public Health (SAJPH) was launched in late 1996. It is a peer reviewed indexed journal, published quarterly as an additional issue of the South African Medical Journal. The journal is regionally focused and there are representatives from Lesotho, Zimbabwe, Mozambique and South Africa on the Editorial Board. It is funded by a grant from the Health Systems Trust. The main goal of the SAJPH is to encourage discourse on policy issues pertinent to public
Research 117 health throughout southern Africa. The first few issues of the journal have covered issues ranging from the cost of providing care to AIDS patients to human rights in the under-graduate medical curriculum.
CONCLUSION The main conclusion sounds much like last year’s. Gaining an accurate understanding of health research in South Africa is significantly hampered by the lack of reliable information on all aspects of ENHR. By documenting individual developments over the last year, it does appear that there has been some change for the better. But this is insufficient evidence. The development of an ENHR mechanism does appear to be gaining momentum, and the imminent appointment of the ENHR committee is encouraging. However, what is more important is that progress is seen in the component strategies of an ENHR and without information this is difficult to assess.
118 UPGRADING 13 HEALTH FACILITIES
A glance at the 1996 review The 1996 Review highlighted the following issues: ➣ the maldistribution of existing facilities ➣ over centralisation of resources at higher levels of hospital care at the expense of PHC ➣ the poor condition of many of the existing facilities ➣ inefficiency of many facilities as a result of inappropriate design ➣ a potential for the involvement of the private sector to supplement services provided in the public sector ➣ the need for a structured approach to health facilities planning and design Overview of the chapter This chapter will discuss progress achieved on a number of the issues highlighted in the 1996 Review. To meet the health care needs of South Africa there needs to be a realignment of the health estate. This is required for two primary reasons: - to allow for the focusing on PHC - to redress inequity. Strategic planning for this change requires a clear understanding, amongst other things of the extent, nature and residual value of the existing estate. Clearly while many new facilities need to be built, existing facilities will continue to form the backbone for the delivery of health services. In many cases, facilities have been allowed to fall into disrepair through neglect or lack of adequate funding. These need to be identified and upgraded to acceptable standards. A review of the National Health Facilities Audit1 (NHFA), will be provided. Results from the NHFA show that there are 434 public sector hospitals and 108 health centres in the 9 provinces; that the replacement value (April 1996) of the estate was some R23.3bn,A while the residual value taking account of the degradation of existing buildings, was some R15.6bn. Although the NHFA did not include clinics, it is estimated that there are currently some 3000 clinics in South Africa with a replacement value of some R3.5bn. A significant clinic building programme has been undertaken by the national Department of Health using RDP and provincial funding.
A Adjustments have been made for additional information on Northern Province facilities not available at the time of the full NHFA of November 1995 - April 1996
Author: Geoff Abbott, Division of Building Technology, CSIR 119 Through this programme, over 400 clinics have been built reducing the estimated backlog of clinics by some 30%. Many provinces have initiated significant capital and maintenance programmes some of which will be highlighted.
The National Health Facilities Audit Background to the NHFA2 In November 1995 a task teamB was commissioned by the national Department of Health to undertake a physical audit of all public sector hospitals and health centres in South Africa. While it was accepted that there would be an urgent need for major capital spending, it was also recognised that there was an enormous investment in existing building stock. Clear, long term strategic capital plans would be required to ensure that the existing estate could be gradually reshaped into one corresponding with new health goals. At the time it was known that many hospitals were in poor condition requiring urgent maintenance, repair or upgrading. But no comprehensive picture of the existing health care estate nor, of the maintenance and repair backlog existed.
NHFA process All public sector hospitals and health centres were included in the NHFA. Clinics were excluded from the NHFA as there was a limit to the time and resources available. A four stage process was used: ➣ preparation and briefingbriefing, during which consultants were appointed and briefing sessions were held in all Provinces to provide background as to the intent, scope, processes and benefits of the NHFA. ➣ facilities surveysurvey, during which each facility was visited and all buildings and the full engineering services infrastructure were audited. A list of 65 different elements were identified (eg. water supply, fencing, internal floor finishes). Each element was evaluated on a 5 point scale for either condition,C suitabilityD or both. In addition an assessment was made of the design capacity of the buildings and current use. This provided an indication of over or under utilisation of the health estate. In all over 17 400 buildings on some 560 separate sites were evaluated; ➣ data capture and analysisanalysis, during this stage data were checked and a variety of reports were compiled. ➣ report back during which sessions were held in each of the provinces outlining the results.
NHFA results In 1995/96 the public health estate comprised 8 academic hospitals and 534 hospitals and health centres on 556 separate sites. Facilities in the Northern Province showed the highest levels of degradation (Figure 1). The replacement value (based on May 1996 building costs) of this estate is estimated at R23 210m (see Figure 2). This excludes the cost of sites and equipment.
B The task team comprising the Health Facilities Planning Directorate of the Department of Health, the CSIR and Raubenheimer & Partners (as financial managers). During the audit 579 firms of architects and engineers were commissioned throughout South Africa to undertake the field work at individual facilities. C Condition scale used: As new, maintain, repair, replace, condemn D Suitability scale used: Ideal, acceptable, tolerable, hardly tolerable, intolerable
120
FIGURE 1 NATIONAL HEALTH FACILITIES AUDIT - PROPORTION OF THE HEALTH ESTATE IN THE 5 CONDITION CATEGORIES a a a a a a a a a a a a a a 100% a a a a a a a a a a a a a a a a a a a a a aa a a a a aa aa a a a aaaa a aaa a a aa a aa aa aa 80% a a a a aa a a aa aaa aa a a aa a a a a a a aa a a aa aa aa a a a a aa a a a a aa a a 60% aa aa aa a a aa a a a a a a aa a a aa aa aa a a a a aa a aa aa a a aa aa aa 40% a a aa a a a a aa a a aaa aaaa a aaaa aa aa a 20% a
0% Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western South Cape State Natal langa Cape Province West Cape Africa
Condemn Replace Repaira Maintaina As new
FIGURE 2 NATIONAL HEALTH FACILITIES AUDIT - CURRENT REPLACEMENT VALUE AND RESIDUAL VALUE OF EXISTING HEALTH ESTATE
R6 000
R5 000
R4 000
R3 000 R million
R2 000
R1 000
R0 Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western Cape State Natal langa Cape Province West Cape
The estimated residual value of the estate is R15 851m or 67% of the current replacement value. From this the estimated amount required to reinstate the estate in its current form would be approximately R7 630m. This includes replacing those buildings which should be condemned, and repairing those that need repair. Facilities in poor condition do, however provide a strategic opportunity: ➣ to close a facility which no longer fits in with the current health service delivery model ➣ to move a facility which is no longer well related to the community served
Upgrading Health Facilities 121 ➣ to upgrade a building to meet current requirements rather than effecting repair (eg separating water supply and fire water supply lines) ➣ to change layouts and accommodation to provide a more effective service environment. Strategic options may include downgrading a facility as part of a restructuring exercise (as currently being undertaken in Hillbrow hospital, Gauteng), consolidating facilities to streamline services (FH Odendaal Hospital North and South consolidated into one facility, Northern Province) or closing facilities (Westfort Hospital, Pretoria). Different standards of provision exist in the different provinces. Figure 3 shows the average area per bed for academic hospitals and for all other hospitals. Similarly the level of utilisation varies between provinces (Figure 4).
FIGURE 3 NATIONAL HEALTH FACILITIES AUDIT - AVERAGE AREA PER BED (CAPACITY) - ACADEMIC HOSPITALS AND ALL OTHER HOSPITALS
300 Academic comlex All other hospitals
250
200
15 0 per bed (capacity) 2
m 100
50
0 Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western South Cape State Natal langa Cape Province West Cape Africa
FIGURE 4 NATIONAL HEALTH FACILITIES AUDIT - LEVELS OF UTILISATION OF HEALTH FACILITIES
120%
100%
80%
60%
40%
20% Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western South Cape State Natal langa Cape Province West Cape Africa
122
Continuation of the NHFA process The information from the NHFA was essential for short and long term strategic service planning. It was intended that in future information on the existing estate would be captured and maintained as part of an ongoing process of facilities management by the responsible authority. This information would enable the continuous monitoring and evaluation of facilities. Three provinces have embarked on different approaches to achieve this. In the Northern Province a re-audit of health facilities was undertaken from November 1996 to February 1997, using the NHFA process. Although this Province still has the most serious problem, a marked improvement was recorded in the overall state of their facilities between the two audits. This can probably be ascribed to the effective use made of substantial capital funding available over the 1995/96 and 1996/97 financial years. Using the audit information indicating the most serious deficiencies at each facility, the Province made a blanket allocation of R5m, R2.5m and R0.5m respectively to those referral hospitals, district hospitals and health centres which featured in their long term strategy. Figure 5 shows the improvement measured.
FIGURE 5 NORTHERN PROVINCE HEALTH FACILITIES AUDIT - OBSERVED IMPROVEMENT IN CONDITION a a 100% a a a a aa aaa aAs new a a 80% aa a aMaintain aa a a a aa Repair a a 60% aa a aReplace aaa Condemn 40%
20%
0% 1995 1996/7
In contrast KwaZulu-Natal has appointed local consultants to co-ordinate the capture of information on their health estate. This is being done by reviewing facilities on a regular basis to check for accuracy of information contained in the database. Any works projects are also entered into the database. This will enable management to have access to the current state of their estate. A process for linking this database to the Works Department Maintenance programme is being investigated. North West Province Works Department have appointed consultants to assist them to develop and implement a full maintenance management system for all their facilities (health, education, housing). The NHFA software will be used allowing access to strategic information for capital planning.
Upgrading Health Facilities 123 Capital programmes The national Department of Health is investigating ways to find the estimated R8bn needed for upgrading. If these funds were found and were to be spent within a relatively short time frame then alternative ways of managing the building process might need to be developed.3 One option being considered is the public/provider model currently being used in the Public Works’ new prisons programme. One of the challenges is the need to ensure that building projects meet functional design requirements adequately while remaining within budget. Difficulties are also experienced with design expertise for health buildings. The roster system used by many Works Departments often has the result that consultants appointed for a new project do not have adequate health building experience. While design guides and guidance are available3 these do not compensate fully for a lack of adequate experience. Different issues often have to be addressed in many of the provinces. For example the Northern Cape has inherited a reasonable stock of facilities. These were designed to accommodate different races separately. The problem is not a lack of capacity but how to remodel existing facilities into more efficient units. As a means to establishing common standards across a province some have listed criteria to which all facilities must comply. Northern Province, for instance, has decided that open Nightingale type ward accommodation will not be accepted; that all patient rooms are to be for a maximum of four beds; and that hospitals should generally not be larger than 400 beds.4 There is a move to set common minimum National Standards whereby the standards set in the R158 private hospital regulations may also be required to be used for public sector facilities. Issues of affordability and appropriateness do, however, need to be carefully considered in this exercise.
Clinic building programmes While full details of the clinics built through various programmes before the 1994 elections are not available, it is reckoned that some 200 clinics were built during the 1992-94 financial years. After May 1994 much of the drive towards clinic building was focussed on the Clinic Upgrading and Building Programme6 (CUBP). It is estimated that there is a need for some 4 000 clinics in South Africa of which about 3 000 currently exist. Because there is no consolidated picture of the condition and suitability of the existing clinics, it is not possible at this stage to provide a comprehensive picture of the shortfall of clinics, or of the maintenance backlog.
IDT Clinic Building Programme The IDT started a R100m clinic building programme in 1993. A major focus of the programme was the involvement of recipient communities in all aspects of the projects, the use of local labour, and the use of locally sourced or produced materials.5 The procurement process is however, normally drawn out through the need to involve communities. Lessons learnt in community involvement and building processes have been used successfully in other larger projects. The redevelopment of the out-patient and emergency sections at Kimberley Hospital was recently undertaken successfully by the IDT using a number of small emerging contractors on one large project.
124 Clinic Upgrading and Building Programme (CUBP) This programme was initiated as a Presidential Lead Project in 1994. It had limited success initially. In August 1995 a Fast Track Clinic Building ProcessE was initiated to speed up the process of delivery. This programme focussed on the building of new clinics particularly in rural areas. In addition midwife obstetric units and houses were added to many existing clinics in order to improve services and facilitate the appointment of staff in remote areas. By March 1998 some R710m will have been spent over the 31 month duration of the project which will see the completion of 461 new clinics, 175 additions to existing clinics (mostly additional Midwife Obstetric Units) and the provision of 810 clinic residential units.6 In many cases provinces intend to carry on with the programme using the Fast Track process. In order to access RDP funding, an innovative process was employed through which planning, design, documentation and tendering tasks, were undertaken simultaneously in order to win construction time. An average 13 month clinic planning and building cycle was reduced to 9 months through the development of a highly modular approach for the design and documentation of the clinics. A range of functional units were designed (clinics, MOU’s, housing) which could be fitted together in a wide range of permutations to cater for varying needs of different communities. Proactive special arrangements were made with provincial Tender Boards to adjudicate tenders within days to ensure the continued rapid ‘fast tracking’ of the process. In some cases the building process outpaced the process for bringing the clinics into operation resulting in the delay of commissioning a number of clinics due, in some cases, to funding not being available or delays in obtaining approval for parts.
Extension of the CUBP Programme While this Fast Track approach was designed to meet the specific needs of the Clinic Upgrading and Building Programme, lessons learnt are being transferred to different applications. KwaZulu- Natal is now extending the programme to include health centres providing in-patient beds, casualty, X-Ray services and day surgery. A similar process is being used for 60 bed standardised community hospitals in the North West Province.7 A major advantage of this process is that the client is assured of a product of known standard.
Strategic capital planning8 Strategic capital planning involves a strategic overview of health care services and infrastructure in a specific geographic area (eg. district) undertaken to ensure the best match between service need, services provided and available resources. Strategic capital planning would normally be undertaken under the auspices of a high level management team. The objective would be to develop a development framework for the area which provides a long term plan for each facility. Strategic capital planning must be dynamic and would be undertaken on a rolling basis (usually a 5 year horizon reviewed annually). The strategic capital planning would provide the initial master brief to specific project teams.
Strategic Capital Planning stages 1 Review of existing environment (eg. population, facilities, services, staff) 2 Projected environment ➣ any major shifts in population or service area/ boundaries expected 3 Policy and service indicators/ standards/ or norms 4 Service projections
E The Fast Track Clinic Building Task Team was appointed in August 1995 by the Department of Health. The team comprised the CSIR (concept module design), Raubenheimer & Partners (project managers and quantity surveyor) and Steyn & Viljoen (architects) under the overall leadership of the Directorate of Health Facilities Planning of the Department of Health.
Upgrading Health Facilities 125 5 Development of service scenarios and feasibility studies of facility implications 6 Evaluation and consolidation ➣ evaluate scenarios and select most effective option for each facility ➣ consolidate projects ➣ prioritise projects ➣ set time frame and programme 7 Monitor and review programme regularly
Key issues in Strategic Capital Planning A number of key issues need to be considered during capital planning: ➣ The key constraints are time, finance and staff. ➣ It is important to recognise the long lead time in bringing new facilities on stream - getting a facility onto a prioritised programme, briefing, design, construction and commissioning can take 5-10 years or even longer for larger projects using normal processes. ➣ The running cost of hospitals normally equals the capital cost after about 2 years. ➣ The running cost of health centres and clinics equals the capital cost after about 1 year. ➣ The availability of staff and funding to run the facility once built.
Upgrading or replacement An estate that is in poor condition provides a unique opportunity to the strategic service planner to effect a significant change. Strategic capital planning should include a full review of all the services in the area before focusing in on individual facilities. Some of the issues that should be considered during strategic planning when considering the future of existing facilities include: ➣ the role of the facility in the overall health service network. This may change over time as new facilities are added or existing facilities in the service network are upgraded or downgraded. ➣ changes in service catchment area (eg. surrounding population is now served primarily by private sector facilities). The following list9 highlights disadvantages of upgrading old facilities and advantages of replacing them with new buildings: ➣ the reusable parts of buildings (generally the structural shell, some walling and roof structure) usually represent only a small proportion of total health building costs ➣ many older buildings were built when modern technology was not anticipated making it difficult to introduce modern engineering services ➣ reusing existing buildings involves a commitment both to their location within the overall hospital configuration and to their general shape and form, limiting planning options ➣ upgrading buildings while maintaining the provision of health services, requires decanting space and involves significant disruption of services ➣ older buildings usually have higher maintenance costs However it is usually only where the condition is so poor (or when the cost of upgrading would exceed about 70% of the cost of a new facility) or the existence of the facility in its current location is questioned, that replacement becomes a valid option.
Health estate planning and management into the next millennium A number of challenges will face all those involved in the provision and management of health service infrastructure in the years ahead. Focus areas should include the following: ➣ the ongoing restructuring of the existing estate which will require effective co-ordinated strategic capital planning.
126 ➣ the reinstatement of the existing health estate to an acceptable condition. This will cost some R8bn. The completion of this programme within a reasonable time frame will be an enormous challenge to health planners and consultants alike. ➣ the addition of new capacity to meet growing service needs. ➣ the ongoing replacement of outdated stock. Assuming a 50 year effective life span means that every year, 2% of the existing estate would need to be replaced. Based on an estate of R24bn replacement value this would require some R480m per year. ➣ the introduction of new, effective processes to ensure that the existing estate is efficiently maintained. Greater emphasis will be placed on the use of information technology to provide the maintenance management framework. ➣ options to restructure the provision of health care through changing the existing public/ private sector mix.
Upgrading Health Facilities 127 128 COMMUNITY 14 INVOLVEMENT IN HEALTH
INTRODUCTION There are many definitions to the notion of “community involvement in health”. This debate will not be re-visited in this chapter as it has already been dealt with in previous issues of the South African Health Review and elsewhere.1, 2 In this context, community involvement in health describes a process where people express their right to be active in the development of appropriate health services. It also means a partnership between individuals, groups, organisations, and health professionals in which all parties examine the root causes of ill-health and together agree on approaches to address them.3 This chapter will focus on government health policies that promote effective community involvement in health. Special attention will be given to the health district and local facilities where there should be maximal community involvement. How the legislative process allows for community involvement will also be assessed.
NATIONAL FRAMEWORK The Reconstruction and Development Programme The government of South Africa’s publicly stated commitment to a people-centred development approach which seeks to engage communities at the various stages and levels of development is an important international landmark. The Reconstruction and Development Programme (RDP) provided the necessary national framework for this. As a result, RDP structures were created at the national, provincial and local levels to facilitate the realisation of its intended objectives. These structures provided the solid foundation for community involvement in development activities, particularly those fashioned around the presidential lead projects of the RDP. The RDP Office was closed in March 1996, signifying what is seen by many as a major set-back for development in general and community involvement in particular. Although the government insists that it still adheres to the RDP as the overall development framework for South Africa, this change has affected the momentum that the launch of the RDP started in development. Most of the structures (mainly forums and committees) that were established are now struggling to remain functional. The unintended outcome has been a weakening of what appeared as an effective strategy for development. Several initiatives have since then been introduced by government including the new macro-economic framework of “growth, employment and redistribution” (GEAR). In a move to address civil society specifically, the Executive Deputy President, Thabo Mbeki, established an “Advisory Committee” comprising senior cabinet ministers and members
Authors: Elise Levendal, National Progressive Primary Health Care Network Shiela Lapinsky, Health Department, Western Cape David Mametja, Health Systems Trust 129 of non-government organisations (NGOs) to advise him on “structural relationships between government and civil society organisations” with respect to the provision of capacity (mainly financial) for development.4 One of the Committee’s finding was that the Independent Development Trust (IDT) and the Transitional National Development Trust (TNDT) were the main source of funding for civil society organisations (CSOs). However, the IDT was seen as playing both a funding and implementation role. This the Committee considered to be undesirable. The IDT should therefore be transformed into a government development agency and cease to function as a funding organisation. The Committee found the TNDT to be beset with debilitating disagreements among its founding members hence the slow pace in the Trust disbursing its resources. The Committee recommended that the TNDT should be phased out and a “statutory National Development Agency” be established.4 This has been accepted by the Executive Deputy President and Cabinet.
Local Government Local governments are seen as a statutory means through which “popular participation in the budgeting and integrated development processes” occur. It is believed that through elected local government representatives, communities will be able to participate at level much closer to them. A discussion document released by the Ministry of Provincial Affairs and Constitutional Development highlights the conflictual relationship that sometimes exists between local government structures and civil society organisations. “In some instances, the newer fora (non-government and community organisations) were regarded - or saw themselves as - the ultimate voice of authority in an area. This has had the effect of undermining municipal initiatives”.5
The new National Health System The Department of Health aims to transform the health system so that it may “foster community participation across the health sector, to involve communities in the planning, management, delivery, monitoring, and evaluation of health services, to establish mechanisms to improve public accountability, dialogue and feedback between public and health providers, and to encourage communities to take greater responsibility for their own health promotion and health care.”6 The draft National Health Bill envisages a National Health System which “encourages communities to participate in all aspects of health”. The Bill also entitles “every user to participate in any decisions affecting their health, unless it is not reasonably practicable”. A National Consultative Health Forum comprising statutory bodies (eg medical and dental council) and representatives from non-statutory organisations (eg. trade unions, NGOs, and professional associations) has been established. Provincial and national summits were also recommended.7 The Department of Health states that it is committed to consultations with the public on its policies. The National Progressive Primary Health Care Network (NPPHCN) reports that of 22 consultations on new policies that were made, only 5 were with community representatives. The remainder were with professional groupings and influential individuals.8,9
Legislative process The National Assembly Portfolio Committee conducted public hearings to encourage the public to contribute to health legislation. A discussion on the pieces of legislation for which hearings were conducted by the Portfolio Committee on Health follows.9,10,11
Proposal for Two Years of Additional Vocational Training for Medical Practitioners These hearings addressed the proposal to introduce two years of additional post-graduate vocational training for medical practitioners. Twenty-five oral submissions were made to the Committee from a range of stakeholders, mainly, professional associations and academic institutions. Only one submission came from community representatives. Well-intentioned attempts by the Committee to elicit contributions from trade unions, civic organisations and other organs of civil society were not successful.
130 Proposal on Regulations on the Dispensing of Medicines A total of 38 oral submissions were received. The majority of inputs at the hearings were received from organisations representing communities. These inputs were from civic organisations, NGOs, CBOs, religious groups and political parties. These organisations represented the national and local levels. These groups generally opposed the regulations because of the fear that they would make medicines less affordable and less accessible.
Choice on Termination of Pregnancy Bill The Choice on Termination of Pregnancy Bill, introduced in mid-September 1996, generated significant public and media interest. Hundreds of groups and individuals made written submissions. There was a high level of public participation.
Nursing Amendment Bill The one-day hearing heard submissions largely from professional organisations, although there was some input from community organisations.
Medical, Dental and Supplementary Health Services Professions Amendment Bill - Medicines and Related Substances Control Amendment Bill - Pharmacy Amendment Bill Limited public hearings were held on these Bills. The Committee intends enhancing the consultation process by: ➣ holding hearings in community settings ➣ undertaking research to formulate concrete mechanisms to facilitate greater inclusiveness in the democratic process ➣ using other media such as community radio ➣ holding an open health day to familiarise people with Parliament and its processes ➣ assist with the holding of hearings in provinces, particularly for Bills which will be debated in the National Council of Provinces ➣ inviting provincial representatives to hearings in the National Assembly.
THE DISTRICT HEALTH SYSTEM Structures for community involvement at district level One of the main transformation strategies of the health system is around decentralisation. This is primarily taking place within the context of the district health system which empowers communities to participate in the system’s governance.12 “A Policy for the Development of a District Health System for South Africa” was adopted as an official policy document of the Department of Health in February 1996. It presents the Department of Health’s long-term vision for the development of the new district health system. Provinces have been given three options for the overall governance of districts (See Chapter 6). The choice of governance options will have profound implications for community involvement in health. “In each of these governance options, the District Health Council needs to be structured to ensure meaningful participation of the community and all other stakeholders and role players concerned with the health of the people in the district”. Envisaged structures at the community level are the Community Health Committees and Community Development Forums. At the district level, the District Health Council is the primary governance structure. Each district hospital should have a hospital board. In a survey done by the NPPHCN as part of the Hospital Strategy Project, it was found that most respondents feel that Hospital Boards should advocate the aspirations of the community. However, community members appear to be reluctant to be involved with hospital financial and budgetary matters - an area they feel belongs to hospital management.3
Community Involvement in Health 131 The responsibilities of District Health Councils are such that many potential members will find themselves in unfamiliar situations. They will be expected to represent the interests of the whole health district, and not just the constituency or forum from which they have been elected. Thus, it is therefore necessary that the health system as a whole, both provincially and nationally, establish a process for the development of Council members so that their role and expectations as part of a ‘corporate’ structure are explained and clarified.
Provincial comparisons The National Progressive Primary Health Care Network conducted an assessment of Com- munity Involvement in Health in Mpumalanga and the Western Cape. A detailed summary of this assessment is given below. Less detailed information was available from the other provinces.13
Mpumalanga Province Understanding the District Health System (DHS) Policy makers have made some progress in broadening understanding of the district health system by encouraging community members to participate in District Facilitating Teams (DFTs). As a result of the intensive capacity building efforts, these community members were very knowledgeable about the District Health System. Outside these teams, understanding of the District Health System was low.
Consultation Communities and other stakeholders were informed about the process and brought on board from the beginning. The DFTs, who were given significant authority to take decisions, included representatives from local government, the department of health, NGO’s, RDP Councils and community leaders.
Needs Assessment Many positive steps have taken place to encourage the participation of communities in assessing their health needs. Community members were included on the DFTs that developed the situational analyses. Much capacity building was done to assist in this process. Despite these positive steps, there were conflicts between health workers and communities about priority health needs of communities.
Capacity Development A structured programme was established to improve the PHC knowledge and strategic planning skills of the DFTs. Sufficient resources were provided to ensure the participation of communities. Despite these efforts, the capacity-building process to develop the District Health System plan for the province was fast and product oriented. This made it difficult for some community members to cope. The Mpumalanga Health Department has expressed a commitment to continue the capacity development process for community health committees. This process has not yet been implemented. A plan has also been devised to reorient health professional to develop an understanding of how to work with communities.
Organisation Steps have been put in place to establish health committees whose role is to assist health providers to identify community needs and constraints. However, no long-term mechanisms have been established to keep communities involved in the district and it is not clear how health committees will be trained and sustained. This could be a major problem, resulting in the loss of all of the capacity that has been developed during the strategic planning process.
Leadership Communities were involved in the development of a district health plan for their province, but the process was mainly driven by skilled professionals. There are also no guarantees that health managers will concede control to communities after district authority structures are created.
132 Within the DFTs, too much emphasis was placed on a few community leaders. It was also not clear how any of these structures would become rooted in communities. The relationship between elected councillors and participatory structures has also not been addressed. Local government structures in the province have not been finalised and uncertainty exists on local governance issues.
Western Cape Understanding the District Health System (DHS) The Province has developed very progressive policies and plans on community involvement similar to Mpumalanga.
Consultation Extensive consultation and popularisation of the provincial health plans occurred during 1995 and early 1996. According to provincial officials, lots of effort was made to make people aware of the provincial health plan. However, as a result of too much time passing before follow- up or action some people seem to have forgotten about these efforts.
Capacity development Plans to train community health committees, working in collaboration with NGOs and training institutions have been developed and are waiting to be implemented. The plans to use professional health workers to initiate community involvement could be problematic as it could lead to manipulation rather than involvement.
Organisation The province has not finalised its decision on governance options. It appears to be leaning towards the local government option wherever possible. This will increase the role of elected local councillors. It will be difficult to structure the relationship between community structures and elected officials.
Leadership There is little authority and no control of financial resources by communities. Many communities have shelved their interest in the district development process and focus on locally based programmes.
Free State The Department of Health in the province regards the District Health System as the major solution to problems of health service provision in communities. Guidelines have been proposed to establish District Facilitating Committees and Interim District Management Committees. Provision is made for community participation in the governance of DHS through the formation of Community Health Committees. District Facilitating Committees have been established which comprise 80% community members and 20% officials. The province has also passed a Hospital Act which compels hospitals to create Hospital Boards which should “represent community needs and priorities in the hospital management”.15
North West In its budget presentation to the provincial Parliamentary Standing Committee on Health, the North West Department of Health emphasised its mission which is “To co-ordinate and deliver accessible, equitable, affordable, efficient and effective developmental health and welfare services through community participation in the North West Province. The Department seeks to foster people’s governance in its hospitals and make clients aware of their health [medical] rights”.
Northern Cape In its budget presentation to the National Assembly Portfolio Committee on Health, the Northern Cape Department of Health revealed as one of its strategic objectives, the promotion of a people and community oriented approach to health. The Department aims to strengthen
Community Involvement in Health 133 community based organisations. In Kakamas and RiemvasmaakA committees comprising health workers and community members exist. The committees are advisory and are often not active. The NPPHCN is providing training to some of the Committees there.
Eastern Cape In response to an NPPHCN information questionnaire, the Department of Health indicated that it aimed to involve the community in the planning, implementation and evaluation of health care services. Community health councils, clinic health committees, hospital boards, health forums and health advisory committees have been instituted. The Department was waiting for legislation to be in place to formalise community health councils. Community representatives responding to an NPPHCN questionnaire indicated their willingness to oversee employment processes within hospitals but did not want to take responsibility for the hiring and firing of staff members.
Gauteng Province In its response to the NPPHCN’s information questionnaire, the Gauteng Department of Health indicated its acceptance of community involvement at all levels of the service. This would be in the form of clinic committees, hospital boards and district health councils. Hospital Boards already exist but need to be restructured. Some clinic committees exist but the majority need to be revived. District Health Councils will only be in place when district structures are finalised. Community capacity will be developed through health promotion programmes and training of representatives serving on clinic and other committees.
KwaZulu-Natal The community is accepted as one of the chief stakeholders to whom the Department is accountable. Regional Management Advisory Teams, District Health Councils, Community Health Forums, NGO’s and CBO’s interaction forums, Hospital Boards, Clinic Committees and PHC committees, Joint Health Services Work Groups with Local Authorities will be established where they do not exist. All these structures are in place except for the District Health Councils and the Provincial District Health Committee due to the slow progress in getting the district health systems off the grounds.
Northern Province No information was available.
Primary School Nutrition Programme (PSNP) The Primary School Nutrition Programme (PSNP) was introduced as one of the Presidential Lead Projects in 1994. Its aim was to improve health status (including nutrition status) and the quality of education and life of the disadvantaged sectors of the South African Society. It was anticipated that the Programme would receive significant attention from and be controlled by communities, parents and teachers in the schools where it operated. An evaluation of the programme demonstrates that community involvement in the PSNP generally meant community members being used as “functionaries” of a vertical feeding programme over which they had little input and control. The many Project Committees that were established (comprising community representatives and teachers) were ineffective and often, the management eventually fell on the shoulders of the teachers. An evaluation of the PSNP shows that, little thought was given to capacity building of the various project committees. Members found themselves without the requisite skills needed for their participation in the programme. Also, community members wanted to be remunerated at levels higher than what the Department was prepared to offer.16
A These are sites where the Initiative for Sub-District Support is operating. This is a project of the Health Systems Trust.
134 Community Health Workers Policies by the Department of Health do not provide for a formal role for CHWs within the public health sector. “It is recognised that this category of health worker (CHWs) may be able to make an important contribution to the health of communities in some instances, and to provide a link between the formal health services and communities. Furthermore, this category should not be incorporated into the formal health services. This obviously does not preclude NGOs/CBOs and other organisations from continuing with CHW programmes.” Many other developing countries have used CHWs as a catalyst for Community Involvement in Health and community development. Though the Department has been reluctant to endorse CHWs, they have provided space in their policy framework for provinces to make their own decisions on this issue. Community Health Workers have an important role to play in the provinces. They have developed a sense of trust in their communities. They speak the local language and are acquainted with cultural norms. These groupings should be more pro-active in taking the process forward on community level.
CONCLUSIONS Although the national framework for development seems to have been weakened, health policies from the Department of Health (both national and provincial) have still managed to highlight the need for communities to be involved in the planning, management and delivery of appropriate health services in their policies. However, besides the political commitment given, implementation still lags behind the good policies that have been developed. Support mechanisms for community involvement need to be put in place at the district level. National and international experience has shown that Community Involvement in Health has to be planned and funds budgeted. Resources should be put aside to support this process. Related to this is the issue of capacity development. This is about the training of health professionals and communities in health services delivery. The training for both groups should be learner-centred, problem-posing, based on self-discovery, action-orientated and outcomes based. Content should include knowledge and skills of how to work with and in communities, knowledge about the health system and health and development. Capacity development is also about making it easier for people to participate in the health system. It is also about reviewing the inflexibility of procedures within the health system. These make it difficult for health professionals to develop Community Involvement in Health and for communities to be involved in health. Bringing community members into a meeting where they have statutory powers to effect change, does not mean that they will be able to do just that. In order to ensure widespread effective participation, there should be support mechanisms, including financial support if meaningful community participation is to be realised.
Community Involvement in Health 135 136 HEALTH 15 AND THE MEDIA
OVERVIEW The past few years have seen the media move from the position of an outside critic to an inside participant. With the new democracy, the media can no longer stand apart blaming others for what is wrong in the health care system, and it now has to look to itself and ask where it has failed in making things work. Yet while it has moved a great distance, the media still has a long way to go in conveying the full picture of what is happening in health. This is particularly true when it comes to the health and development issues affecting the poor. While there are many developments in the country, many of these developments are passing marginalised communities by, and the press has done little to put across their side of the story. A study by the Community Agency for Social Enquiry (CASE)1 highlighted the dearth of stories on the poor in the mainstream media. Its analysis found very few reports relating to Africans of low income in rural areas. It also found that the health issues that were covered were of relevance to the whole population. The usual response of the media to this criticism is that it is in the business of selling news, and the subject of the poor is not news. Yet when the status of the poor is viewed from the stance that health and development are the most accurate barometer of a government’s progress, the perspective changes. Whether a government is delivering on its promises or not is news by any media’s standard. On this topic, Argus editor Moegsien Williams is direct. “The media has done half a job, it has told only half the story, and it has to hold accountable politicians who have made promises,” he says. A good newspaper, he says, is one which reflects the mosaic of South Africa in all its intricacies and complexities, which redefines what constitutes news, and develops new journalistic approaches. “Journalism needs to show the relationship between poverty and politics, and to pick up on the drama and undercurrents of South Africa. Unless we cover the soul of the nation, press freedom will not emerge as important because we will remain irrelevant to their lives,” he says. Sunday Independent editor John Battersby takes a similar view; “We have to get out to (impoverished rural areas) and tell the story. We do have that window of opportunity. If society is to change, media has to go through that fundamental transformation as we are there to reflect what is happening in society.” The main reason why stories on poverty feature so seldom in the media is the basic tension between the need to cover stories which are important, on the one hand, and the profit motive of the media on the other. The questions remain of whether the media would not serve the country’s longer term economic interests better by more thoroughly examining government’s economic policies, and whether the media in a country like South Africa should not give the same attention to poverty indicators as it does to business indicators.
Author: Kathryn Strachan, Business Day 137 Indian journalist and author Palagummi Sainath recently gave South African editors his perspective. “Of course a newspaper needs to make a profit. But journalism, particularly in the social sector, is at its best when tied to ideals or principles that go beyond profit. Newspapers are not all there is to journalism, and journalism is not all about newspapers.”
A CLOSER LOOK AT WHAT HEALTH JOURNALISM NEEDS Sunday Times and SAfm journalist Pat Sidley believes part of the problem is that people in the media lack investigative skills, and there are neither the resources nor the leadership to pass on these skills to new people coming into journalism. It is not only reporters, but editors in particular, who lack an adequate grasp of society, its needs and transition. In all sectors, but particularly in health, the media does not understand nor convey the full picture, she says. If one of the functions of the media was to give people options which would enable them to make choices, then how well had it done? Health Systems Trust programme director David Harrison recites a recent news item which stated “hospitals are crumbling and nurses are leaving”. That was all. “We need to show the other side, the overall picture. We need to show why the most visible changes are happening in hospitals, and why rationing is necessary,” he says. David Robbins, seasoned health journalist and author, believes the broader issues are being lost in the constantly renewed flood of detail. “This is happening because in nearly every sphere radical change is taking place. The whole country is in transition. This generates as much confusion as it does good stories. The old sureties of who’s good and who’s bad have disappeared. Health is an excellent example of this process in action. People are constantly asking: what is the context? My feeling is that most newspapers (and TV and radio stations), the main purveyors of information and opinion in democratic countries, simply don’t have the answers. “It starts with the journalists. Some ... of those who write the health stories simply don’t have a firm grasp of the context. It’s too complex, perhaps, or changing too rapidly. So we fall back on the superficially dramatic: the toyi-toyiing nurses, the under-funded hospitals, the importation of foreign doctors, for example, without knowing (far less explaining) the framework in which such events are taking place. The result is that the readers are left with the dangerous impression that there is no contextual framework, in other words that there’s no policy to speak of.” Robbins believes that this lack of a contextual base has left a lot of journalists and newspapers in a position of fundamental weakness. This in turn has made them far more susceptible to the demands of an imaginary audience, an audience of sensation hungry controversy-mongers who needed something to get their teeth into before turning to the sport. The heart transplant row of 1996 was a good example. So many reports assumed that the health authorities were the bad guys and the talented surgeon the misunderstood good guy. There was little reported of the less newsworthy policies underlying the position of the health authorities. Policies of equity, parity of access, and the economic necessity to rationalise transplants were either too boring or not newsworthy. To balance the picture, however, we need to remember Sarafina, the great health controversy of 1996. This was a real controversy. The media played a crucial role in insisting that the department account for its actions. But it’s all the false alarms such as the heart transplant furore that cause concern. They incidentally have the effect of blunting the impact of the real issues when they come along. The truth is that the journalist’s old yardstick “is it in the public interest” has been quite amazingly distorted by our imagined audience. The media needs to continually ask itself “whose reality” and “whose perceptions” it is reflecting. Here, says Palagummi Sainath, the press often underestimates its readers. In fact, readers are on the whole far more enlightened than most journalists, and the greatest achievements of the press in any part of the world has come when it has appealed to reason, logic and the higher instincts of readers, he says. “This is the moral imperative of good journalism. The greatest names in the press appealed not to self-interest but to the nobler instincts.”
138 MATERNAL, CHILD AND 16 WOMEN’S HEALTH
MATERNAL, CHILD AND WOMEN’S HEALTH: A SOUTH AFRICAN INNOVATION Maternal and child health (MCH) has been identified as one of the essential components of health care services to be delivered in the context of the primary health care philosophy. In the restructuring of the health system in South Africa, MCH service delivery crosses all levels of care which are linked by appropriate referral systems. This approach is integral to the PHC philosophy. Furthermore, targets are defined as children under 18 years in accordance with the Convention on the Rights of the Child. The inclusion of women and mothers, as a discrete identifiable component in the MCWH spectrum is different from the MCH service delivery in other countries and therefore represents a South African innovation.
Context In 1994/95 MCWH Plan was developed to guide policy and programmes, and in 1996, efforts towards implementation of the policy priorities. All provinces have appointed managers responsible for MCWH. Provincial and national managers meet regularly to discuss strategies, obstacles and challenges. The White Paper on Health1 emphasises the areas of the government’s plan for MCWH. The principles of the White Paper and the stated policy intentions provide a useful reference framework against which to measure progress and to identify opportunities for accelerating efforts.
Policy Priorities of the National Department of Health:
✧ Clear objectives and targets should be set at the national, provincial, district and community levels in accordance with the goals of the RDP, the health sector, and the Convention on the Rights of the Child. ✧ MCWH services should be accessible to mothers, children, adolescents and women of all ages, with a focus on the rural and urban poor, and farm workers. ✧ MCWH services should be comprehensive and integrated. ✧ MCWH services should be efficient, cost-effective, and of good quality. ✧ Women and men will be provided with services which will enable them to achieve optimal reproductive and sexual health. ✧ Individuals, households and communities should have adequate knowledge and skills to promote positive behaviour related to maternal, child and reproductive health.
Authors: Marian Jacobs, Child Health Unit, University of Cape Town Alyssa Wigton, Child Health Unit, University of Cape Town Nonhlanhla Makhanya, Health Systems Trust Beatrice Ngcobo, Gender Commission 139 This chapter will review some key developments in the sphere of MCWH over the past year. While the government’s national policies and plans provide the framework for the review, contributions from other players, such as academic and research institutions, and non-governmental bodies, are also recognised.
THE RDP: PUTTING WOMEN AND CHILDREN FIRST The Reconstruction and Development Programme gives explicit priority to the needs of women and children. In the health sector, these intentions were given expression in the presidential lead programmes of free health care for women and children and the primary school nutrition programme. While the Presidential Lead Programmes are often cited as evidence of a commitment to children, to demonstrate this commitment in financial terms in all sectors concerned is more difficult. Although the total spending on health in South Africa is quite high when compared to other countries at a similar stage of economic development, key indicators of health such as infant mortality are unacceptably high, indicating that spending patterns have been inappropriate.2 In addition to the key role that the health sector plays, there are other sectors through which adequate funding has direct bearing on the health of children. Two in particular are early child development (ECD) and social welfare. Public sector service delivery and financing for early child development falls between the Departments of Health, Education, Social Welfare, Housing, Labour, Justice, South African Police Services and the South African National Defence Force, each of which focuses on a different aspect of ECD. This fragmentation of service provision defies development of comprehensive approaches to ECD through government, leaving non-governmental organisations with the responsibility of developing effective holistic programmes within the constraints of declining resources. The recommendations contained in the Lund Commission on Child and Family Support, presented to Parliament in 1996, which strive to ensure equity and increased access to social welfare support, could have important implications for the health of children, and for approaches to financing equitable child-related initiatives in other government departments. While the numbers of children covered by a social welfare grant will increase, the absolute amount of money available to those currently receiving support will decrease. On the one hand, this shift has precipitated intense debates about expenditure on children in the context of the RDP commitment to putting children first. On the other hand, the prerequisites of birth registration and completed immunisation in order to access the grant could have important positive spin-offs for the health sector. The Women’s Budget 3 book was published during the year by the IDASA Budget Information Service. This challenged the commitment to women through examination of fiscal policies and resource allocation dedicated to women. The Children’s Budget 4 has raised similar discrepancies between policies and resources, suggesting that this is an issue which needs to be addressed in order to translate the country’s political commitment to women and children into programmes.
Observing Human Rights Within the country, implementation of two international human rights treaties - the Convention on the Rights of the Child and the Convention towards Eliminating Discrimination Against Women (CEDAW) - has identified the need for a human rights orientation in all health policies and programmes for women and children. The other initiatives include: ➣ Truth and Reconciliation Commission ➣ Health Rights Campaign (under the auspices of the National Progressive Primary Health Care Network)
140 PRIORITIES CLEAR OBJECTIVES AND TARGETS SHOULD BE SET
Reducing Mortality One of the important measurable objectives of the health sector is the reduction of mortality. There are no reliable national data on mortality (see Chapter 1). A national household survey of maternal mortality is being initiated by the Women’s Health Project at the University of the Witwatersrand. The system of Perinatal Audit provides an exciting model of a data system to inform district based decision making. This consists of a process through which information about maternal and perinatal deaths is collected at district level. This information is then discussed with a local heath care team to identify causes of death, determine any avoidable factors, and institute corrective action to prevent future deaths. The results of a pilot project undertaken by the Department of Obstetrics and Gynaecology at the University of Pretoria have now been developed into a simple user-friendly perinatal audit system, which is complemented by a computer programme called the Perinatal Problem Identification Programme (PPIP). This system is being applied in a number of districts around the country, and is set to become a system through which promotion of quality district-based care can be promoted by all public sector institutions striving to link local information systems to health care. Reducing Preventable Conditions This is another objective of the Department of Health. Prevention of infectious diseases and the transmission of sexually transmitted diseases (see chapter 22), have been emphasised and increasing attention is also being paid to appropriate strategies for the prevention of commonly occurring female cancers.
Preventing infectious diseases During the year, there were reports of a serious epidemic of Shigella dysentery in KwaZulu- Natal.5 There is a need for broad public health measures - including surveillance - to address the epidemic. Neonatal tetanus is still a cause of significant mortality in South Africa, especially in the rural areas. Based on admissions to a neonatal intensive care unit, staff at the King Edward Hospital in Durban identified promotion of maternal immunisation as the most important factor for eliminating neonatal tetanus.6 In this context, providing access to antenatal care is a priority and efforts to secure adequate supplies of vaccine provide one simple, yet vital link in strategies to prevent this condition. Acute flaccid paralysis (AFP) surveillance is the mechanism which the World Health Organisation has identified for monitoring progress towards eradication of poliomyelitis. In South Africa, the surveillance is being undertaken by all provincial health departments. Liaison with the districts to recognise an outbreak and implement outbreak response measures remains a logistical challenge.
Preventing commonly-occurring female cancers In South Africa, cancer of the cervix is the most important cause of cancer deaths in women, and early intervention through screening can have a substantial impact on reducing deaths. The debates about implementation of mass cervical screening programmes7 in the public sector have pivoted around appropriateness and feasibility in settings with poor infrastructure and resources. However the government has signalled its intention to implement a national strategy for cervical screening by including this issue in its policy documents.
Maternal, child and women’s health 141 MCWH SERVICES SHOULD BE ACCESSIBLE TO MOTHERS, CHILDREN, ADOLESCENTS AND WOMEN OF ALL AGES, WITH A FOCUS ON THE RURAL AND URBAN POOR AND FARM WORKERS Promoting access A flagship of the Department of Health’s efforts to address preventable mortality while promoting access to all was the national mass immunisation campaign of winter 1996. The impact of this campaign is not yet known but a systematic review of mass immunisation8 suggests that such approaches make little contribution to promoting and sustaining coverage and infrastructure for primary health care. Promoting equity Support for health care decentralised to the district level is at the heart of two non-governmental initiatives which have emerged during the year, the Equity Project in the Eastern Cape and the Initiative for Sub-district Support, a programme of the Health Systems Trust. Initiatives from the Child Health Unit at the University of Cape Town have supported the overall policy of equity.
The Child Health Policy Institute 9 aims to ensure that policies and programmes are beneficial to the health of children by: ✧ determining key policy questions from role-players in child health ✧ conducting and collating science-based investigations and analyses ✧ developing analytical tools and resource materials monitoring and evaluating child health-related legislation and policies ✧ providing education and training opportunities in child health policy.
The Maternal and Child Health Information and Resource Centre has been established to disseminate maternal and child health information, news and resources to health workers at local and district level, especially in rural areas of Southern Africa. This is done via a newsletter - MCH News, an internet web page,10 distance library and information services and responses to specific enquiries in relation to clinical and programme management.
The activities of these two initiatives are conducted in collaboration with a wide array of service, management and academic institutions around the country, and the services and products are available as national resources. Farming communities have often been cited as marginal sectors in determination of strategies to reduce poverty. In the last year there has been a resurgence of interest in the plight of children on commercial farms. One area in which these concerns have emerged is child labour. Collaboration between the International Labour Organisation and South Africa to identify the extent of the problem of child labour, especially on farms, has led to discussions to develop strategies to combat this problem. The Department of Health has been an active participant in these discussions, and will form part of the team being assembled to undertake the investigations later in this year. The issues of health care for children on farms are not simply concerned with children as labourers, but also as dependants of workers who are often poorly paid, not unionised, and whose health is plagued not only by the social and economic circumstances of the farms themselves, but also by lack of access to health care. An organisation currently involved in addressing some of these concerns is the Rural Foundation, and in the forthcoming year, there are plans to develop firm recommendations for structured, institutional responses from the health sector as a whole, rather than the sporadic, ad hoc projects which have been directed at this problem in the past.
142 A specific marker of the problems experienced by children on farms is foetal alcohol syndrome. In the Western Cape, where the system of paying farm labourers by the “dop system” (alcohol as part of the package of payment for work) still prevails. The issue of alcohol-related health conditions has been a concern for years, and various development organisations have used different approaches to attempt to address the problem. In the past year, a Foundation for Alcohol-Related Research11 has been established in the Department of Human Genetics at the University of Cape Town, heralding opportunities for closer collaboration between health and other sectors in efforts towards redress.
MCWH SERVICES SHOULD BE COMPREHENSIVE AND INTEGRATED An essential package of services Recommendations from a major study published by the Centre for Health Policy in 199612 provide a backdrop for defining an essential package of services to be delivered through the national health system. Initiatives towards developing consensus on a core set of relevant MCWH indicators are being undertaken by national and provincial departments, and also within smaller regions and districts around the country.
Antenatal care In the process of defining essential care to be available to every person, the frequency of antenatal care visits has been questioned by those provinces and regions which are attempting to develop equitable “packages” of services13 . There is consensus that any schedule should take local conditions into account, that quality of care is as important as quantity and timing of visits, and that antenatal care should be linked to a clear system of referral and management protocols.14
Screening for child disability Although the extent of childhood developmental disability is undetermined in South Africa, the demands of disabled children on health services attest to the importance of including early detection and management of this problem in the range of services to be provided in an essential package of care. A national meeting was convened to discuss this issue mid-1996.15 The consensus statement which emerged indicated guidelines for the types of screening; the schedule and tools which should be used; which interventions should be prioritised; and what personnel and training would be needed. Integrated, comprehensive care Integrated management of childhood illnesses For pre-school aged children, preventable diseases remain the most important cause of death. The Department of Health has reacted to this situation by initiating a long-term plan to reduce mortality, disability and chronic illness caused by these diseases, and to promote health. The first stage of this plan includes development of an Integrated Management of Childhood Illnesses (IMCI) approach.16 This approach consists of guidelines for managing sick children up to the age of six years. The process consists of assessing and classifying the extent of the illness, treating the child, counselling the caregiver, and following up the patient. The first conditions targeted are diarrhoeal disease, acute respiratory infection (ARI) pneumonia, malnutrition, measles and malaria, with the initial phase dedicated to the management of diarrhoeal disease, ARI and malnutrition. The process involves consensus development with appropriate modifications for implementation at provincial, regional and district levels of care. Co-ordination is managed by a national technical advisory group comprised of academic and health service providers supported by international agencies such as UNICEF and WHO.
Maternal, child and women’s health 143 At provincial level, development of case management guidelines prior to the IMCI initiative has provided pointers to strategies for success. Provincial efforts have included: ➣ The Well Child Initiative adopted by Mpumalanga ➣ The process towards development of case management guidelines in the Western Cape ➣ The pilot training based on the BASICS project in a region in the Eastern Cape The national IMCI strategy seeks to use these experiences to define the core essential components for every province and district.
INTERSECTORAL COLLABORATION The ratification of the Convention on the Rights of the Child (CRC) provided a new impetus for accelerating intersectoral action and collaboration to promote the well-being of children, and the Department of Health played a leading role in co-ordinating the process towards implementation of the country’s National Programme of Action for Children,17 launched in 1996. This plan, which is founded on the tenets of the CRC, has been a useful instrument for identifying missed opportunities for collaboration between the health sector and other sectors, and has facilitated intersectoral partnerships for planning and programming in areas such as: ➣ children with disabilities ➣ child sexual exploitation and child labour ➣ child development through early child development ➣ the health promoting schools initiative These initiatives are discussed further in this plan, and they reflect the general shifts towards giving equal weight to recognising the rights of children to develop and to be protected, and not merely their right to survival. National and regional programmes to prevent and manage all forms of child abuse are being spearheaded by the welfare sector around the country, and health strategies are being incorporated into these multidisciplinary plans. There remains a challenge for the health sector to mainstream child abuse as an area for urgent attention. The Commission on Gender Equality (CGE) was established to consolidate South Africa’s plans to address the concerns of women, and provides a similar forum for developing intersectoral approaches to women’s health challenges. It is an independent, statutory body created by the Constitution. It was created as part of the mechanism to promote and protect gender equality within a broader struggle for democracy and social justice. The CGE works towards a society based on equality where all people have the opportunity to realise their full potential, regardless of gender, race, class, culture, religion, sexual identity, and geographical location. Fundamental to this vision, is the transformation of gender relations, including the distribution of power and resources. The Act that established the CGE mandates it to promote gender equality in South Africa by undertaking the following tasks:
Monitoring and Evaluation - the Commission is authorised to monitor, investigate and evaluate the protection and promotion of gender equality within government, and in civil society. Where the commission finds examples of inequality, it can make recommendations to remedy the situation. Assessing laws within national, provincial and local government - The Commission is tasked with monitoring national, provincial and local government legislation to ensure that they reflect and promote gender equality. Where the Commission identifies a problem with the law, it may recommend that it be changed. International Conventions - The Commission has powers to monitor adherence to international instruments like the Convention for the Elimination of All Discrimination Against Women (CEDAW).
144 Research - The Commission will conduct research, in-depth analysis, and investigations of gender oppressive practices, customs, traditions and laws.
What has the CGE done since its establishment? Information and Evaluation Workshops - The workshops were held in May 1997. Participants from government departments and civil society shared information on structures they have set up, and issues they focus on to promote gender equality. A report with this information has been published. The information in the report is very useful for networking. Similar workshops will be held in all provinces before the end of the year. Strategic Planning - The Commission had its first strategic planning meeting at the end of May 1997. At this meeting, key work areas were identified. These include the law and justice system, custom, culture and religion, and eradication of violence against women. Public participation in designing the logo - The CGE is currently planning workshops in KwaZulu-Natal which will involve groups from Mpumalanga and the Northern Province to help design the CGE logo. The aim is to create a symbol with which other partners involved in the process of transformation of gender relations are able to identify with. Submissions to Parliament - The CGE has made submissions in the following areas: the National Budget, the Lund Proposal, and the Domestic Violence Bill.
Programme of Action - All the activities that the CGE is engaging in, including the logo process, will help to inform its programme of action, which will be launched before the end of November 1997.
HEALTH AND EDUCATION The links between health, education and nutrition have been highlighted in Chapter 24. The results of national surveys on young child anthropometry, micronutrient status and strategies for control of parasite infestation helped in understanding the link between nutrition and education. The RDP gave effect to the importance of this link in the primary school nutrition programme. However, school nutrition programmes are but one component of school health services, and during the year there were other discussions and initiatives in this area: ➣ The health promoting schools movement has been widely accepted as a model through which health and education can be integrated and has been adopted in the Western Cape. ➣ An analysis of school health service in KwaZulu-Natal18 showed that infrastructural issues (eg transport, organisational linkages) are key obstacles to successful implementation of school health services ➣ The National Commission for Educational Support Services was established to investigate how best to support scholars with special educational needs.19
DISABILITY South Africa’s Constitution lists disability as a special focus for implementation of human rights, and within this context, the issues of children formed the focus of a special meeting.20
Recommendations for the health sector which emerged at this meeting included the need: ✧ to institute early identification measures and an information system which is capable of tracking progress with programmes ✧ to ensure that legislation makes provision for ensuring that disabled children have access to health care, with specialised treatment available at specialised facilities to develop dedicated budgets for children with disabilities ✧ to ensure that children with disabilities have equal access to nutrition programmes ✧ to work towards equitable distribution of services between the different levels of care.
Maternal, child and women’s health 145 Within these recommendations, the importance of training health care workers, as well as parents, was emphasised.
MCWH SERVICES SHOULD BE EFFICIENT, COST-EFFECTIVE AND OF GOOD QUALITY
Approaches to developing norms and standards for services are an important challenge for the health sector, and for specific programmes within the system, such as MCWH initiatives.
Defining norms and standards Neonatal care In the area of neonatal care, the University of the Witwatersrand is currently undertaking a province-wide survey of neonatal bed availability and occupancy to determine shortages and excesses against norms developed on the basis of Baragwanath Hospital data.21 This study could provide an important complement to the guidelines which are published in the Perinatal Education Programme manuals which are used for training health professionals in obstetric, perinatal and neonatal care in almost all provinces.
Developing management tools Several organisations are developing analytical tools to assist in planning, implementation, supervision, monitoring and evaluation of district level programmes. A Maternal and Child Health Management and Information Manual is in development at the Child Health Unit, University of Cape Town.
Identifying appropriate levels of care In the year under review, budgetary cuts, together with efforts towards the national policy of decentralisation, resulted in some relocation of general ambulatory services from tertiary hospitals to community-based facilities (eg. Red Cross Children’s23 and Tygerberg Hospitals22) Earlier reports to examine utilisation of a teaching hospital and a community health centre by paediatric patients showed that: ➣ 48% of children being managed by the general medical out-patient services of a teaching hospital were unreferred23 ➣ 69% of teaching hospital visits were inappropriate for a tertiary institution24 ➣ accessibility and user perceptions of quality are two key factors in determining user’s choice; these can be targeted in promoting more appropriate use of primary care facilities. In implementing the policy of appropriate levels of care, greater attention will have to be paid to understanding the reasons why patients prefer the perceived inconvenience and costs of presenting themselves to tertiary institutions over using primary level care services.
WOMEN AND MEN WILL BE PROVIDED WITH SERVICES WHICH WILL ENABLE THEM TO ACHIEVE OPTIMAL REPRODUCTIVE AND SEXUAL HEALTH
Within this policy principle, provision of sexuality and reproduction-related information and provision of peer group education on sexuality and lifeskills are explicit aims, focusing on both men and women. The Planned Parenthood Association, an NGO, has taken the lead in bringing the principles of planned parenthood, reproductive health and responsible sexuality primarily to youth and young adults. This has been effected through: ➣ A Youth Sexuality Project which offers contraception services, counselling and education.
146 It is being developed as a model which could be replicated for youth health services elsewhere ➣ A Schools Project which aims to equip teachers with the knowledge, confidence and skills to implement teaching in these areas through the curriculum ➣ The Male Involvement Programme which specifically addresses the educational needs of men in the field of reproductive health and contraception. Public sector participation in all phases of these projects has provided an opportunity for consideration of “mainstreaming” them into core public health sector programmes. The current status of the availability of comprehensive HIV/AIDS, STD and family planning services at all health centres are reviewed elsewhere in this document. There is little data available on the provision of cervical smear services. Overview of the new Termination of Pregnancy (TOP) Act On the 1st of February 1997 the Choice of Termination of Pregnancy Act came into effect. This law provides a legal framework through which women can exercise their constitutional right to reproductive choices. The underpinning objectives of the Act, as reflected in the preamble, can be summarised as follows: ➣ To provide for legal TOP in a context that recognises the value of human dignity, the achievement of equality, security of the person, non racialism and non sexism, and the achievement of human values and freedoms which underlie a democratic South Africa. ➣ To recognise that both women and men have a right to be informed of, and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and that women have the right of access to appropriate health care services to ensure future safe pregnancy and childbirth. For the first time in South African history, the Act provides for an untrammelled right to abortion in the first twelve weeks of pregnancy. Ideally, all that the women need to do is to request for, and give consent to, the abortion. While the Act inevitably assumes that health services will give effect to the intention of the Legislature, giving practical meaning in the form of service provision is problematic. This is reflected by National TOP statistics within the first three months of implementation (see Table 1 below). In the first 3 months, nearly 7 300 terminations were performed. It is difficult to predict what the demand will be. However, of these terminations, around 60% were performed in Gauteng; and around 40% were performed after 12 weeks. Both of these factors indicate some problems in implementation.
Maternal, child and women’s health 147 TABLE 1 NATIONAL TOP STATISTICS FEBRUARY TO APRIL 1997 NUMBER OF TERMINATIONS BY AGE OF WOMAN, GESTATIONAL AGE OF FOETUS Western Cape Western Cape Eastern Cape Eastern Cape Northern Cape Northern Cape Free State Free State KwaZulu-Natal KwaZulu-Natal North West North West Northern Province Northern Province Mpumalanga Mpumalanga Gauteng Gauteng Sub-total Sub-total Total Total Western Cape Eastern Cape Northern Cape Free State KwaZulu-Natal North West Northern Province Mpumalanga Gauteng Sub-total Total Western Cape Western Cape Eastern Cape Eastern Cape Northern Cape Northern Cape Free State Free State KwaZulu-Natal KwaZulu-Natal North West North West Northern Province Northern Province Mpumalanga Mpumalanga Gauteng Gauteng Sub-total Sub-total Total Total
Gestation weeks <12 228 121 333 74 10 3 50 74 593 1 186 >12 73 50 22 83 6 3 28 41 421 727 Age <18 68 20 25 0 3 0 33 10 ? 159 February >18 233 151 30 157 13 6 45 105 ? 740 Total 301 171 55 157 16 6 78 115 1 014 1 913 Gestation weeks <12 72 75 178 40 2 14 101 540 1022 >12 232 96 95 44 8 13 34 431 953 Age <18 77 20 42 0 1 9 10 226 385 March >18 227 151 231 84 9 18 125 745 1 590 Total 304 171 41 273 84 10 27 135 971 2 016 Gestation weeks <12 266 116 18 0 137 1 266 1 803 >12 85 115 6 0 41 1 008 1 255 Age <18 85 54 3 0 16 487 645 April >18 2 6 6 177 21 0 16 2 1 7 8 7 2 413 Total 351 175 42 231 92 24 0 178 2 274 3 367 Total 956 517 138 661 192 40 105 428 4 259 7 296
Realistically the Act reflects the intention of the legislature to make legal TOP equally accessible to all South African women. However, in itself the Act cannot ensure or guarantee equitable and unrestrained access to TOP. Figure 1 shows the relative access to TOP by showing the ratio of the proportion of TOPs performed relative to the proportion of population, by province. Ideally, each province would have a ratio of 1. Gauteng is clearly doing proportionally much more than its share whilst KwaZulu-Natal, Northern Province and North West are doing much less than their proportional share.
FIGURE 1 RATIO OF PROPORTION OF TOPS / PROPORTION OF PROVINCIAL POPULATION
2.5
2
1.5
% TOPs / % population % TOPs 1
0.5
0 Western Eastern Northern Free KwaZulu North Northern Mpuma- Gauteng Cape Cape Cape State Natal West Province langa
Source: Barometer. Reproductive Rights Alliance Vol 1, Issue 1, June 1997.
148 Progress with Implementation Although the first three months of implementation has not been easy, there are reasons to be positive: ➣ All the Provincial co-ordinators for the MCWH Programme have been appointed. ➣ Provinces have had training sessions on TOP Values Clarification. ➣ National Guidelines for implementation have been developed and circulated to Provinces. ➣ Research around implementation issues is underway in some Provinces. The Reproductive Rights Alliance has produced documentation regarding implementation within the first month. It is hoped that Provinces still experiencing problems will learn from others through the sharing of success stories. There are a number of problems around the implementation of TOP, especially around moral objections. ➣ Many service providers have conscientious objections to TOP. ➣ Personnel who have volunteered to participate are often emotionally affected, however there is no counselling service provided for them. ➣ Health providers who are opposed to TOP are still experiencing the moral dilemma of being expected to refer clients accordingly. ➣ Some health workers have displayed hostile attitudes towards those involved in TOP.
INDIVIDUALS, HOUSEHOLDS AND COMMUNITIES SHOULD HAVE ADEQUATE KNOWLEDGE AND SKILLS TO PROMOTE POSITIVE BEHAVIOUR RELATED TO MATERNAL, CHILD AND REPRODUCTIVE HEALTH
Promoting health - not just preventing disease Communication strategies There is broad agreement that the multimedia strategy which underpins “Soul City” has been South Africa’s most successful strategy to date. The third series of the project was launched in the middle of 1997, and the focus on violence, HIV/AIDS and household energy provide opportunities for reinforcing some of the messages from the two earlier series, and for linking health messages to other areas such as electrification. The first series which focused on MCH has been converted into an education package which can be used by schools, trainers and other resource persons, and the methodology of linking such education to entertainment - “edu-tainment” - is one which could usefully be adopted by other NGOs and government alike.
The role of legislation In seeking to support positive health seeking behaviour, review of the enabling role of legislation warrants some investigation. In the past year, some legislation promulgated outside of the health sector has had important implications for MCWH. The new Labour Relations Act (1996) has extended the terms of the Basic Conditions of Employment Act (1994) by providing job security, along with leave for pregnant and lactating women. The draft Employment Standards Act stipulates four months of maternity leave for women, without specifying whether payment is mandatory. There is thus a challenge to legislation to ensure that the health rights of all working women and their dependent off-spring are protected.
Maternal, child and women’s health 149 YOUTH HEALTH This is a special area which crosses many of the priorities reflected in the Department of Health’s white paper.1 Some examples of the problems are given to illustrate: ➣ In 1996, a published survey of more than a thousand teenage girls from the Transkei25 showed that at least 23% of them had been pregnant before. This alarming result invites a response from those charged with MCWH service delivery - in both governmental and non-governmental health services. ➣ In a series of articles in the South African Medical Journal a comprehensive overview of the behavioural factors underlying the situation of youth health is provided. The articles endorse the need for action and point to specific interventions required on behalf of the health sector.26 NGO’s have responded to this situation, and have been extremely innovative. Examples of these are the Planned Parenthood Association of South Africa and the Adolescent Health Project of the Health Services Development Unit at Acornhoek, Mpumalanga.
OTHER AREAS OF CONCERN Increasing attention is being given to the importance of chronic illnesses. Disability is well recognised in this area, but less attention has been paid to conditions such as epilepsy and asthma. Although asthma was formerly regarded as a concern for developed countries, international evidence has pointed to the fact that childhood asthma is a common condition in developing communities as well. In South Africa, the estimated prevalence is 3-6% and mortality and morbidity has increased, in spite of available knowledge about effective medical treatment. This underscores the need for seeking appropriate management in the context of current knowledge, the available resources and the model of comprehensive care. Although much attention has been paid to the environment, the special needs of women and children have not yet entered these debates. An example in this regard is the national concern of the impact of tobacco on health. While child risk behaviour patterns have been identified, and legislation restricting sales of cigarettes to minors is one intervention, results of a study in the greater Johannesburg metropolitan area27 provided overwhelming evidence that even in this limited area, legislation is ineffective in ensuring compliance by retailers. There is need for wider-reaching, more effective strategies to ensure that children are protected from the effects of tobacco smoke.
WHAT HAS NOT BEEN ACHIEVED In an integrated model of health care, identifying women and children as a line item in the health sector budget has proven extremely difficult. While there is widespread contention that political commitment to women and children needs to be matched by budgetary commitment, this issue will need much more discussion in the future. Although policy frameworks have outlined the importance of intersectoral collaboration, examples of these types of efforts which respond to the health-related needs of women and children are few and far between. Exceptions include various non-governmental organisation (NGO) programmes, such as those that link nutrition services, with programmes to combat parasitic infections, micronutrient deficiencies, and household food insecurity. In many instances, the needs of women and children are still seen as falling under the auspices of welfare, despite the fact that the RDP has identified these needs as mainstream concerns for development. This links closely to the intersectoral issue described above, and a mechanism must be found for the period of transition from social welfare to the community development approach which underpins the RDP. While government has identified “youth” as a special group, it has been tardy in developing comprehensive programmes which address the issues of concern. At national level, the appointment
150 of a director has not yet been made. Despite the establishment of the National Youth Commission in 1996, and despite the promulgation of the Youth Commission Act in support of a focus on youth, programming to meet the health needs of youth has not yet been achieved.
CHALLENGES Maternal mortality remains a concern, and the serious unresolved problem of deaths from preventable causes has challenged the health sector to make an appropriate plan, despite the absence of reliable statistics. In rising to this challenge, a system has been devised to address maternal and perinatal mortality at the source. While management of climacteric and menopausal symptoms has been one of the stated intentions of national policy, little work has been done in the area of developing appropriate public sector services for “mature women”. Well-women’s clinics have been established in the private sector, and these may provide useful models for investigating in the context of comprehensive, integrated care at district level.
CONCLUSION Many policies to guide effective implementation of integrated and comprehensive maternal and child health services in South Africa are in place. Clear objectives and targets to guide implementation of MCWH services have been set, and have been developed within a human rights framework which supports the ideals of the RDP. Many initiatives are underway to improve our understanding of the extent of maternal, children’s and women’s mortality and morbidity, and to reduce the occurrence of preventable illnesses. Promoting equity through access is a key aim of the Department of Health for MCWH services, but in many parts of the country, women and children still have limited or no access to appropriate health services. Several initiatives started during the year have aimed to improve accessibility. These are particularly focused on understanding the needs of those living in the most disadvantaged areas, such as on farms. In addition, recognition that MCWH services need to be comprehensive and integrated has led to several efforts to identify an essential package of services. Academic and research institutions in the country are taking the lead in defining this package for MCWH, as well as determining models for providing care that is integrated and involves intersectoral collaboration. Ongoing efforts emanating from the government, such as the National Programme of Action for Children’s Steering Committee and the Commission on Gender Equity also support an intersectoral developmental approach. Another key aim of the Department of Health is to ensure that MCWH services are efficient, cost-effective and of good quality. Again, several initiatives are underway to define appropriate standards and norms for MCWH services. Concurrently, as transformation of the services is taking place, researchers are attempting to monitor the impact, in order to inform future system changes. Finally, key aims of the Department of Health focus on the importance of ensuring optimal reproductive and sexual health of both men and women, as well as the importance of appropriate health education to promote healthy behaviours. In the area of youth health in particular, these aims are particularly important, as several studies have shown that the health and related needs of this group are significant. Certainly as programmes shift from an emphasis on preventing mortality and disease due to preventable conditions to a development approach, the needs of this group should be a priority. This review of the year’s activities in MCWH demonstrates that efforts towards implementing programmes for providing appropriate and accessible MCWH services are being consolidated at national, provincial and district levels. However the extent of health problems still to be addressed suggest that wide-spread implementation is far from adequate. The Department of Health has provided the signals of intent: what is needed is the transformation of good intentions into
Maternal, child and women’s health 151 programmes and practices which can make an impact. This is a challenge to service providers, policy-makers and academics in both government and non-government institutions. The period under review suggests that such partnerships are not only attainable, but essential.
152 MENTAL HEALTH 17
INTRODUCTION This chapter reviews major developments in mental health services in South Africa over the last 2 years. An overview is given of the roles of National, Provincial and District levels - what has been proposed and progress to date. The non governmental organisation and private sectors are not reviewed. Violence and trauma issues are covered in Chapter 25.
Overview of situation The past ideological framework to mental health care has been a combination of racial discrimination, paternalism and institutionalisation.1 Mental health services have been vertical, fragmented, and have over emphasised curative services.2 A form of privatisation exists as several provinces contract out the delivery of long term psychiatric services to a private hospital company, at a cost of R146 million for 1996. More recently, the 1995 report of the task team appointed to investigate human rights violations and alleged malpractice in psychiatric institutions concluded: “There is no parity in the standard of care in psychiatric institutions. The standard of care in formerly black institutions...is below that of formerly white institutions…” and recommended reviewing “all existing agreements with private organisations providing psychiatric in- patient care...” 3 Currently mental health policy has received more attention due to the wider awareness amongst activists and politicians and more articulate lobbying by mental health professionals. This is reflected in documents by the ANC,4 the RDP5 and the White Paper of the National Department of Health.6
White Paper - Principles of Mental Health and Substance Abuse6
✧ A comprehensive and community based Mental Health and related service (including substance abuse prevention and management) should be planned and coordinated at the national, provincial, district and community levels, and be integrated with other health services provided ✧ Essential National Health Research should include Mental Health and substance abuse to identify the magnitude of these problems ✧ Human resource development for mental health services should ensure that personnel at various levels are adequately trained to provide comprehensive and integrated Mental Health care, based on PHC principles. (This includes training in planning, implementing, supervising, monitoring and evaluating Mental Health programmes; dealing with post-traumatic stress and the impact of violence; screening, counseling and identification. Drugs required for the management of psychiatric problems must be available at all levels of health care provision as appropriate.)
Authors: Tennyson Lee, Centre for Health Policy, University of the Witwatersrand Ruth Zwi, Department of Health, Gauteng 153 Tables 1, 2a and 2b illustrate the proposed policy directions and progress at National and Provincial level respectively, and Table 3 the proposed policy direction at District level.6
TABLE 1 POLICY DIRECTIONS AND PROGRESS AT NATIONAL LEVEL6,11
Function Degree of implementation Activity in place Activity partly No progress or completed in place made
POLICY DEVELOPMENT
Formulate National Mental Health Policy
Build in human rights culture
Develop norms and standards:
✧ for mental health services community
✧ for mental health services hospitals
✧ for forensic services
✧ for substance abuse services
✧ for education and training of Mental Health human resources
Develop guidelines
Formulate objectives and indicators
Promote human resource development and capacity building
Promote integration
Promote community preventive and rehabilitative programmes
Review legislation
Determine priorities
Promote equity
Develop appropriate pharmaceutical protocol
ORGANISING
Coordinate intradepartmental Mental Health issues
Coordinate interdepartmental Mental Health issues
Promote intersectoral collaboration
Collaborate with traditional healers
Liaise internationally
Coordinate with provinces
Establish advisory board
Organise special programmes:
✧ substance abuse
✧ child abuse
✧ women abuse
✧ victims of violence
Plan provide and monitor forensic psychiatric services
Plan and promote services for mentally handicapped
Plan and promote services for psychogeriatrics
STAFFING
Filling posts own office
Develop norms and standards for training
Develop multidisciplinary team approach
FINANCING
Ensure adequate budget for Mental Health and Substance Abuse at all levels
CONTROL
Research: monitor, initiate and promote
Monitoring mental health service capacity and quality, ensure equity
Coordinate and maintain data base and epidemiological statistics
154 2.2 Specialist Western Cape Western Cape Western Cape Western Cape Western Cape North West North West North West North West North West Northern Province Northern Province Northern Province Northern Province Northern Province Northern Cape Northern Cape Northern Cape Northern Cape Northern Cape Mpumalanga Mpumalanga Mpumalanga Mpumalanga Mpumalanga KwaZulu-Natal KwaZulu-Natal KwaZulu-Natal KwaZulu-Natal KwaZulu-Natal Gauteng Gauteng Gauteng Gauteng Gauteng Free State Free State Free State Free State Free State 544 200 000 2 756 7 637 100 8 552 500 2 839 300 000 720 300 5 071 3 339 700 300 3 782 Eastern Cape Eastern Cape Eastern Cape Eastern Cape Eastern Cape No; Y = Yes; (Y) = to a small extent; D/K = Don’t know; Blank cell = information not supplied; * = 1993 data Blank cell = information not supplied; * 1993 (Y) = to a small extent; D/K Don’t know; No; Y = Yes; Total population (1995) Total population (1995) Financing Financing Management Management Key: Key: Total population (1995)Financing % allocated to Mental Health Mental Health budget (rands)1997 % hospitals% clinics or health centres 000 130 6 % other 509 57 779 D/K 000 274 000 150 D/K dedicated D/K 3 426 196 D/K 37 800 000 7 346 000 122 000 163 194 6.5 5 89.8 D/K 3.6 (no D/K budget) D/K 1.15 65 35 2.2 D/K 8.93 3.5 96.5 7.7 90 Management DirectorPrincipal or Senior Specialist no post no post no post no post no post no post 1 no post 1 Senior Spec no post Key: N = unfilled post no post no post no post 1 Principal no post no post no post 1996 Mental Health budget (rands)1996 582 701 141 directorDeputy Assistant directorChief medical officerPsychologistCoordinator 243 000 boardAdvisory Policy 000 144 document?Mental Health policy document?Deinstutionalisation policy unfilled postEfforts to deinstitutionalise: no postat present 1 unfilled postin future bill of rights?Patient no post N unfilled post Healers? with Traditional Collaboration no post N no post no post 4 086 250 with Private sector?Collaboration MHS N 34 833 000 hospitals no postNo. dedicated psychiatric no post no postNo. beds no post N N clinicsNo. dedicated community Y unfilled post 4No. patients registered no post no post N D/K N no post D/K N 000 700 195 5 no post no post N N N Y no post D/K 1 no post see text Y Y no post 1 Y see text no post 1 D/K unfilled post (Y) N 2 083 Y no post 78* no post no post no post unfilled post (Y) N Y unfilled post N 5 877* Y 4 690 N N N 80 no post no post no post 1 1 24 000 (Y) N N unfilled post N 2 300 Y 2 (Y) no post N no post 20 N 1 D/K (Y) 2 400 N N N no post Y 0 100 N 5 000 N N 1 no post N 0 (Y) N Y 5 168 68 Y 1 N Y Y 101 Y Y N N N N 3 Y N 2 042 N Y Y D/K 8 646 260 Y 1 N 300 224 18 N Y N 3 481 Y 4 Total population (1995) Total population (1995) Financing Financing Management Management Key: Key: TABLE 2A SERVICES AND DEDICATED POLICY, STRUCTURE, LEVEL: FINANCING, MANAGEMENT PROVINCIAL AT AND PROGRESS DIRECTIONS POLICY
Mental Health 155 2 0 0 5 51 37 140 drs 140 Western Cape Western Cape Western Cape Western Cape Western Cape North West North West North West North West North West 338 52 Northern Province Northern Province Northern Province Northern Province Northern Province 33 49 D/K Northern Cape Northern Cape Northern Cape Northern Cape Northern Cape Mpumalanga Mpumalanga Mpumalanga Mpumalanga Mpumalanga KwaZulu-Natal KwaZulu-Natal KwaZulu-Natal KwaZulu-Natal KwaZulu-Natal 8 15 0.5 5 Gauteng Gauteng Gauteng Gauteng Gauteng Free State Free State Free State Free State Free State Eastern Cape Eastern Cape Eastern Cape Eastern Cape Eastern Cape Evaluation Evaluation Hospitals Hospitals PHC services and Mental Health (MH) PHC services and Mental Health (MH) Personnel Personnel Evaluation evaluation?coordinate funding for researchprovide HeaIth Information System (HIS) exist?useful MH statistics in this HIS? managerial decisions?HIS help make Y Y N N N Y N N N N Y little Y little Y N N N N Y some N N N some Y N Y Y some Y N Y N some Y N Y N N Y N N Y Hospitals No. district hospitals careNo. offering psychiatric hospsNo. regional/general careNo. offering psychiatric hospsNo. academic/tertiary careNo. offering psychiatric 49 7 4 3 23 0 5 4 1 1 4 0 13 2 4 3 D/K 60 12 12 2 2 22 0 0 0 0 0 11 1 1 7 2 2 2 0 29 0 0 4 0 4 0 29 8 0 3 3 3 Plans to train next 2 years next Plans to train planned to trainNo. PHC workers 200 Y Y 250 Y D/K Y 100% Y 100% D/K Y 100% Y nurses 672 Y Y No. PHC staff trained MH care last 2 yrs MH care No. PHC staff trained D/K see text nurses 100 0 5% 80% D/K 0% nurses, 176 PHC services and Mental Health (MH) No. PHC clinics offering MHS in last 2 yearsNo. started in next 2 yearsNo. will start 5 300 all see text see text 80 20 D/K D/K 23 23 93 14 260 0 total occupational therapists in hospitalphysiotherapists in community physiotherapists total physiotherapists in hosp nurses psychiatric in comm nurses psychiatric nursestotal psychiatric 5 0 655 0 10 655 3 158 38 3 158 1 1 640 1 720 6 1 80 1 369 0 0 10 65 0 55 assistants 3+15 0 269 assistants 3+14 269 0 39 41 429 480 0 Personnel in hospitalpsychiatrists in community psychiatrists 9 4 35 0.5 37 total psychiatrists in hospitalpsychologists in communitypsychologists total psychologists in hospitalsocial workers in communitysocial workers total social workers in hospitalOTs in community OTs 10 9 0 10 7 0 4 5 7 7 45 11 7 50 18 10 56 10 16 28 30 23 16 1 1 0.5 1 1 (+ 4 visiting) 1 1+ 8 1 0 36 0 42 41 40 Evaluation Evaluation Hospitals Hospitals PHC services and Mental Health (MH) PHC services and Mental Health (MH) Personnel Personnel TABLE 2B AND EVALUATION HOSPITALS, HEALTH, LEVEL: PERSONNEL, PROVINCIAL PHC SERVICES AND MENTAL AT AND PROGRESS DIRECTIONS POLICY
156 TABLE 3 PROPOSED POLICY DIRECTIONS AT DISTRICT LEVEL6
1. Providing Mental Health and substance abuse prevention, promotion and rehabilitative services 2. Planning and implementing in-patient and day-patient care for the mentally ill and substance abusers, establishing a 24 hour consultation service for mentally ill patients and victims of substance abuse. 3. Providing training for health facility staff 4. Undertaking mental health education programmes in communities 5. Establishing and maintaining Mental Health committees and maintaining collaboration with other sectors, private practitioners, traditional healers and NGOs. 6. Providing emergency and crisis interventions and counseling 7. Collecting data and initiating and contracting out research in accordance with local needs, with the support of relevant institutions 8. Developing appropriate indicators for monitoring and evaluation.
Sources of information Sources of information for this review included the National Mental Health and Substance Abuse Directorate, senior mental health management at provincial level, and key informants. Interviews, questionnaires (to the 9 provinces) and document review were used. Demographic figures are based on a 1995 Centre for Development and Enterprise Report.7
Critical elements/components Critical components of a mental health service within a systems framework are outlined in Table 4. This chapter will primarily focus on finance, management, policy, personnel, and provision of care (particularly with respect to range of services, decentralisation and integration, and the district health service).
TABLE 4 CRITICAL ELEMENTS/COMPONENTS OF A MENTAL HEALTH SERVICE WITHIN A SYSTEMS APPROACH FRAMEWORK
Input Process Output
Financing ✧ Budget for MH ✧ Decentralisation ✧ Caseholding ✧ Budget for hospital versus ✧ Integration into PHC ✧ Discharge rate community MH care ✧ District Health System ✧ Patient satisfaction ✧ Community Based care Management ✧ Deinstitutionalisation ✧ Structures/organisation ✧ Intersectoral links including NGOs Policy ✧ Links with other Health Departments ✧ Economic environment, housing, ✧ Identification of patients needing care employment, violence ✧ Redressing psychological Promotive and preventive consequences of Apartheid: TRC ✧ Life skills training ✧ Legislation ✧ Reducing stigmatisation in ✧ Bill of Rights Mental Health ✧ Intersectoral coordination ✧ Substance abuse Receipt of care ✧ Privatisation ✧ Utilisation ✧ Acceptance and satisfaction Personnel ✧ Understanding and participation ✧ Distribution ✧ Traditional Healers Information systems ✧ Training including of PHC workers Quality of care Range of services ✧ Promotive and preventive ✧ Levels of prevention
Facilities and equipment ✧ Accessibility ✧ Race, geography, private/public
Drugs
Mental Health 157 Finances The budget for 1997 for the Mental Health Directorate of the National Department of Health is R2.7 million. Most of this has been allocated to direct running costs of the National office, and not specific projects. At provincial level, the hospicentric tendency of the budget is clear. However it should be noted that some of the hospital expenditure in provinces like Gauteng and Western Cape is due to cross border flows - i.e. patients attending from other provinces for general psychiatric and forensic services. In Gauteng, 27% of patients in hospitals were from other provinces.8 These provinces do not pay for this hospital care and this remains a problem.
Management Gauteng province has a mental health manager at director level. The other provinces have senior management in various positions ranging from principal specialist, deputy director, assistant director to co-ordinator. Five provinces cited the creation of mental health posts at head office level as one of the most critical requirements for development of the mental health service. However, while progress has been made in this regard, the general picture is of insufficient creation of senior posts. Once created, insufficient progress has been made in filling them. The North West Province has made good progress in establishing district mental health co-ordinators.
Policy Progress at National level While no national mental health policy exists at present, the National Directorate is working with the different provinces in developing policy at provincial level. The National Directorate therefore plans to integrate this experience into national policy development. The National Directorate has accepted the basic principles proposed in a number of policy documents.4,5,11 Progress at National level was hampered by the delay in appointment of the Director who was then seconded to the Truth and Reconciliation Commission. The present Director has been in office for 10 months. However Table 1 shows that a wide range of activities have been initiated by the National Directorate. Positive developments have been a focus on three neglected areas: mental health promotion, women, and children and adolescents. In line with this, there has been a particular emphasis on intersectoral collaboration. Collaborators include: ➣ The Departments of Welfare, Safety and Security, Justice and Correctional Services who participate in the Victim Empowerment Group of the National Crime Prevention Strategy. The aim of this group is to ensure that victims are appropriately treated, and not secondarily victimised through the system, and to reduce the risk of a recurrence of the violent act. The plan is to train police and justice officials to deal more effectively with victims. PHC workers would need training in detection, and management of Post Traumatic Stress Disorder as part of their training in primary mental health care. ➣ Intradepartmental collaboration among the Health Promotion, AIDS, Maternal and Child Health, Chronic Diseases, Nutrition and Oral Health Directorates in a “Health Promoting Schools Initiative” to address life skills programmes. Work is also occurring with the Maternal and Child Health Directorate in planning a campaign against drinking in pregnancy. ➣ The Department of Welfare has policies regarding substance abuse, which clarify roles of service providers, and which motivate for the detoxification of patients at secondary hospitals, as well as at special centres. At present these centres are the only places where detoxification takes place.
Truth and Reconciliation Commission The Truth and Reconciliation Commission (TRC) ends in 1997. While issues relating to mental health have been placed on the agenda of the TRC, there has been limited translation of the psychological implications of the Commission9 into actual practice, (eg. training for mental health care providers; adequate pre-testimony briefing and de-briefing). An important development at community level is the Khulumani Group, a victim support group developed in 1995, even
158 before the start of the TRC. This group is involved in organising education workshops for victims in communities and in setting up a social support network for fellow survivors of past abuses.10
Legislation No changes have been made to the Mental Health Act of 1973. The Act has been criticised for not protecting the rights of patients who are detained involuntarily and for reinforcing the non- transparent functioning of mental institutions.11 While Section 66A of the Mental Health Act protects mental institutions from public scrutiny, in practice public institutions have become more open. Provincial attitudes towards changing section 66A are mixed. Draft amendments now exist for the Criminal Procedures Act, the Sterilisation Act and aspects of the Mental Health Act. In the Medicines and Related Drugs Control Act 101 of 1965 most psychiatric drugs are categorised as Schedule 5 or higher and require a prescription from a registered medical practitioner. This has meant that nurses are not allowed to store or dispense psychiatric drugs, unless specifically authorised. This issue has been acknowledged as needing urgent redress to allow nurses to provide a more comprehensive service. It is important that this legislation be changed and the following quote from a PHC nurse highlights this issue: “The service is very keen that we take on new responsibilities but wait until something goes wrong - then you are all alone. The service will not cover you then.”12
Substance abuse South Africa has a high per capita consumption of absolute alcohol (8.5 litres per year).13 Levels of risky drinking are as high as 30% among some high risk groups, eg. adult urban residents.13 Despite this clear problem, the policy process with respect to substance abuse is proceeding in an ad hoc and fragmented manner.13
Provincial level (see Table 2a) Four provinces have finalised policy documents, while the remaining 5 are in the process of formulating policy. In addition, the North West province, has already developed strategic and operational plans. There has been little policy development in the de-institutionalisation of patients or in a patient bill of rights. This is understandable given the emphasis on institutionalisation to date, and the lack of facilities to support patients in the community. Intersectoral co-ordination at provincial level remains rudimentary. Insufficient co-ordination is occurring with traditional healers and the private sector.
Personnel The total number of mental health personnel in South Africa registered with professional boards is as follows: ➣ psychiatrists (427) ➣ clinical psychologists (1 051) ➣ psychiatric nurses (26 825) ➣ social workers (9 700) This information was obtained from the relevant professional councils. There is no information on: ➣ the distribution in the public and private sectors ➣ whether those registered are actively working ➣ where they are working The maldistribution of qualified psychiatrists in the public sector is highlighted in Table 2b. There are 50 psychiatrists in Gauteng with 1 each in Mpumalanga, Northern Cape, North West and Northern Province. These figures exclude psychiatric registrars, and medical officers in psychiatry, and Gauteng has an additional 80 psychiatric registrars or medical officers. The low numbers of personnel within the allied disciplines is clear.
Mental Health 159 For mental health to be integrated into health services, personnel will require training for their expanded role. However the low number of PHC workers trained in mental health in the last two years points to the limited degree of integration of mental health into PHC services which can occur in the short term. Limited training of PHC staff implies that the mental health problems will continue to be missed by the primary care worker.14 Gauteng has completed a course in training of trainers in primary mental health care as a means to increase the number of front line nurses who can see patients with mental health problems.12
Provision of care Range of services Many generalist hospitals are at present not offering psychiatric care. Table 2a shows the maldistribution of psychiatric hospitals (only public sector hospitals appear on the table). The services remain mainly direct curative care, with promotive and preventive services remaining underdeveloped. Child and adolescent services, and psychogeriatric services remain even less developed than adult mental health services. Child and adolescent services provide a good example of where a dedicated post and budget is necessary. In Gauteng for example, having a Deputy Director for child and adolescent services has allowed the move from policy recommendations15 to implementation in piloting the role and relationships between regional mental health teams and PHC personnel. It has also increased capacity to take on the intra- and intersectoral work which is particularly critical in child and adolescent services.
Decentralisation and integration The Free State has the most decentralised mental health service in the country, having started in 1985.16 Despite this headstart, it has still not yet managed to fully integrate its services. Mental health care is mainly provided on specific days at specific times. Psychiatric patients are still mainly seen by the mental health team. Generalist nurses believed that specifically trained psychiatric workers should be responsible for the psychiatric work at the clinic.16 This points to the concerted effort required for integration to successfully occur. Such efforts are being started in the Western Cape. Despite widespread policy to decentralise and integrate health services, including mental health services, there has been little work on how this is perceived by different personnel categories. In Gauteng, interviews were held with groups of PHC nurses in each of the 5 regions.12 While the groups felt decentralisation and integration was a positive move in terms of supporting a holistic approach to health service delivery, they were concerned about the potential workload. “A generalist who is expected to do everything usually will end up rushing around and not doing justice to the service she gives individual clients.” The need for training was consistently raised by the groups - they felt that they had been insufficiently informed of policy changes. These findings are similar to a larger study on decentralisation where it was found that “…a critical and common concern across provinces was the high level of uncertainty and insecurity among health personnel, particularly nurses, leading to unwillingness to take on additional responsibilities...This was, at least partly, thought to be generated by a lack of clarity about how work and responsibilities may change as a result of decentralisation…” 17
District Health Service Tension exists in some provinces between regional or district managers and mental health programme managers regarding what integration means to the job description of the psychiatric nurse. Regional directors saw a role for a specialist mental health team consisting of the psychiatrist, psychologist, social worker and occupational therapist but had differences of opinion regarding whether the psychiatric nurse is part of the mental health team or should be completely integrated into PHC delivery.12 In one district, a psychiatric nurse who had previously serviced 20 clinics on a visiting clinic basis was moved into a generalist role and was permanently stationed in a fixed clinic, so that the remaining 19 clinics lost out on a mental health service. Most mental health programme managers propose that some vertical technical support (for
160 example continued education, support and supervision of PHC workers within districts) remains necessary at provincial and regional level. The lack of development of mental health services within a District Health Service must be seen in the context of the early stage of development of District Health Services themselves. Basic philosophical and organisational questions (such as the relationships and roles of programme, regional and district managers, and the level at which support services, for example training, should lie) remain unanswered. Two district health services managers were interviewed. They agreed with the mental health roles proposed for the district health services.6 These included district generalist personnel taking on the care of chronic stable patients. However they indicated they would need more staff for this. They perceived that district health personnel were overworked and that additional roles were being increasingly foisted upon them. They also felt that every vertical programme was pushing its own agenda, usually with little co-ordination occurring between these programmes. Concern was also expressed that de-institutionalisation would increase the number of homeless people in the districts.
Monitoring, evaluation and research Six provinces responded that the mental health statistics in their province’s health information system were not useful (see Table 2b). An exception is in Gauteng, where results of the newly developed community mental health information system indicate a low number of children and adolescents in the service, and a low rate of transfer of psychiatric patients from mental health services to PHC. Managers have used this information to prioritise the child and adolescent service, and the integration of mental health into PHC.18 Only three provinces play a co-ordinating function regarding evaluation and only two fund research (Table 2b). This underlines the importance of ensuring that research undertaken meets the needs of health services providers, an important principle of Essential National Health Research.19 Research relevant to mental health services completed, in progress, or near commencement includes expenditure on public and private sector mental health services,20,21 quality of care,22,23 integration of mental health services into PHC16,24,25 training,12,26,27 and individual needs for service assessment for children and adolescents with serious emotional disturbances.28 The National Directorate of Mental Health and Substance Abuse is funding a project on the development of norms and standards for mental health services.
Issues which have hindered progress Provinces listed the following issues as having hindered progress: ➣ Personnel: moratorium on filling posts, lack of personnel - particularly at PHC level and at middle management level (and therefore a lack of mental health co-ordinators at regional or district level), lack of training, excessive workload, insufficient trainers, no multidisciplinary team approach, disagreement on the role of the mental health team. ➣ Managerial support: no national director in place for extended period, no national policy and few guidelines on Mental Health, minimum interprovincial co-ordination and collaboration, a lack of provincial office support. ➣ Transformation at early stage: District Health Service not able to take over primary mental health services; no agreement on priorities and strategies; too many priorities in the face of needing to rationalise and deliver community mental health services; no consensus on comprehensive PHC and who delivers it; lack of infrastructure; no transport; poor communication systems; lack of funding; failure to deliver integrated service with NGOs, inadequate supervision at community service level.
Key steps required Provinces saw the following as key steps: ➣ Increased support from the National Mental Health and Substance Abuse Directorate regarding mental health information, research, policy directions, interprovincial
Mental Health 161 co-ordination, revision of the Mental Health Act, development of norms and standards, developing a higher profile for mental health. (Of note, most of these issues have been prioritised by the National Directorate of Mental Health and Substance Abuse in a 7 point plan29). ➣ Personnel issues: Training (both clinical and managerial), training of trainers, personnel recruitment, consensus on roles. ➣ Facilities: review of chronic care facilities, development of day care centres, downscaling of specialist hospital service, with expansion at primary and secondary level services. ➣ Managerial: interprovincial co-ordination. ➣ Policy: increase promotion and prevention activities, develop norms and standards, accelerate the integration process (not just mental health into PHC but between primary, secondary and tertiary levels of the mental health service), define the minimum package of services at different levels, revise legislation (particularly Mental Health Act, Criminal Procedures Act, prescribing of drugs) develop policy on de-institutionalisation, review feasibility of the Essential Drug List.
CONCLUSION AND RECOMMENDATIONS There is much to be done, with limited resources and an unevenly developed service. The National office has a key role to play in terms of the co-ordination/facilitation role, particularly in policy, training and information systems.
BOX 1
Examples of proposed Mental Health roles at primary, secondary and tertiary levels30 Primary level (PHC staff) ✧ Provision of a basic health service to patients with mental disorders ✧ Identification of mental disorders designated as priority conditions (eg. chronic psychotic states, dependence on drugs or alcohol) ✧ Identification of patients who should be seen by visiting secondary level personnel or referred to a higher level health facility ✧ Identification of patients in whom physical symptoms indicate an underlying psychological problem ✧ Provision of education on the maintenance of good mental health ✧ Keeping a register of patients referred back to the community from higher level health facilities, and ensuring continuity of treatment Secondary level (specialised Mental Health personnel) ✧ Diagnosis, treatment, and follow-up of patients, including those referred from primary- level clinics ✧ Continued education, support and supervision of PHC staff Tertiary level (specialised Mental Health personnel) ✧ Deal with complex problems of diagnosis and treatment referred from secondary and primary levels ✧ Organise training in mental health for all levels of the health service ✧ Have supervisory responsibilities for secondary-level facilities ✧ Undertake research and evaluation work
The following steps also need to be taken: ➣ The roles of generalist PHC workers and the mental health team need clarification. The proposals by the WHO of roles at the different levels of care, (Box 1) provide a useful start for the debate. Whatever the specific roles, the mental health programme should continue providing technical support for the horizontal implementation of PHC services (eg. in Free State province, all clinics are visited at least every 3 months by psychiatric registrars).
162 ➣ Develop relationships with the NGOs delivering a mental health service. ➣ There is a perception that all services are being foisted onto Primary care; this needs to be addressed by all levels of management. While the list of steps seems long, they may be approached practically through asking: What policy, strategic and operational plans, enabling legislation, budgetary allocation, training programmes, and, information and monitoring systems need to be in place within the next 2, 5 and 10 years in order to offer integrated, comprehensive mental health care within a District Health Service? At least 2 points are favourable for the development of mental health services. While South Africa has much to learn from other developing countries grappling with similar problems, it has many more resources. Secondly, the newly acquired democratic status of the country has placed the principle and rhetoric of mental health at a higher level than ever before. The opportunity exists at present to significantly improve not only mental health services, but mental health as a whole.
Mental Health 163 164 ORAL 18 HEALTH
INTRODUCTION This chapter reviews the major issues in the oral health sector during 1996. The oral health sector has tried to develop policies which contribute to the overall transformation of South African society. The major issues in the oral health sector during 1996 can be regarded as: ➣ Formulation of a national oral policy ➣ Drafting of fluoridation regulations ➣ Human resource development ➣ Education and training ➣ Building unity at a professional level
BACKGROUND Oral health in industrialised countries has improved dramatically over the last two decades. These advances mean that most of the oral diseases which continue to burden the population of South Africa can be prevented and controlled with fairly simple interventions. The formulation and implementation of public oral health policy is a critical first step in lessening the oral disease burden.
Oral disease levels in South Africa Oral diseases are widespread in South Africa affecting large numbers of people. The greatest burden of disease falls on children and on the poor.
Tooth decay and bleeding gums In the Report of the Oral Health Committee1 appointed by the Minister of Health evidence is presented which indicates that by the age of 6 years two thirds of children in the major metropolitan areas have experienced problems with their teeth. In some communities more than half of the adult population over the age of 35 years have lost all their teeth.2 A study of periodontal disease in South Africa revealed that inflammation of gums and calculus is endemic, while in some areas 23% of children suffer from acute ulcerative gingivitis. Current disease levels are likely to worsen as a result of rapid urbanisation and life- style changes. These changes normally result in an increase in sugar consumption, especially among children which lead to an increase in dental caries. Increased access to tobacco and alcohol can also be expected to result in an increase in periodontal disease, oral cancer and oral trauma.
Author: Usuf Chikte, Department of Community Dentistry, University of Stellenbosch 165 Oral health status is traditionally measured by clinical indicators, that do not capture the suffering and consequences of oral diseases graphically described by Jonathan Kozol3 “Although dental problems don’t command the instant fear associated with low birth weight infant death or cholera, they do have the consequences of wearing down the stamina of children and wearing down their ambitions. Bleeding gums, impacted teeth and rotting teeth are routine matters for children. Children get used to feeling constant pain. They go to sleep with it. They go to school with it. Sometimes their teachers get alarmed and try to get them to a clinic. But it’s all so slow and heavily encumbered with red tape and waiting lists and missing , lost or cancelled welfare cards, that dental care is often long delayed. Children live for months with pain that grown-ups would find unendurable. The gradual attrition of accepted pain erodes their energy and aspirations. I have seen children with teeth that look like brownish, broken sticks. I have seen teenagers who were missing half their teeth. But, to me, most shocking is to see a child with an abscess that has been inflamed for weeks and that he has simply lived with and accepts as part of the routine of life.”
Oral cancer The Cumulative Life Time Risk for development of oral cancer ranged from 1:65 in coloured males to 1:455 for black females. The latest age standardised incidence rates for oral cancer are 8.2 per 100 000 for coloured men, 6.5 per 100 000 for Indian women, 4.5 per 100 000 for African men and 4.3 per 100 000 for white men.4 These high incidence rates prevail despite public health efforts directed at decreasing consumption of tobacco use, betel nut chewing and alcohol abuse .
Oral health services in South Africa The approach to disease eradication remains largely curative, delivered at an individual level. Most oral health care service delivery is dependent on sophisticated and expensive technology. Many South Africans, particularly those living in rural areas, are thus denied access to oral health services.
Education and training of oral health personnel The training of dental personnel takes place at six dental schools which are located in or near the major metropolitan areas of the three most affluent provinces in the country. These schools were legally and traditionally segregated along racial and language lines. Training takes place within a biomedical framework with little attention given to the primary health care approach. There appears to be a reasonable gender distribution of incoming dental students. African students, however, remain under-represented at most dental faculties.5
Dental Schools ➣ University of Stellenbosch - Cape Town ➣ University of Western Cape - Cape Town ➣ University of Witwatersrand - Johannesburg ➣ University of Pretoria - Pretoria ➣ MEDUNSA - near Pretoria ➣ University of Durban Westville - Durban (not training dentists) NATIONAL ORAL HEALTH POLICY None of the drafts of the National Health Bill circulated during 1996, specifically address issues in the oral health sector. However the section on oral health in the White Paper for the Transformation of the Health System in South Africa,6 which is based on the findings of the Oral Health Committee, appointed by the Minister of Health 1994, does give a national unified vision for the transformation of oral health services based on the primary health care approach. This vision sees oral health services focusing on equitable, preventive services integrated with the primary care services. It suggests that there should be a minimum package of services which could be delivered by oral hygienists or therapists.
166 Towards the end of 1996 the Department of Health circulated a document entitled National Oral Health Policy: Draft 2 to various stakeholders for comment. This document spells out its mission as the promotion of oral health and prevention of oral disease through the Primary Health Care Approach. It identifies the critical performance areas at a national and provincial level; sets detailed goals to be obtained by the year 2005; and outlines priorities for the public oral health services in terms of users, providers and services. In addition, the document outlines various levels of care; addresses the financing of dental care and provides personnel norms detailing the numbers and categories of oral health resources needed in South Africa. Arising from this draft policy there are a number of issues which require further clarification: ➣ The national/provincial split in terms of responsibilities ➣ Mechanisms for ensuring that the determinants of oral health are addressed in an integrated fashion across all appropriate sectors ➣ Norms and standards for primary oral health care ➣ Training of oral health care personnel other than dentists ➣ An appropriate oral health information system. The lack of a national policy on transformation in oral health, hampers the role of the provincial governments to operationalise and implement their provincial oral health plans.
FLUORIDATION Fluoridation is the controlled adjustment of a fluoride compound in the public water supply which effectively prevents tooth decay. It remains the most equitable, safest, most practical and cost-effective oral health intervention. The addition of fluoride to the water supply is cheap. Calculations on the cost of fluoridating the water supplies of Port Elizabeth, showed that the cost per person per year would be R1.28.7 Fluoridated water is 18 times less expensive than toothpaste and 61 times less expensive than having a tooth filled.8 Fluoridation reaches everyone in the community, a feature which is both its greatest strength and greatest problem in terms of social policy. There has been considerable media attention given to fluoridation, highlighting the general lack of understanding. Opposition to fluoridation has centred on claims of risk to the environment or to human health. These arguments have a weak scientific base but a strong emotional appeal. Despite the considerable media coverage less than a quarter of South Africans have heard or read about fluoridation. Only about 25% of South Africans could correctly identify the purpose of water fluoridation. However, whatever the levels of knowledge or sources of information, more than 60% of South Africans favour the adoption of water fluoridation if it can reduce tooth decay. Several influential health and community organisations have endorsed fluoridation. The Department of Health supports the fluoridation of public water supplies. A National Fluoridation Committee was set up by the Minister of Health with the purpose of ensuring that all communities in South Africa have access to appropriate sources of fluoridation. The committee has drawn up draft regulations on fluoridating public water supplies in South Africa. These regulations once finally approved, will be promulgated in terms of the existing Health Act, 1977 and be open for public comment for a period of three months. The draft regulations are expected to be mandatory. Criteria for the exemption of local authorities from fluoridating public water supplies have been drafted, as have technical specifications for the implementation of water fluoridation. In the absence of a national regulatory framework, water authorities are reluctant or unable to introduce water fluoridation. The challenge facing the Department of Health is to get agreement from the Department of Water Affairs and Forestry to get the Regulations on the Fluoridation of Public Water Supplies gazetted. Although fluoridation is a key implementation policy in the transformation of the health sector the failure to deliver on this policy represents a form of health care negligence: the withholding of benefits of contemporary scientific knowledge.
Oral Health 167 HUMAN RESOURCE ISSUES Oral health care workers registered with of the Interim Medical and Dental Council of South Africa at the end of 1996, are shown in the box below. Approximately 276 new registrations are added each year. However the average growth over the past 15 years to the end of 1996 was 160 per year. Of these 104 were dentists, 42 oral hygienists and 14 dental therapists.9 The unofficial estimate of African dentists is 4 per cent, female dentists about 11 per cent, while the African, Asian and so-called Coloured dentists are estimated at 25 per cent.5
TABLE 1 INTERIM MEDICAL AND DENTAL COUNCIL REGISTER - 1996 (NUMBER OF ORAL HEALTH WORKERS, PUBLIC AND PRIVATE SECTOR)
Dentists 4 235 Oral Hygienists 891 Dental Therapists 236 Total Oral Health Workers 5 362
Although most of the dental needs of the population fall within the scope of work of dental therapists most of the clinical treatment in dental work is performed by highly trained dentists. The National Human Resources Audit10 has identified dental therapists as important members of the oral health team, and an urgent need for additional training of this category of health worker has been expressed. This has also been stated in the White Paper.6 The report of the Health Services Committee of the Dental Association of South Africa on human resource planning11 indicates that there is an oversupply of dentists. The percentage of dentists as a proportion of the total oral health workforce should be reduced to around 20%-25% instead of the current 77%. Although the Committee of Dental Deans express similar views in their documents on human resource development, only two of the six dental faculties are training dental therapists at present. The dental schools have not adhered to their own recommendations to train fewer dentists. This is largely due to their dependence on the educational subsidies derived from training dentists. The training of dental therapists has also not been pursued. This is partly due to the State’s lack of commitment to creating posts for such personnel in the public sector.
Vocational Training for dentists, oral hygienists and dental therapists In May 1996 the Medical and Dental Education Committee resolved to revise the present system of undergraduate education and training in dentistry. It decided that a period of post- graduate vocational training in accredited oral health facilities prior to registration for independent practice would be introduced. The period of postgraduate vocational training for dentists was determined as one year after the completed undergraduate education and training. The Minister of Health was requested to ensure that the necessary legislation be put in place to provide for the introduction of the program by 1 July 1998. The Department of Health was also requested to ensure that sufficient funded and supervised posts in accredited oral health facilities to be made available.
Dental Technicians Amendment Act The Dental Technicians Amendment Bill was introduced to Parliament during 1997 and enacted. This Act provides for the recognition of the profession of dental technologists and provides for an extension of the scope of work which may be performed by dental laboratory assistants. The Aill also seeks to regulate the current practice whereby dental technicians illegally give financial discounts to dentists. Criticisms levelled at the Bill included a failure to address the question of expanding the scope of work (in terms of clinical procedures) performed by dental technicians; issues around occupational safety and the composition of the South African Dental Technicians Council. These criticisms were addressed by the Health Portfolio Committee and the National Council of Provinces. (See also Chapter 3 on legislation).
168 EDUCATION AND TRAINING The recommendations of the National Commission for Higher Education and the financial constraints placed on oral academic health centres have influenced developments within dental education sector.
National Commission on Higher Education (NCHE) A proposal of the Working Group of the National Commission on Higher Education locates the planning of dental education within a national body, the Health Personnel Educational Council (HPEC). The HPEC will be broadly representative and will include stakeholders from the Departments of Education and Health, professional bodies and higher education institutions. The HPEC would, it is hoped, provide direction for the determination of the number, location and size of the dental schools needed; as well as the number of different categories of health personnel for the country. Issues such as widening access to dental schools, the formation of regional consortia and rational funding mechanisms would also be addressed. The proposals have yet to be accepted and negotiations between the various stakeholders are in progress. (See Chapter 9)
Rationalisation of Academic Health Centres The need to rationalise academic oral health centres emerged from the national decision to focus on the primary health care level and to build equity into provincial health budgets. As a result, academic health centres in Gauteng and the Western Cape have received considerably less funding than in previous years. The University of Witwatersrand amalgamated its dental and medical schools into a single Faculty of Health Sciences. The decision was financially driven and based on the need to reduce inefficiency arising from the duplication of the facilities, staff, laboratories, equipment and administration. Implicit in the decision was recognition that the faculty could not support itself through increasing the number of students trained in dentistry. Amalgamation will also offer students a wider selection of courses and encourages collegiality and collaboration between health professions. The dental faculties of the Universities of Stellenbosch and the Western Cape are compelled, as part of rationalisation, to reduce their joint annual budget to R25 million by the year 2000. Faced with the task of reducing expenditure, members of the Management Committees of the two faculties have been meeting as the Inter-Faculty Rationalisation Committee. As these meetings have progressed, a vision of a single oral health institution providing for the education and training of the Western Cape has emerged. This shared vision has yet to be translated into a reality.
ESTABLISHING UNITY WITHIN THE DENTAL WORKFORCE The issue of unification of the different dental organisations representing dentists, (the Dental Association of South Africa, the Independent Dental Practitioners Association of South Africa, the National Dental Forum, and the South African Medical and Dental Practitioners of South Africa) into a single organisation also received considerable attention in 1996. The issue of unification focused largely on numbers and their representation within a new organisation. A new set of values which embodies the values generated by the different histories of the organisations has yet to be formulated. These values include policies on affirmative action, on redressing historical disadvantage and discrimination and on promoting access for the majority of the population to oral health services.
CONCLUSION This chapter reviewed the major issues in the oral health sector during 1996. In the oral health sector these focused on the formulation of a national oral health policy, drafting of fluoridation regulations, education and training, ensuring the production of appropriate number and mix of oral health personnel and building unity at a professional level.
Oral Health 169 170 OCCUPATIONAL 19 HEALTH
INTRODUCTION This chapter focuses on occupational health services in the public sector. Less emphasis is given to occupational safety (i.e. accident prevention) although its importance is obvious. Occupational health is not always well understood. Consequently a description of the discipline and its current status are included. The major initiatives to build a system for occupational health service provision, including compensation, are then described and evaluated.
OCCUPATIONAL HEALTH
The Scope of Occupational Health in Developing Countries
✧ Primary aim - control of work place hazards to prevent occupational ill health Examples of ill health include: ✧ occupational stress and musculo-skeletal disorder (eg. lower back injury) ✧ lead poisoning ✧ asbestos related disease ✧ delayed fertility ✧ silicosis ✧ hearing loss
✧ Secondary Aim - Identification of affected workers ✧ Detection of work related conditions and appropriate health management ✧ Treating cases as sentinel events which can influence: - hazard control - compensation - rehabilitation
Since prevention is the primary aim, occupational health must, in the first instance, be practised at workplaces, not in clinics or hospitals. This practice of occupational health prevention in the workplace requires a supporting infrastructure. An example of this is a laboratory to measure the concentrations of hazardous chemicals collected from workplace air. Without this laboratory the adequacy of hazard control and compliance with statutory standards cannot be assessed.
Authors: David Rees, National Centre for Occupational Health Tony Davies, National Centre for Occupational Health 171 Because workers with work-related problems will present to the general curative health services, occupational health services need to be integrated into these comprehensive services. The principle that the polluter pays is supported by the occupational and environmental health sector. In effect this means that the primary responsibility for control of hazards and for the provision of occupational health services lies with the employer. A statutory framework of minimum standards is formulated by the state and the social partners of organised labour and employers. Employers must comply with these standards by providing in-house services or by purchasing services from outside providers. Enforcement agencies monitor compliance and penalise transgressors. This chapter will focus on the major initiatives to build an Occupational Health System in South Africa.
OCCUPATIONAL HEALTH IN SOUTH AFRICA In South Africa, the Department of Labour develops and enforces laws and regulations for general industry and the Department of Minerals and Energy has this responsibility for the mining industry. There are very large numbers of workers with little or no access to occupational health services. These workers are either employed in sectors without services (eg. the informal, micro, small business and agricultural sectors) or they present with diseases after having left the workplace (e.g migrant workers and retired workers with diseases of long latency between first exposure and manifestation). If there was total reliance on the private sector these workers would not have access to occupational health services. Therefore, despite the onus for the provision of services being on employers, the state plays a large role in occupational health service provision. In addition for the need of the state to fill the gap in the provision of occupational health services left by private sector employers, the state as a major employer in its own right, needs to provide occupational health services to its own employees. Much has been written on the poor state of occupational health service provision in South Africa. The Commission of Enquiry on Occupational Health1 (the Erasmus Commission) concluded in 1976 that “it has regrettably to be stated categorically that, except in the mining industry, industrial health not only occupies a secondary position in industry in this country, but that industrialists have put very little time, money and organisation into the prevention of occupational diseases”. Recent publications confirm a general deficiency in the quantity of occupational health services offered.2 The Minister of Health’s Committee on Occupational Health reported in 19963 that “even in the Health Sector, for hospital and clinic employees, occupational health services are largely underdeveloped”. The 1995 Report of the Commission of Inquiry into Safety and Health in the Mining Industry4 (the Leon Commission) noted “the lack of attention in the regulatory system to health issues, (subsequently addressed in the Mine Health and Safety Act, 1996) and the poor record of the industry in controlling occupational disease”. The Minister of Labour, in 1996, clearly stated two of the root causes of inadequate development of services: “The provision of an efficient occupational health and safety service in South Africa, including compensation for injured and diseased workers, is severely hampered by the lack of an overall national policy and implementation strategy in this field. It is further hampered by the fragmentation of responsibility across various governmental departments”.5 Taken together these reports say that: ➣ there is no clear national policy and this is compounded by fragmentation of responsibility to produce the policy ➣ occupational health services need to be greatly extended at all levels of practice ➣ trained occupational health practitioners are scarce ➣ enforcement of statutory obligations is inadequate.
172 These problems are reflected in the Department of Health’s occupational health principles presented in the White Paper for the Transformation of the Health System in South Africa.6
PRINCIPLES OF OCCUPATIONAL HEALTH IN SOUTH AFRICA6
✧ Effective interdepartmental co-ordination and organisation of the various components of occupational health and safety is required. ✧ The development of occupational health services and associated human resources is required at the national, provincial, regional and district levels. ✧ Norms and standards for a healthy and safe working environment must be developed with other departments. ✧ Benefit examinations for the identification of compensable disease in former mine workers should be extended to under-served areas. ✧ The harmonious development of occupational health and safety is required across Southern Africa.
NATIONAL POLICY AND COORDINATION Two recent developments are important: the Department of Labour’s Committee of Inquiry into a National Health and Safety Council and the appointment of a Task Team of the Department of Labour and the Department of Health.
Committee of Inquiry into a National Health and Safety Council The Committee’s mandate was: ➣ To conduct a situational analysis of the state of Occupational Health and Safety and Compensation in South Africa that identifies: - the problems and the nature thereof - disharmony/duplication/omission within the areas of Governmental departments having an occupational health and safety function ➣ To conduct a comparative analysis using international standards and legislation, of present practices regarding the administration of occupational health and safety and compensation. Its major recommendation was that a statutory National Council should be established to develop integrated national occupational health and safety policy.5
Task Team of the Department of Labour and Department of Health This Task Team was established in 1996 to promote co-ordination and co-operation on occupational health activities. Responsibilities of the Departments of Labour and Health were identified. In summary, the primacy of the Department of Labour was recognised in the development of national policy, the promulgation of legislation in non-mining industry, and its enforcement and co-ordination at national and provincial levels. The Department of Health’s primary responsibilities are to provide comprehensive occupational health services to underserved workers (a provincial responsibility) and to provide occupational health referral and support services to the system as a whole. These two initiatives are the foundation on which to build a coherent system, but the historical poor co-operation among the government departments will have to be overcome. The establishment of a National Council and strategies to implement the principles developed by the Task Team, particularly co-ordination at Provincial level, are the key issues to monitor in 1997 and 1998.
Occupational Health 173 FIGURE 1 PROPOSED OCCUPATIONAL HEALTH UNIT
Occupational Medicine Information Referral Clinic Surveys Developing Protocols Occupational Hygiene and Laboratory Audit
Compensation Advice Office
Rehabilitation
Provincial / Regional Rehabilitation Services
EXTENDING OCCUPATIONAL HEALTH SERVICES Currently services include those provided by the public and private sector. These services include first contact between workers and primary providers at workplaces or general health services. Important developments include the Report of the Committee on Occupational Health3 with the consequent emergence of provincial occupational health and safety structures, private sector initiatives, the Mine Health and Safety Act, 1996, the establishment of a new National Centre for Occupational Health and extending benefit examinations to underserved areas.
The Report of the Committee on Occupational Health This Report presents a sound model for the provision of public sector occupational health services. Put simply, occupational health services would be based on the infrastructure of the provincial health services and the district health system. The secondary services would be provided by regional Occupational Health Units managed provincially (Figure 1). These services would provide a skeletal infrastructure for underserved workers in the province, for support services to handle complex issues and some expertise for occupational health services for provincial employees. Technical and scientific support would be provided from a national level through carefully selected advisory, training, research, laboratory and technical information functions. Responsibility for this support would fall on the new National Centre for Occupational Health. Implementation depends upon: ➣ training primary care providers ➣ in-service of training environmental health officers and bringing them into the system so that they can recognise and evaluate workplace hazards and advise on control measures; ➣ supporting the enforcement agencies of the Departments of Labour and of Minerals and Energy ➣ establishment of the provincial occupational health units. At the time of writing no systematic approach has been developed and no occupational health units established. However, the Western Cape, Gauteng and Eastern Cape have accepted in principle the need to establish these. All the provinces except Free State, Mpumalanga and KwaZulu- Natal have appointed officials to oversee the process.
174 Mine Health and Safety Act, 1996 In this new Mine Health and Safety Act7 occupational health (as distinct from safety) is given much greater prominence than before. Some of the mandatory activities are: ➣ involvement of workers ➣ risk assessment ➣ occupational hygiene measurements ➣ medical surveillance by trained practitioners. This provides the statutory incentive for the establishment of comprehensive, coherent services in the mining sector. Problems include the scarcity of trained practitioners, a relatively small budget for standard setting and enforcement, and declining profitability of mines.
The new National Centre for Occupational Health (NCOH) The specialised support and referral services of the NCOH were remodelled in 1996 to extend national capacity for the occupational health system as a whole.8 Inter-departmental co- operation will be a major factor in determining whether the intention to develop services across departmental boundaries is realised or not.
Extending benefit examinations for mineworkers These medical examinations, conducted at state expense in terms of the Occupational Diseases in Mines and Works Act, are to identify current and former mineworkers with occupational disease. It is estimated that up to two million people are eligible for benefit examinations throughout Southern Africa, but that financial and medical resources are available for only a small fraction (estimated at less than 30 000 per year). Table 1 shows the large number of workers employed in RSA mines. Survivors are eligible for benefit examinations twice yearly.
TABLE 1 SOURCES OF MINE LABOUR AND NUMBER OF BLACK WORKERS EMPLOYED
RSA Mozambique Malawi Botswana Lesotho Swaziland Other Total
1939 160 636 75 676 6 563 14 427 52 044 7 152 10 129 316 760 1949 108 669 85 975 9 196 11 905 35 275 6 614 28 442 286 076 1959 138 075 103 125 20 314 19 219 48 896 6 766 33 631 370 026 1969 122 319 88 117 53 315 19 571 59 661 5 586 6 245 354 814 1979 215 577 38 995 15 033 17 645 94 379 7 926 9 518 399 123 1989 243 556 42 807 2 212 16 051 100 529 16 730 - 421 885
Source: Adapted from The Twilight Years: Labour Migration in the Newish South Africa, Dr Jonathan Crush, Queen’s University, 1997.
IMPROVING REGULATION AND ENFORCEMENT Effective enforcement of occupational health and safety standards and regulations is fundamental to protecting workers’ health. It is not surprising that the Leon Commission and the Committee of Inquiry into a National Health and Safety Council included comprehensive recommendations on this issue. In general, it is recognised that: ➣ South Africa has no overall regulatory policy. Consequently, the health and safety inspectorates have not developed strategies consistent with national policy. ➣ A potential conflict of interest may arise when the same government department is responsible for both maximising production and ensuring that effective health and safety measures are developed and implemented. The Department of Minerals and Energy is in this position. Its participation in the formulation and implementation of national policies and strategies is, therefore, desirable. ➣ The resources of the Department of Labour’s health and safety inspectorate are inadequate to cope with increasing demands. Strategies to enhance the enforcement capacity of the
Occupational Health 175 inspectorate should include making more effective use of existing resources. An example would be to use environmental health officers in the health departments. ➣ The effective regulation of occupational health and the provision of occupational health services requires and integrated approach and the co-operation and combined efforts of the Departments of Labour, Health and Minerals and Energy. ➣ In the longer term, the information of a national health and safety policy should lead to the enactment of a health and safety statute applicable to all sectors (ie. a uniform policy and statute covering all workplaces.
COMPENSATION Compensation should be seen as a right for all workers, and the provision of effective and accessible services for identifying and compensating occupational injury and disease should be an obligation for the government departments concerned. Underlying compensation legislation is a trade-off which enables a system of no fault compensation to be introduced. The worker surrenders the right to sue the employer for damage to his/her health, while the employer undertakes to pay the levy required to fund compensation of disability due to work related injury and disease, and to meet the costs of medical attention for injured or sick workers. South Africa has two statutes: ➣ the Compensation for Occupational Injuries and Diseases Act (Act No 130 of 1993) which covers injury throughout industry and occupational diseases in industries other than mines ➣ the Occupational Diseases in Mines and Works Act (Act No 78 of 1973 as amended) which applies only to mine workers in respect of occupational diseases. In respect of serious disability due to injury at work the system appears to work well. But little has been done in the way of audit. In the past it was thought that almost all severe accidents were reported and the statistics published in the annual reports of the Workmens’ Compensation Commissioner. However, a recent study in the area served by the Salt River mortuary has shown that about a fifth of fatal accidents at work are not reported, and therefore not counted or compensated.9 As far as occupational disease is concerned the situation is obviously far from satisfactory. For most of the current decade only about 100 cases of occupational disease (excluding those from the mines) were reported each year from South African industry. In addition, the processing of these claims has been inadequate.10 In contrast the mining industry, reports many hundreds of cases each year predominantly among miners in service. The vast number of migrant workers who have returned to their rural homes do not have access to medical services which are able or willing to investigate their condition and complete the necessary forms. As a result those South African industries, including mines, which expose workers to injurious dusts or toxic chemicals have been able to disown their responsibilities and thereby transfer significant costs elsewhere. This point is illustrated by recent surveys. Arkles,11 in a study of the quality of life of disabled gold miners living in Lesotho concluded that there had been a systematic transfer of the costs of disability due to injury or ill health to the communities from which migrant labour has been recruited. This is confirmed by the comments of the Leon Commission on the failure to provide recognition centres in labour sending areas where former miners could be examined for health problems. The interim results of a more recent study of miners recruited through TEBA, a recruitment bureau for the mining houses, from the Libode District of the Eastern Cape suggest a massive burden of occupational lung disease.12 This study of a random sample of miners recruited between 1969 and 1980 shows that only one third of the men examined have neither pneumoconiosis nor tuberculosis. Thirty-six per cent have pulmonary tuberculosis, with or without pneumoconiosis,
176 and 55% have pneumoconiosis, with or without tuberculosis. Only 19% of them had been compensated in the past. Community based activity in the Northern Province has shown that there is a huge reservoir of undetected, and therefore uncompensated, occupational lung disease in the area surrounding the Pietersburg asbestos field.13 Table 2 shows the approximate payments to claimants and medical practitioners in recent years - administrative costs are not included.
TABLE 2 PAYMENT TO CLAIMANTS IN TERMS OF OCCUPATIONAL DISEASES IN MINES AND WORKS ACT AND WORKMAN’S COMPENSATION ACTa/COMPENSATION FOR OCCUPATIONAL DISEASES ACT (1990/91- 1995/6)
Occupational Diseases in Mines and Works Act Workmans’ Compensation Act / Compensation for Occupational Diseases Act Rands Rands 1990/91 31 353 232 1991 242 881 600 1991/92 42 899 888 1992 291 147 000 1992/93 39 021 904 1993 387 714 000 1993/94 41 788 567 1994 410 760 000 1994/95 30 564 630 1995 522 574 000 1995/96 38 802 504 - - a The Workman’s Compensation Act was replaced by the Compensation for Occupational Diseases Act in 1993. Payments in terms of Workman’s Compensation Act/Compensation for Occupational Diseases Act are directly to claimants and to medical practitioners for medical costs. Occupational injuries and diseases are included.
A review of the compensation legislation and the structures required to ensure uniform accessibility must be a priority. Compensation costs are an incentive to industrialists to improve working conditions, and unless management have to meet the full costs of neglect, the working environment will not improve. The Leon Commission concluded, on the basis of the evidence submitted to it, that dust levels in the mines had not changed over a period of 50 years and that there is no evidence to indicate a decline in the prevalence or severity of any occupational disease in the mining industry over the past 20 years.
CONCLUSION Major policy initiatives to overcome fragmentation and to establish public sector occupational health services have been reviewed. Except for the potential influence of the Mine Health and Safety Act on the mining sector, occupational health services in the private sector were not considered. Recommendations to improve enforcement and the case for a review of the compensation system were presented. Key issues to monitor are: ➣ the establishment of a National Health and Safety Council ➣ the creation of structures to co-ordinate occupational health and safety at provincial level ➣ the establishment of Regional Occupational Health Units ➣ the provision of occupational health services for public sector workers ➣ a process to review the compensation system ➣ establishment of recognition centres.
Occupational Health 177 178 DISABILITY 20
INTRODUCTION Disability has often been regarded as a peripheral issue in discussions on health services. Despite a number of progressive policies included in the South African Constitution that declares equal rights for all, and the White Paper on the Transformation of Health Services in South Africa, disabled people are still regarded in the main as an insignificant minority. In the health sector particularly, they are regarded as cases to be “cured”, failing which they are referred to Welfare for “care”. The denial of human rights, and the exclusion and marginalisation of disabled people is manifested in many forms within the health sector.
Acton said “We must never forget that society holds a tremendous responsibility for the existence of disability in its midst. The obligation to respond is greater than that of caring for the less fortunate; it is a matter of correcting a flaw in our culture, a flaw that has denied to millions of people the human rights that we have declared for everyone”1
This chapter presents different models of understanding disability, and different resultant definitions. Disability in relation to poverty, rehabilitation and Primary Health Care (PHC) is highlighted. Finally, there is discussion on the policy and planning implications of addressing this, and making PHC truly “accessible for all”.
CRITICAL COMPONENTS OF DISABILITY Historical developments Medical model To date in South Africa, services for disabled people have been based on an understanding of disability as individual pathology, the disabled person being seen as a problem to be corrected. Its development can be traced to the great strides in medical science and technology, which led many to believe that dysfunction could be explained through rational scientific argument; the cause of any condition regarded as abnormal being attributed to the malfunction of a physiological system. Pathology thus provided the means by which “dis”-ability could be distinguished from able-bodiedness, “ab”normality from normality.2 Disability as malfunction has since grown to be seen as a specialised health problem, at the heart of which is an emphasis on clinical diagnosis. Consequently the aim of medical rehabilitation is to assist the individual to be “as normal as possible”.3 Without doubt, the contribution of modern medicine has led to increased survival rates and prolonged life expectancy for many disabled people, as well as the eradication of some disabling conditions. “But the issue for the late twentieth century is not one of
Authors: Sue Philpott, Disability Action Research Team (DART) Pam McLaren, Disability Action Research Team (DART) 179 life-expectancy but expectation of life and it is here that the negative and partial view prompted by the medicalisation of disability is most open to criticism”.3 One of the implications of the medical model of disability is that it reduces problems of disabled people to their own personal inadequacies or functional limitations. In addition, by focusing primarily on the impairment, secondarily on the individual who bears it and only minimally on the social and physical impairment, it contributes to the exclusion of disabled people from society. Services for disabled people, based on this approach, tend to foster dependency. The very professional-client relationship “enshrines the professional in a world of exclusive and privileged knowledge and consequently entombs the disabled individual in a fundamentally dependent role”.3 Services tend to be welfare-oriented, reflecting the perception of “looking after” or “providing for”, and promotes an attitude of dependence. Finally, the medical model provides the framework in which medical experts decide what they think disabled people need.
FIGURE 1 DISABILITY - THE MEDICAL MODEL
Is "Housebound" Can't use hands "Confined" to wheelchair
Can't walk Can't get up steps
PROBLEM:
Needs doctor ‘DEFECTIVE PERSON’ or a cure Is sick
Can't see or hear Needs carers and help
Has fits Bitter attitude
Social model In contrast to the medical model, the social model of disability views the medical condition as only part of the so-called problem. Instead, it is realised that the problems that disabled people face are caused not primarily by their impairments, but by the way that society is organised to meet the needs of non-disabled (so-called “normal”) people. In this view, the locus of the problem is the disabling world. The result is that disabled people are unnecessarily segregated and excluded because of a badly designed built environment, inaccessible public transport and discriminatory attitudes and practices. By virtue of this, disabled people are an oppressed and marginalised group in society. It could be regarded as “apartheid of disabled people” - as people do not have access to the same opportunities as others simply on the basis of a physiological characteristic. Based on this view, intervention is not primarily focused on the individual disabled person, trying to bring about “normalisation”, cure or care. Instead, it involves removing the barriers that prevent disabled people from exercising their right to participate in society - in other words, it involves challenging the disabling world.2
180 FIGURE 2 DISABILITY - THE SOCIAL MODEL
Inaccessible transport Badly designed buildings Poor job prospects
No parking spaces No lifts
PROBLEM: DISABLING WORLD Isolated families Superior attitude
Poverty and low income Segregated education
Few sign language interpreters Prejudiced attitudes
Definitions of disability Differing opinions on definitions of disability stem from the fact that “disability is relative and dependent for its definition on local attitudes and physical barriers, which change from one society to another”.2 Notwithstanding, both WHO and the Disability Rights Movement have proposed definitions relating to disability: WHO proposed the following distinctions4: Impairment is any loss or abnormality of psychological, physiological or anatomical structure or function (eg. a missing or defective body part, paralysis after polio). Disability is any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being (eg. difficulty in speaking, hearing or walking). Handicap is a disadvantage for a given individual resulting from an impairment or a disability that limits or prevents the fulfilment of a role that is normal (depending on age, sex and social and cultural factors) for that individual (eg. lack of access to employment for a person with a hearing impairment due to discriminatory attitudes). In these definitions, impairment is defined objectively in terms of observable function, while disability and handicap are seen in terms of what is “considered normal” for an individual.
The Disability Rights Movement Based on the view that the problem of disability arises not so much from the individual with an impairment, as from the way that society is organised, the following definitions are proposed: Impairment refers to the part of the body which is impaired in some way and consequently is limited in its functioning (eg. a mobility impairment). Disability refers to the disadvantage or restriction of activity caused by the way society is organised which takes little or no account of people who have physical, sensory or mental impairments. As a result such people are excluded and prevented from participating fully on equal terms in mainstream society. Disability is thus imposed on people with impairments who, as a result, become disabled not by their impairments, but by society.5
Disability and poverty The link between poverty and disability has been well documented.6 Poverty-related factors lead to many preventable impairments (eg. malnutrition leading to stunting) and the social
Disability 181 disadvantage of poverty feeds into that of impairment (eg. making it almost impossible for a child with lower limb paralysis to get access to education). This leads to a perpetuation of the poverty cycle, as disability entrenches poverty. Prevention programmes form part of the backbone of PHC. Such programmes often entail medical interventions and initiatives - such as immunisation campaigns. However, this is only one dimension that needs to be addressed, and programmes must also include: ➣ recognition of poverty-related factors which contribute to impairment, and ➣ recognition of factors in society (such as attitudinal and physical barriers) which discriminate against people with disabilities. Prevention programmes need to be developed in conjunction with those for early identification and intervention, particularly for young children. This is a priority where effective therapy can be provided for conditions for which definitive treatment is available (eg. meningitis and TB), and for conditions that cannot be reversed, it improves the outcomes. A fundamental premise of early intervention programmes is that the disabling effects of impairments can be reduced, thus enabling children to live fuller lives.7
Rehabilitation services Rehabilitation in South Africa Historically, rehabilitation services in South Africa have been centralised and institution-based. They have been characterised by racial bias and segregation, favouring white urban disabled people. There has been little co-ordinated planning, with fragmentation of the different disciplines. As yet there is no national policy on rehabilitation. NGOs have played an important role in the development of innovative, community-based approaches to providing rehabilitation and support services to disabled people. However, most of these still remain outside the formal health system, with no co-ordination or standardisation of training courses. In the main, services have been underpinned by the medical model of disability, seeing it as a medical issue, requiring medical management, with the medical/rehabilitation “expert” making decisions on behalf of the disabled person. As a result, there has been little empowerment of disabled people through the process of rehabilitation.8 In contrast to this approach, rehabilitation has great potential to be used as an enabling tool, to equip the disabled person to be integrated into society.
UN definition of rehabilitation Rehabilitation has been defined as9 “a process aimed at enabling persons with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychiatric and/or social functional levels, thus providing them with tools to change their lives towards a higher level of independence. It may include measures to provide and/or restore functions, or compensate for loss or absence of function or for a functional limitation. The rehabilitation process does not involve initial medical care...”.
182 FIGURE 3 RELATIONSHIP BETWEEN DISABILITY AND POVERTY
AGGRAVATING FACTORS ALLEVIATING FACTORS exposure equity in health care lowered resistance education less access to medical treatment immunisation accident prevention good nutrition
D y i t s
r
a
e
b
v
i
l o
i
P t y
ALLEVIATING FACTORS AGGRAVATING FACTORS adaptation of society ignorance equalisation prejudice information less access to rehabilitation knowledge less access to compensation community based rehabilitation reduced productivity
Source: Swedish Internatonal Development Authority. Poverty and disability: a position paper. SIDA, Health Division, 1995
Assistive devices and rehabilitation Assistive devices are an essential component of rehabilitation, in that they provide a means of compensating for loss or limitation of function. In addition, they are a mechanism for the equalisation of opportunities for disabled people, by enabling them to participate on equal terms with other in society. A recent study10 which investigated the assistive devices service in KwaZulu-Natal, identified a number of barriers that are present, which prevent the service from achieving its purpose (ie. provision of an accessible, appropriate and affordable service). These barriers include: ➣ the high cost of devices ➣ the lack of knowledge regarding services ➣ negative attitudes of service providers towards disabled people ➣ centralisation of the service with no clear policy for provision ➣ a lack of environmental accessibility. Recommendations included: ➣ provision of mechanisms to make assistive devices “affordable for all” ➣ improved information systems regarding disability ➣ promotion of community-based services ➣ service providers’ role as “enablers” ➣ promotion of environmental accessibility.
Disability 183 The Department of Health is currently drawing up a policy on provision of assistive devices services at primary level.
Making PHC “accessible for all” Central to the philosophy of PHC is the commitment to provision of accessible, affordable and appropriate services to individuals and their families in the community. It also includes a strong focus on community participation, equity and intersectoral collaboration. Health policy makers and planners need to ensure that the aims of PHC become a reality for all citizens, including disabled people, who remain amongst the most poor and marginalised members of society. This means: ➣ ensuring that all PHC services (including Maternal and Child Health, Under 5’s Clinics) cater for disabled people ➣ ensuring that rehabilitation services specifically are given due recognition and status as a tool for the empowerment and enablement of disabled people.
IMPORTANT POLICY AND PLANNING DEVELOPMENTS Important policy documents Integrated National Disability Strategy11 This document is intended to provide a framework from which integrated and coherent policy can be developed to address the unequal social, economic and political forces that have affected disabled people in South Africa. It is only by understanding and recognising the ways that disabled people have been marginalised and disempowered that an effective and sustainable programme for change can be developed, and the needs and rights of disabled people addressed. Significance of this document for the Health sector: ➣ it involved a great deal of consultation, and as a result there is a high level of consensus on it within the disability sector ➣ it clearly portrays disability as a development and human rights issue, rather than a medical/health problem (“medical model”) ➣ it calls for the transformation of society, towards a Society for All (“social model”) ➣ it outlines elements in an integrated national disability strategy, which include medical care and rehabilitation.
White Paper for the Transformation of the Health System in South Africa12 Core concepts in this policy document include: the development of the district health system; increased access to services by making PHC available to all citizens; and the development of a National Health Information System to facilitate health planning and management, and strengthen disease prevention and health promotion. The implications of these concepts for disability are: ➣ “universal accessibility” must include mechanisms to accommodate disabled people ➣ the integrated package of essential PHC services must include rehabilitation, and rehabilitation personnel as members of PHC teams ➣ disabled people and parents of disabled children need to be involved in various aspects of planning and provision of health services ➣ mechanisms for public accountability should include the disability sector ➣ training of community rehabilitation workers should be related to the National Qualifications Framework, and linked to existing training of therapy assistants. This means that the training is standardised and can be upgraded. However, it poses problems for those already trained, and limits access for those who do not have a school-leavers certificate.
184 Provincial rehabilitation policies While there is no national rehabilitation policy, some provinces have formulated their own policies, which can be useful guidelines in the interim. However, there is still a need to clarify the role of the health sector in rehabilitation, particularly in relation to other sectors such as Education, Welfare and Labour.
Indicators of progress While it is relatively easy to formulate policies that are inclusive of disabled people, it is imperative that mechanisms are built in to ensure that these are put into practice. Indicators for this include: ➣ physical accessibility of health facilities (eg. ramps for wheelchairs, balustrades and bubbled surfaces for people with visual impairment, access to communication for deaf people) ➣ knowledge, skills and attitudes of health personnel at primary level regarding disability ➣ involvement of disabled people’s organisations in the management, planning and evaluation of health services ➣ allocation of resources which reflect a priority placed on early identification and intervention ➣ research protocols and data collection methods that reflect the situation of disabled people (eg. coverage of nutrition programmes).
Factors hindering progress These include: ➣ the tendency for health personnel to view disabled people as “welfare cases”, and as a separate group to others that they serve - leading to discrimination and segregation of disabled people ➣ the lack of clear responsibilities and poor co-ordination between the Departments of Health and Welfare - leading to lack of a comprehensive service ➣ the low priority and status given to rehabilitation services - leading to insufficient budget and resource allocation ➣ little meaningful participation of disabled within the health service - leading to the lack of appropriate services, lack of ownership by disabled people ➣ lack of consensus of service providers regarding the future development of rehabilitation services - leading to lack of planning and policy development ➣ lack of co-ordination of disability-related research - leading to inaccessible data, non- standardised methodologies, and studies that are not comparable ➣ no age-adjusted and gender-adjusted prevalence rates relating to the different types of impairment - leading to absence of data for effective planning ➣ no central data base for disability-related research - leading to fragmentation and duplication of data collected with no co-ordinated mechanism for dissemination.
Factors facilitating progress These include: ➣ the process of broad consultation on the National Integrated Disability Strategy Document ➣ the strong disability rights movement in South Africa, which has led to the setting up of the Disability desk in the office of the Deputy President, and a Parliamentary representative ➣ the new democratic ethos in South Africa, which is embodied by the new Constitution. This has identified particular groups which were particularly oppressed under the apartheid system, and led to greater awareness of those previously excluded and marginalised. The concept of inclusion of disabled people fits well into this new ethos.
Disability 185 KEY AREAS WHERE PROGRESS MUST BE MADE Disability awareness programmes for health personnel All health personnel (from primary to policy level) should undergo training in disability awareness. This should be done in consultation with disabled people’s organisations, and aim to address stereotypes of disability and promote positive attitudes in a culture of human rights. It should lead to specific plans for health facilities at a local level.
Collection of statistics and baseline data There needs to be an in-depth analysis of existing disability-related studies, in order to ascertain their reliability. In addition, mechanisms need to be set in place for collection of statistics and baseline data on impairment and disability. These need to be co-ordinated and integrated into the agenda of Essential National Health Research programmes. The national Department of Health recently awarded a large tender for a national survey of disability. The results of this survey will be available in 1998.
Ensuring environmental accessibility of health facilities An accessibility audit of existing health facilities should be conducted to assess the extent to which they are accessible for disabled people. Architectural plans for new clinics and other facilities should also be assessed in terms of these criteria.
Promotion of community-based rehabilitation The importance of community-based services for disabled people needs to be emphasised. This includes the full integration of rehabilitation into PHC, with co-ordinated planning and implementation. The role played by disabled people and parents of disabled children in promoting the rights of disabled people needs to be acknowledged and affirmed.
Monitoring of existing services Existing services need to be reviewed, to assess the extent to which they are adequately addressing the health needs of disabled people. This includes budgetary allocations, and priority placed on early identification and interventions for children with developmental delays and/or other impairments. Participation of disabled people in planning and management of health services at district and sub-district levels should be encouraged, as part of community participation in PHC.
Monitoring new policies to ensure that they accommodate disabled people All policies that aim to provide equitable, accessible and appropriate health for all, need to be assessed in view of the extent to which they cater for disabled people. A touchstone for such review is the Integrated National Disability Strategy.11
186 HIV / AIDS 21
INTRODUCTION Recent trends in Southern Africa suggest a severe epidemic, described by UNAIDS as “explosive”. The November 1996 ante-natal survey confirmed these trends with particularly high rates in KwaZulu Natal, Northwest, Free State, Mpumalanga and Gauteng provinces.
TABLE 1 NATIONAL HIV SURVEYS OF WOMEN ATTENDING ANTENATAL CLINICS OF THE PUBLIC HEALTH SERVICES IN SOUTH AFRICA, 1994 - 1996
Province 1994 (%) 1995 (%) 1996 (%) KwaZulu-Natal 14.4 18.2 19.9 Mpumalanga 12.2 16.2 15.8 Free State 9.2 11.0 17.5 Gauteng 6.4 12.0 15.5 North West 6.7 8.3 25.1 Eastern Cape 4.5 6.0 8.1 Norhtern Province 3.0 4.9 7.9 Northern Cape 1.8 5.3 6.7 Western Cape 1.2 1.7 1.7A South Africa 7.6 10.4 14.1
Source: Seventh National HIV Survey October/November 1996
The results of the survey1 were used to estimate the number of South Africans infected with the virus at the end of 1996. In order to extrapolate the results found in antenatal clinic attenders into the total population, certain assumptions were made: ➣ The prevalence rate of HIV infection in all pregnant women in South Africa is the same as the prevalence rate in women attending public antenatal clinics. ➣ The prevalence rate of HIV infection in all women aged 15 to 49 years is the same as the prevalence rate in pregnant women. ➣ The male to female ratio of HIV-positivity is 0.73:1. ➣ 30% of babies born to HIV positive women are infected. In total, based on the above assumptions, it is estimated that almost 2.4 million adults were HIV positive at the end of 1996 and 156 000 babies born since 1990 were infected with HIV.1 Provincially, it is estimated that KwaZulu-Natal had almost 750 000 infected people; followed by Gauteng with 466 000 infected. The Northern Cape, with the smallest population has an estimated 22 000 HIV infected people. The age group 20-24 carries the highest rate of infection. Most HIV infections occur in people under the age of 30. The rate of new infection is possibly slowing in the
A The Western Cape data is under review and is reportedly of the order of 3%
Author: Liz Floyd, Gauteng Department of Health 187 provinces most affected by the epidemic. The provinces with relatively low infection rates remain most vulnerable to rapid spread of HIV in the near future. Prevention still remains the major priority. In addition special efforts need to be made to prepare for the emerging care needs. Figure 1 shows the projected HIV prevalence for antenatal attendees, based on an exponential growth curve. The 1996 Health Review highlighted the nature of the AIDS epidemic, factors driving it and the impact of the epidemic. The Sarafina 2 issue was highlighted as a controversy around government transparency and accountability. Late in 1996 President Mandela publicly acknowledged mistakes in handling Sarafina 2. The effects on the AIDS programme were substantial. The programme was paralysed and leaderless at national level for four months until a new Director, Rose Smart, was appointed in December 1997. With her appointment work has resumed at a rapid pace. The lack of credibility following Sarafina 2 affected the whole AIDS programme, including many roleplayers who had nothing to do with Sarafina. For example, questions regarding the effectiveness and financial accountability of all AIDS programmes affected NGO funding. The overall result was that AIDS workers faced a national AIDS programme that lacked credibility combined with a particularly severe epidemic. This year, 1997, has been dubbed the year of delivery. For the AIDS programme visible delivery is acutely relevant. The programme needs to re-build its credibility based on its ability to deliver effective programmes. The NACOSA National AIDS Plan reflects well-developed policies that act as a framework to guide implementation plans. This chapter uses the NACOSA Plan as a starting point against which to review progress with implementation. In addition, it focuses on progress with implementation at local and provincial level and draws on the reports of the 1997 STD / AIDS Review.
FIGURE 1 HIV PREVALENCE IN ANTENATAL CLINIC ATTENDERS - BASED ON THE NATIONAL SURVEYS CONDUCTED DURING OCTOBER/NOVEMBER OF EACH YEAR
50
40
30 Exponential growth curve
20 HIV prevalence (%) HIV prevalence
10
0
1990 19 91 1992 1993 1994 1995 1996
THE NATIONAL AIDS PLAN: A BLUEPRINT FOR IMPLEMENTATION NACOSA (The National AIDS Convention of South Africa) was convened in 1992, prior to the completion of political negotiations, with a mandate to develop a national AIDS strategy and plans to implement this strategy. These plans were developed through extensive consultation. They drew on international experiences, especially those in other African countries. The NACOSA Plan was developed with technical assistance from WHO. It was completed prior to the major policies guiding transformation of the health sector (eg. integration of services,
188 district development). As a result, there is an emphasis on a technical, relatively vertical AIDS plan which is weak on supporting community level mobilisation. The UNAIDS (the new integrated United Nations AIDS Programme) now emphasises a broader-based intersectoral response with greater integration of activities. One of the goals of the National Plan was to provide a framework which unites all players in working towards a common goal. The South African process has been widely recognised as an effective and democratic way of developing a representative and united response to the HIV and AIDS epidemic. The principle that people with HIV and AIDS should be involved in all processes was emphasised. Working groups were established to develop the six components of a National AIDS Plan: ➣ education and prevention ➣ counselling ➣ health care ➣ human rights and law reform ➣ welfare ➣ research The National AIDS Plan was adopted by the Minister of Health shortly after the 1994 elections and there were high expectations that it would be implemented timeously and effectively. The Plan remains the reference point for developing programmes and responses to deal effectively with the challenges of HIV and AIDS.
COMPONENTS OF THE NACOSA PLAN
PREVENTING THE SPREAD OF HIV through changing behaviour, treating STDs and providing condoms. Activities include: ✧ Raising awareness through media and community campaigns. ✧ Educational programmes: - Lifeskills programmes in schools - Community education through NGOs - Outreach projects for special groups. ✧ Workplace education ✧ Control of Sexually Transmitted Diseases (STDs), including management based on the syndromic approach. ✧ Supplying condoms ✧ Reducing blood spread: - safe blood supply - universal precautions ✧ Reducing transmission from mother to baby. ✧ Addressing the socio-economic factors contributing to the spread HIV through the RDP and supporting the Women’s movement. REDUCING THE IMPACT OF THE EPIDEMIC through providing comprehensive, co-ordinated care services; building acceptance and support of people with AIDS (PWAs) and providing welfare support. Activities include: ✧ Developing PHC, hospital care and TB services. ✧ Developing counselling services ✧ Fighting discrimination and building support groups. ✧ Providing home-based and hospice care ✧ Providing Welfare support, especially for affected children.
HIV / AIDS 189 IS THE PLAN STILL RELEVANT? The National STD and AIDS Review (see later in this chapter) indicated that the Plan requires development in some areas but remains a very strong base for the AIDS programme. Its major strength is that it retains credibility within the AIDS sector. A more accessible, focussed version is required to empower the wide range of people playing a role in the response to the epidemic. A large portion of the remainder of this chapter goes through the major elements of the NACOSA plan, highlighting the activities undertaken in implementing the policies of the plan. It also refers to areas where policy requires further development in order to guide implementation. At the same time areas of inactivity and deficiencies in implementation are highlighted.
PREVENTING THE SPREAD OF HIV Raising awareness through media and community campaigns Policy The AIDS plan includes a mass communication campaign using the electronic media (eg. TV, radio) through employment of an advertising agency. It also emphasises the active involvement of the press in communicating with the public. The plan includes development of small media (pamphlets, posters, stickers). These small media support educational activities and should be developed at provincial or local level. The national AIDS programme has previously commissioned two national advertising campaigns and has now tendered a third campaign to a consortium of NGOs. The AIDS Media Forum is developing skills around communication and media.
Implementation ➣ World AIDS Day is an annual AIDS awareness focus, consisting of a national event and multiple small community events supported by media. ➣ Radio is emerging as the priority for communication and is increasingly being used for health promotion. There is a noticeable improvement in SABC coverage of AIDS issues. Although condom advertisements have been blocked in the past this has been lifted and there are now advertisements. ➣ Evaluation of Soul City showed it to be particularly effective. Soul City is a multi-media project which includes an educational TV drama, radio as well as booklets. ➣ Theatre is consistently used and generally takes the form of mobile, small local amateur or semi-professional groups who are linked into local culture. They are particularly effective in reaching students in schools. Some of the problems with the implementation of this section of the NACOSA plan are: ➣ The relationship between the press and the national programme deteriorated over the Sarafina issue and needs to be rebuilt. ➣ The national programme no longer budgets for a significant volume of small media products and few provinces have the capacity to produce their own. This has resulted in a shortage of small media products to support services. ➣ There is a lack of detailed policy on mass communication and how best to use campaigns. ➣ Considerable effort goes into local community events around World AIDS Day. Most events focus on awareness of AIDS. The methods used and results achieved with such campaigns have not been well documented or evaluated and deserve more critical analysis.
Educational Programmes - Lifeskills programmes in schools The concept of a Lifeskills programme has been adopted by the Departments of Education, Health, Welfare and Police Services. However, the focus varies in each Department. The new curriculum of the Department of Education includes a Lifeskills Programme. While sexuality education is prioritised by the AIDS Programme, the Lifeskills programme covers a wider range of issues. The national strategy on Lifeskills is to train two teachers per school in Lifeskills within 1997.
190 Implementation The Lifeskills policy is implemented by Provincial Departments of Education supported by the Provincial Health Department. The first phase of the project consist of training of trainers. Funds have been allocated and a few provinces started training of trainers in the first half of 1997. The rate of implementation is affected by various factors within the Education Department, the working relationship between Education and Health and the capacity of the task teams and trainers. The benefits of this Lifeskills programme will only start reaching students in 1998. Supplementary activities are necessary both in the short and medium term. At local level a number of Lifeskills activities are run by schools, NGOs, health service staff and theatre groups. However, it is difficult to assess how many youth are exposed to sexuality education at this stage. Youth are also reached through radio, TV and youth clubs. The Welfare Department has started introducing Lifeskills in Youth institutions.
HIV in Schools Nkosi Johnson, of Gauteng, was probably the first school child who was publicly known to have AIDS. The school and the Education Department were caught under prepared. After efforts were made to address parents’ and teachers’ concerns, most parents responded positively. A policy on children with HIV is now being drafted in detail.
Community education through NGOs, Outreach Projects for special groups, workplace education Policy The NACOSA plan identifies the need to support NGOs in mobilising society around HIV prevention and care. In addition outreach projects should provide education for groups deserving special attention (including sex workers and prisoners). More details are needed to guide educational programmes and project implementation. The Department of Correctional Services has developed an AIDS policy which is strongly influenced by the AIDS Law Project.
Implementation ➣ The national AIDS programme has funded NGOs for two years. Despite this overall NGO capacity in the AIDS field has decreased. ➣ There has been a noticeable improvement in co-operation between local communities and health services. Small community groups working on AIDS play a valuable role. These groups need to be supported in a more organised manner. ➣ Specialised projects exist and there is increasing experience in working with sex workers and their partners. There is also increasing experience in working with prisoners. ➣ The Department of Correctional Services is starting to implement the AIDS policy with good support from NGOs involved in AIDS work. Additional resources are required to reach significant numbers of prisoners. ➣ Results from workplace programmes vary at this stage. Unions have limited involvement in education programmes and their efforts have focussed on negotiating benefits for workers with HIV/AIDS.
Control of sexually transmitted diseases (STDs) Policy The programme is based on making effective STD treatment accessible through all primary care services and promoting public awareness of STDs. Tanzania demonstrated a significant drop in new HIV infection rates as a result of effective STD treatment. STD policy is well-developed nationally and protocols for the syndromic treatment of STDs have been finalised.
Implementation Through strong national leadership there has been implementation of the policy. This includes
HIV / AIDS 191 training trainers in the management of STDs and also STD managers. Trainers have been trained in each province. In turn these trainers, in several provinces have trained large numbers of nurses. As a result of this training there is improvement in the quality of care, although this varies across provinces. All provinces use the syndromic approach, although there is some variation of the treatment protocols. Application of the protocols in the private sector is limited by the relatively high cost of STD drugs.
Barrier methods Policy The Plan commits the provision of free condoms to the public. It supports social marketing of condoms.
Implementation ➣ A large scale national supply of condoms has been sustained despite a few hitches in deliveries to provinces. ➣ However, KwaZulu-Natal, Gauteng and Mpumalanga provinces distributed 70% of condoms nationally with low distribution in the other provinces. ➣ Acceptance of condoms appears to be increasing, especially amongst young people. ➣ Pilot projects to provide female barrier methods, including the female condom have been initiated with problems. Detailed guidelines and plans need to be developed for the introduction of the female condom.
REDUCING TRANSMISSION FROM MOTHER TO BABY Policy The NACOSA Plan pre-dates recent research results on perinatal transmission of HIV, including the documentation of transfer of infection through breast-milk. A national conference in 1996 on breast feeding supported the UNICEF policy to maintain the focus on promoting breastfeeding. However, this is a complex policy area with no easy answers. It needs to be addressed as a priority issue.
Implementation The lack of clarity on policy results in an uncoordinated mix of practices. For example some antenatal clinics screen everyone for HIV and some clinics do not have the capacity to test. Capacity to support HIV positive women needs to be increased everywhere and should include counselling and follow-up care with the development of support groups.
PROVIDING CARE AND SUPPORT Fighting discrimination and building support groups Policy The National AIDS strategy emphasises the human rights of People With AIDS (PWAs) and the importance of PWAs being involved in planning and development of programmes.
Implementation ➣ Discrimination remains a fundamental problem and undermines access to support and health services. ➣ PWAs still face rejection, dismissal, isolation and physical violence. Issues of confidentiality and notification need rapid clarification. ➣ The organisation of PWAs is making slow but encouraging progress, but is still focused in urban areas. However PWAs are involved in policy development at national level and in some provinces.
192 ➣ There are strong role-players in the area of AIDS human rights: including the National Association for People with AIDS (NAPWA), the AIDS Legal Network, and NACOSA and the AIDS consortium. ➣ There is national AIDS programme support for: - National Association for People With AIDS - the employment of PWAs as educators (eg. The Faces of AIDS project) - funding of the AIDS Law Project.
Medical Care for PWAs Policy Policy on AIDS care has not been developed at national level. In the absence of national policies several provinces have developed their own. However most provinces have insufficient capacity to do this. The new TB Policy makes a valuable contribution to AIDS Care as TB treatment is one of the most effective, affordable treatments available to PWAs.
Implementation In the absence of national policy, the medical care of PWAs relies on local initiatives and remains dominated by hospital care. Standards vary enormously and confusion persists around the rationale for testing. There is insufficient access to care and services providing dedicated care (eg. HIV clinics), are being overwhelmed by demand. Most medical care should be provided by comprehensive primary level services. But this is dependent on the development of PHC services which have the capacity to provide appropriate curative care. This requires a PHC nurse with clinical skills, essential drugs and access to basic laboratory tests. There are insufficient services for terminal care. Many hospitals are unwilling to provide terminal care and NGO hospice care is focussed in cities. The AIDS programme has started to fund hospices through NGO funding and a few projects provide home-based care. Home-based care is emerging as an urgent need. Common problems in community level care are: ➣ Networking and co-ordination are clearly priorities that need more attention. ➣ Services have developed in an uncoordinated way and the distribution is not always rational. PWAs and service providers have difficulty in finding out what services are available. ➣ Projects are relatively isolated and often do not benefit from shared experience. ➣ The scale of services needed for the AIDS epidemic is large. The situation requires formal funding of NGO services with financial support to volunteers.
DEVELOPING COUNSELLING SERVICES Policy The Plan emphasises counselling as an essential component of care. Strategies for developing counselling services are detailed. A counselling policy has been developed in KwaZulu-Natal and Gauteng.
Implementation The implementation of the policy requires a commitment to counselling by management and significant human resources. The results vary enormously. ➣ Hospitals still commonly test for HIV without pre-test counselling. This contributes to post-test counselling problems faced by counsellors. ➣ ATICCs (AIDS Training Information and Counselling Centres) have historically trained counsellors and provided counselling. A variety of NGOs sustain counselling.
HIV / AIDS 193 ➣ Increasingly counselling capacity is being developed in hospitals and clinics by training nurse counsellors. Problems for nurse counsellors include high workloads; playing combined nurse and counsellor roles; and weak management support for their counsellor role. Complementary strategies include a national project to employ lay counsellors (funded by the RDP) and building NGO capacity in counselling.
PROVIDING WELFARE SUPPORT Policy The NACOSA plan addressed Welfare issues in some detail and set out the process for developing comprehensive Welfare policy. The Welfare White Paper outlines the broad direction of policy. Further research on needs assessment and available services is being carried out.
Implementation Children Welfare services face a range of immediate problems with children: ➣ Care of HIV infected children in institutions ➣ A disproportionately high rate of HIV infection among abandoned babies. These babies are difficult to place and have special needs. ➣ Orphaned children. KwaZulu-Natal is most affected and a range of responses have been generated. The Gauteng Welfare Department is planning a conference to address these problems. Several NGOs provide care for abandoned and terminally ill children.
Adults Problems for adults include: ➣ unemployment or loss of benefits ➣ homelessness ➣ delays in accessing Disability Grants These problems compound the difficulties of coping with a difficult illness in the face of discrimination. The Welfare Department has been criticised for slow progress in finalising and implementing policy. Meanwhile the needs increase rapidly. NGOs, especially those with a religious orientation, play a major role in meeting the psycho-social needs of PWAs. Their responses include: ➣ Support groups for PWAs ➣ Homes for ill people who have nowhere to go but do not meet hospital admission criteria ➣ Material support with food parcels and transport ➣ Advocacy around discrimination, especially on employment issues ➣ A few income-generation projects It is likely that there will be reliance on NGO leadership in this area of work. Funds need to be made available to support NGOs in this work.
MOBILISING AND ORGANISING THE RESPONSE TO THE EPIDEMIC Policy The Plan outlines national and provincial functions and structures. It spells out the need to mobilise resources, and develop management capacity to decentralise the programme. Because the plan was completed prior to major transformation it does not reflect the new government structures. NACOSA recommended the programme be located in the President’s office to support an inter-sectoral response. The plan assumes vertical support for implementation of activities. While
194 activities are integrated into PHC services and schools the structures for supporting these activities were not detailed. Since the original plan was completed, the importance of advocacy to promote political leadership of the programme and the need to strengthen the inter-sectoral response have emerged more strongly. Activities to mobilise include : ➣ Government leadership of an intersectoral programme ➣ Developing the capacity of NGOs and community groups ➣ Advocating for a broad response and sufficient resources ➣ Developing structures and capacity at each level of government ➣ Developing plans and monitoring implementation with research and evaluation ➣ Building international links, especially within Southern Africa.
Organisation of the programme The organisation and management of the programme has probably been the most difficult aspect of implementation. The slow pace of programme implementation has been determined partly by the transformation process. For example the appointment of key staff has taken an excessively long time. Capacity in many provinces remains very low relative to the demands of the programme. The programme has been located in the Health Department rather than the President’s office and Health has initiated an inter-departmental process. Initially NACOSA reflected the inter-sectoral component of the programme, but with time NACOSA increasingly reflects the perspectives of health NGOs and health workers. The inter-sectoral aspects of the programme are therefore under- developed. There has been tension around the benefits of a centralised, vertical programme versus a decentralised integrated programme. Part of this debate relates to the extent to which the programme is driven from the top by technical approaches or driven from below by appropriate community mobilisation. The original highly centralised, vertical AIDS programme of the Department of Health was changed substantially and re-organised in 1997. A range of functions have been devolved to provinces with greater involvement of provinces in national planning. At District and Regional level, the extent of integration of AIDS programmes has been debated. In practise several components of the plan rely on integration into District services (eg. STDs, AIDS care) while several components are not implemented within the health services (eg. educational programmes for the Lifeskills programme). Some aspects of the programme deserve vertical implementation in the short term to achieve rapid results (eg. media campaigns, outreach projects). The flexibility of NGOs for rapid implementation should be utilised while the transformation proceeds at the necessary pace. The rate of implementation of the AIDS plan is obviously a cause for great concern. The challenge lies in combining the great potential for community mobilisation with technical expertise that guides effective use of limited resources. There are special difficulties and many potential advantages in implementing an AIDS programme in the present period of transformation within the country.
HIV / AIDS 195 THE NATIONAL STD/AIDS REVIEW 1997 A National Review was carried out by teams of provincial programme workers supported by international experts in July 1997. The plan for the Review is based on the positive experiences of the recent EPI and TB Reviews. Through a participative process this review identifies strengths and weaknesses in the programme and recommends practical strategies for rapid strengthening of implementation. The review highlighted that AIDS workers are struggling in a number of areas including: ➣ prioritisation of AIDS programmes in the face of general restructuring and competing priorities ➣ overcoming discrimination against PWAs ➣ insufficient familiarity with aspects of the AIDS policies. Many of the recommendations have been covered in previous sections. They include: ➣ The need for strong leadership of the programme, especially in the current period of re-structuring ➣ NGO funding is urgently needed ➣ Provincial capacity needs to be recognised and strengthened. ATTICCs are recognised for their capacity building and support roles in various sectors and need strengthening ➣ District-level planning and implementation requires high prioritisation ➣ A coherent understanding of media and educational strategies needs to be developed including methodology, materials development and evaluation ➣ A major advocacy and education effort is required around discrimination against PWAs ➣ National Care policies and guidelines need to be developed urgently. Management needs to prioritise implementation of care and provide training for health care workers ➣ Welfare Services require urgent development.
CONCLUSION South Africa faces a particularly severe AIDS epidemic. The groundwork for the response to the epidemic has been laid through the development and adoption of the National AIDS Plan with strong political support from the Minister of Health. South Africa has significant capacity and resources upon which to draw. The AIDS Plan is implemented as one of the priority programmes in the re-structuring of the health services. However given the stage of the epidemic, the rate of implementation of services and other responses is a real concern. Recommendations of the national STD/AIDS Review need to be rapidly implemented.
196 TUBERCULOSIS 22
CURRENT SCENARIO South Africa is facing one of the worst tuberculosis epidemics in the world, with disease rates more than double those observed in other developing countries and up to 60 times higher than those currently seen in the USA or Western Europe. In 1996 the country had an estimated burden of 158 689 cases. This translates into a rate of 362 per 100 000 of the total population.1 Great variation is, however, observed among the nine provinces, as illustrated in Table 1. The highest rates are in the Western Cape (559 per 100 000) and the Eastern Cape (504 per 100 000). The provinces most severely affected in terms of actual numbers of cases are the Eastern Cape and KwaZulu-Natal, both with more than 34 000 cases.
TABLE 1 TUBERCULOSIS INCIDENCE IN SOUTH AFRICA AND PROPORTION ASSOCIATED WITH HIV INFECTION (1996)
Province TB incidence rate Number of TB cases Proportion HIV- (per 100 000) positive (%) Eastern Cape 504 34 371 20.4 Free State 282 8 272 32.1 Gauteng 375 26 378 25.2 KwaZulu-Natal 381 34 178 45.0 Mpumalanga 286 8 716 39.5 Northern Cape 340 2 675 13.6 Northern Province 260 13 927 16.7 North West 271 9 557 25.9 Western Cape 559 20 615 12.0 South Africa 362 158 689 27.0
Source: Department of Health, Directorate Communicable Disease Control, May 1997
Table 1 also indicates that 27% of tuberculosis patients were infected with the human immunodeficiency virus (HIV) in 1996, resulting in 42 000 more tuberculosis cases than would have occurred in the absence of the HIV infection.2 Although South Africa has lagged behind other African countries in terms of HIV incidence (probably because of geographical, social and political barriers) the HIV epidemic has increased exponentially during the last six years. Its adverse impact on tuberculosis is already evident in provinces with high HIV rates, such as KwaZulu-Natal and Mpumalanga. The tuberculosis problem in South Africa is largely a result of historical neglect and poor management systems, compounded by the legacy of fragmented health services. Previous treatment programmes did not ensure that infectious (mainly sputum smear- positive) patients were cured. Cure rates were unknown prior to the introduction of the
Author: Karin Weyer, Tuberculosis Research Programme, Medical Research Council 197 Tuberculosis Register in 1995. The implication of this failure is evident from Figure 1, which indicates cure rates for registered new smear-positive patients for 1995. Although the data are limited, it is clear that cure rates are much lower than the internationally accepted target of 85% considered necessary to achieve an impact on the tuberculosis epidemic.3 On average about 70% of patients completed a full course of treatment in 1995. However, only 51% could be considered bacteriologically cured. Five of the nine provinces reported cure rates below 50%, while the highest cure rate (Western Cape) was only 66.4%.
FIGURE 1 NEW SMEAR-POSITIVE CASES TREATED SUCCESSFULLY IN 1995
100
80
60
Percentage 40
20
0 Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western South Cape State Natal langa Cape Province West Cape Africa
% Cured % Treatment completed
Source: Department of Health, Directorate Communicable Diseases, May 1997
In addition to low cure rates, a lack of standardisation of control programme procedures and a lack of focus on crucial aspects such as case holding have resulted in very high treatment failure and interruption rates, as illustrated in Figures 2 and 3. On average, 17.3% of new smear-positive patients failed to complete treatment, while 5.4% remained smear-positive after a full course of chemotherapy. Mpumalanga was a notable exception, with a failure rate below 2% and an interruption rate of less than 10%. Northern Cape reported an alarming failure rate of 15.8% and Eastern Cape documented an interruption rate of 24.6%.
198 FIGURE 2 TREATMENT FAILURE RATE OF NEW SMEAR-POSITIVE CASES (1995)
16
14
12
10
8 Percentage 6
4
2
0 Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western South Cape State Natal langa Cape Province West Cape Africa
Source: Department of Health, Directorate Communicable Disease Control, May 1997
FIGURE 3 TREATMENT INTERRUPTION RATE OF NEW SMEAR-POSITIVE CASES (1995)
25
20
15
Percentage 10
5
0 Eastern Free Gauteng KwaZulu Mpuma- Northern Northern North Western South Cape State Natal langa Cape Province West Cape Africa
Source: Department of Health, Directorate Communicable Disease Control, May 1997
Tuberculosis 199 Failure to complete the required course of treatment leads to the increased risk of patients developing multidrug resistance (MDR) tuberculosis. More than 2 000 patients develop this type of tuberculosis per year in South Africa. Of these MDR patients fewer than 30% survive.4 The cost involved in their treatment is high. One case of MDR tuberculosis costs more than R60 000, compared to around R3 000 per uncomplicated tuberculosis case.
Efforts to contain the epidemic The need for a focused and accountable tuberculosis control programme was identified by the post-election Department of Health and has resulted in the implementation of a new control strategy during 1996. This strategy is based on the Framework for Effective Tuberculosis Control proposed by the World Health Organization3 and has been adapted to accommodate the diverse nature of health services and infrastructure in South Africa.5 The new strategy, collectively known as DOTS (Directly Observed Treatment, Short-course), was introduced in the country during 1995- 96.
DOTS strategy for tuberculosis control in South Africa
✧ Government commitment to tuberculosis control as a specific health system activity, integrated into primary health care and supported technically at national level ✧ Case detection through passive case finding, using standardised case definitions and a diagnostic service based primarily on a network of peripheral microscopy centres ✧ Standardised, directly-observed short-course treatment, with the focus on ensuring cure of smear-positive patients and a more vigorous treatment approach to re-treatment cases ✧ Careful recording and reporting of patients and their treatment outcome and evaluation of control programme effectiveness by pre-determined performance criteria. The Tuberculosis Register forms the basis of this system, which decentralises tuberculosis control to the district or clinic level while also allowing for monitoring of the control programme at district, provincial and national level.
In June 1996, the Department of Health convened a team of local and international experts to review the tuberculosis situation and the process of implementation of the new strategy. This team confirmed the severity and urgency of the tuberculosis problem in South Africa and warned that without improved control, the epidemic will skyrocket even further out of control.3 Inadequate management of tuberculosis was highlighted as one of the control programme’s major weaknesses and several recommendations for improvement were made.3 The Tuberculosis Review generated a lot of attention and enthusiasm. However, it is now almost one year later and given the severity and urgency of the tuberculosis problem, the question is: What has been achieved?
Recommendations from the 1996 Tuberculosis Review
✧ The Department of Health should publicly declare the seriousness of the tuberculosis epidemic in South Africa and the urgency of the necessary response ✧ The Department of Health should make control of the tuberculosis epidemic a top priority by ensuring optimal tuberculosis management at all levels. A management team should be appointed at national level and provincial authorities should designate co-ordinators for tuberculosis control in every district ✧ Health Services should implement the DOTS strategy as described in the National Guidelines in order to achieve an 85% cure rate of new smear-positive cases ✧ National and Provincial Departments of Health should ensure appropriate tuberculosis microscopy services ✧ National and Provincial Departments of Health should invest adequate resources in tuberculosis management and training ✧ The Tuberculosis Control Programme should ensure accountability through the use of the tuberculosis register to measure the key programme outcome indicators and by establishing a financial management system
200 ACHIEVEMENTS AND CONSTRAINTS Tuberculosis was declared a top health priority by the Department of Health in November 1996 and National Health Minister Zuma committed her Department to implementing the new control programme and to increasing attention and resources to effectively control the tuberculosis problem. Subsequent to this announcement, tuberculosis was declared a provincial emergency in both the Western and the Eastern Cape. All provinces have pledged their commitment to implementing the DOTS strategy and operational plans have been developed, both nationally and provincially. However, the translation of plans on paper into action has so far been limited. This has been largely due to the restructuring of health services (resulting in confusion and uncertainty over responsibilities for funding and for providing health services) and numerous other health problems competing for attention. District-based tuberculosis control programmes have been shown to be most effective in developing countries,3 but in many provinces in South Africa district management structures have yet to be finalised, resulting in considerable delay in implementation of the tuberculosis control programme. A national Tuberculosis Manager was appointed in November 1996. Recruitment of the other members of the proposed national management team has been slow. Provincial Tuberculosis Co-ordinators have also appointed in only four provinces (Mpumalanga, Northern Cape, Northern Province and Western Cape). District Co-ordinators have also only been designated in four provinces (Mpumalanga, Eastern Cape, Free State and North West). The new strategy is supposed to be implemented through Demonstration and Training Districts (DTDs), which should serve as template models for effective DOTS implementation. The idea is that there would be rapid expansion to other districts once satisfactory cure rates have been achieved. A national DTD which has a cure rate of over 80% has been established in Mpumalanga Province. Provincial DTDs have been identified in all provinces but to date have been established in only five (Mpumalanga, Eastern Cape, Northern Province, North West and Western Cape). Microscopy services rendered by the South African Institute for Medical Research have shown remarkable improvement in some provinces. Turn-around times for results have been reduced from more than two weeks to less than 48 hours in Mpumalanga and the Western Cape. In government laboratories, however, the status quo remains, despite strategic plans having been developed and considerable external funding being available. State bureaucracy is largely to blame for the slow progress in establishing new microscopy centres. Since sputum microscopy forms the basis for diagnosis of tuberculosis and for monitoring of treatment outcome, the tuberculosis control programme is severely hampered in some provinces by the lack of these centres. Training courses for managing tuberculosis at district level have been held and various in- service training sessions for health care workers have taken place. Continuity and standards are, however, difficult to maintain due to rapid staff turnover and right-sizing within the public health sector. There is also a lack of co-ordination of training opportunities within the different health sectors, resulting in primary health care staff frequently having insufficient knowledge and understanding of tuberculosis control principles. Doctors and other health professionals in the private sector still represent a considerable problem and there is an urgent need to target all cadres of health care providers for training in tuberculosis control. One of the weakest links in the tuberculosis control programme is the collection and dissemination of information through the Tuberculosis Register. This weakness arises mainly because of a lack of co-ordination and collaboration between the two national Health Directorates responsible for tuberculosis care and for health information. Although registers and quarterly reports are supposed to be completed by all facilities providing tuberculosis care, on average only 50% of such facilities submitted these reports during 1996. Feedback to these facilities is minimal, despite the availability of simple and effective computer-generated reports at district and provincial level. To manage effectively, appropriate information is needed. Urgent improvement is required in using the Tuberculosis Register. This register is the key management tool for control.
Tuberculosis 201 ACTION REQUIRED OVER THE NEXT YEAR Tuberculosis, despite being fully treatable and curable, is South Africa’s number one infectious disease and one of the major killers of young adults. Therefore, the limited pace and extent of implementation of the new control programme give cause for concern. Estimates by the MRC National Tuberculosis Programme indicate that current trends in the epidemic will continue unless effective control is achieved. This will result in an estimated 3.5 million new cases of tuberculosis over the next decade and at least 90 000 deaths.2 The financial implications are staggering: Given that more than R500 million is spent annually on tuberculosis in South Africa, in excess of R18 billion would be required over the next ten years if current tuberculosis control strategies continue unaltered. On the other hand, progressively successful HIV control together with effective tuberculosis control would mean a turn-around in the tuberculosis epidemic by the year 2003, as indicated in Figure 4.2 At least 1.7 million tuberculosis cases will be prevented and more than R2 billion would be saved. Over the next year particular attention should be given to: ➣ Improving tuberculosis management ➣ Ensuring cure of patients ➣ Training health care staff ➣ Improving microscopy services ➣ Improving use of the Register and available information systems ➣ Working closely with HIV/AIDS control programmes
FIGURE 4 FUTURE TRENDS IN TB IN SOUTH AFRICA (1995-2005)
TB incidence / 100 000 1 400 TB & HIV controlled
1 200 Current trend continued
1 000
800
600
400
200 1994 95 96 97 98 99 2000 01 02 03 04 2 005 year
Source: Fourie,PB, Weyer K. Impact of HIV on the tuberculosis epidemic in South Africa. In: World Health Organization. Tuberculosis Control in South Africa. (WHO/TB/96.208). Geneva: WHO, 1996.
In the new South Africa, there is real promise for success in meeting the challenge of tuberculosis. The tools to diagnose and cure the disease are available. Financial resources are available. It is a matter of putting tools and resources to effective use. While the verbal commitment exists to push through the mire of complacency and ineffectiveness, we need to act on this commitment and to direct our energy into rapidly establishing effective tuberculosis control throughout the country. The management of tuberculosis in South Africa is a matter of time and opportunity. There is ample opportunity in time, but little time in opportunity - the opportunity is now, and there is no time to waste.
202 SEXUALLY TRANSMITTED 23 DISEASES
THE EXTENT OF THE STD EPIDEMIC Sub-Saharan Africa has the greatest burden of sexually transmitted diseases (STDs) in the world and STDs, excluding HIV, are among the top five causes of morbidity and mortality in young adults.1 In South Africa, STDs constitute a grave public health problem due to the high incidence of acute infections (estimated to be in the region of 11 million STD cases treated annually) and the resultant complications and sequelae (see Box below). In addition, STDs promote the transmission of HIV infection and are thought to be an important factor in the rapid spread of HIV in Africa. There are also substantial economic implications that arise from the STD epidemic. The stigma attached to these diseases has negative social effects including abusive behaviour and marital strife.
Potential sequelae of sexually transmitted diseases by age and sex category
Potential sequelae Women cervical cancer, pelvic inflammatory disease, leading to infertility, lifelong pain and/or ectopic pregnancies New borns spontaneous abortion, stillbirth, prematurity, neonatal death, blinding eye infections (opthalmia neonatorum), chlamydial pneumonia, congenital syphilis Men infertility
There is no national surveillance system for STDs in South Africa and therefore the only epidemiological data available comes from published studies and health facility reports. Most information is on women and studies show that over half of all antenatal clinic attendees have at least one STD.2 More specifically a recent review estimated that up to 15% of family planning and antenatal clinic attendees were seropositive for syphilis, 16% harbour chlamydial infections, 8% have gonorrhoea and as many as 20-50% have other vaginal infections.2 The majority of these individuals either have no symptoms or mild symptoms for which they do not seek medical treatment. Therefore, those who seek treatment only represent the tip of the iceberg. It has been well established internationally that 60 to 70% of gonococcal and chlamydial infections in women are asymptomatic. Local studies have shown that the majority of rural women will not seek medical treatment for these infections. There is less information on men but it is now believed that there is a higher burden of asymptomatic infections than previously thought. The result is a reservoir of infection in the community that is difficult to eradicate.
Author: Mark Colvin, Medical Research Council 203 Vulnerability of Women Women are disproportionately affected by the STD epidemic in several ways and STDs are the second most important cause of morbidity in women of child-bearing age. While both sexes are susceptible to STDs, women tend to suffer from more chronic and severe sequelae than men. The vulnerability of women, particularly in developing societies, is further enhanced by their typically inferior economic, educational and social status which limits their ability to refuse sex or to negotiate safe sex. Informal sex work is often a strategy for survival and lower literacy levels restrict their access to information. The cultural expectations that women should be virgins at marriage and faithful to one partner influence health service providers' attitudes and are not conducive to a “women friendly” environment.
Addressing the Epidemic Historically, the public health threat posed by STDs has not received the attention it deserved, probably because the greatest burden of disease fell on the previously disenfranchised black majority. In addition, the fact that STDs are widely perceived as being the result of self-inflicted and aberrant behaviour also played a role in the neglect of this epidemic. The consequence is that South Africa’s heavy burden of STD and HIV infection will not decrease significantly unless a comprehensive, national strategy is implemented to address the epidemics. On the positive side, lessons learnt from other countries indicate that the prevalence and incidence of STDs can be dramatically reduced. For example, in the Scandinavian countries certain infections such as gonorrhoea and syphilis have been almost eradicated.3,4 Nearer to home, a study in Mwanza, Tanzania, demonstrated a 41% reduction in HIV incidence as a result of improved STD management.5 The challenge for South Africa is to use our limited resources to address the problem effectively.6
Components of a national programme to reduce STDs Communicable diseases, including STDs, have historically been the responsibility of local authorities with a resultant lack of national co-ordination or standardisation of STD preventive and curative services. This problem has been partly addressed by the formation of the HIV/AIDS and STD Directorate of the national Department of Health in January 1995. The main components of this strategy are:
Syndromic management Syndromic management of STDs refers to treatment based on patterns of symptoms and signs rather than on specific aetiologic diagnoses. It is promoted by the WHO as being pragmatic, appropriate and effective and is actively supported by the National Department of Health. This is a novel approach to disease management and its successful implementation requires health care personnel to be convinced of its merits and to be trained in the techniques. Towards this end the HIV/AIDS and STD Directorate has initiated a nationwide training programme for Provincial, Regional and District Programme Managers and to date about 50 managers per province have attended these courses. In addition the Directorate is running 3 day courses for clinicians and has produced management protocols and training manuals for dissemination. While private sector practitioners have attended the syndromic management courses, it is the retraining of this sector that poses the greatest challenge as they are more difficult to reach than public sector health workers. The importance of involving the private sector is illustrated by evidence that much of the treatment given in this sector does not comply with recommended regimens. A study in KwaZulu-Natal showed that 90% of workplace clinics provided inappropriate or partial treatment for STDs7 and another study in Northern KwaZulu-Natal showed that 64% of treatments given by the rural general practitioners were inappropriate.8
204 Partner Notification Allied to syndromic management is the practice of partner notification or contact tracing. By offering treatment to sexual partners, whether they have symptoms or not, reinfection of the index patient is prevented and ongoing transmission halted. In under-resourced settings contact tracing in the community by health care personnel is often not feasible and instead reliance is put on the index patient to inform his/her sexual contacts. There are currently a number of projects underway around the country that are attempting to improve the return rate of contacts by creating improved “contact slips” and making services more accessible.
Promoting Healthy Living and Appropriate Health Seeking Behaviour The dissemination of information on STDs to the community, and to the youth in particular, is an important component of promoting healthy behaviour. The DOH and a variety of non- governmental organisations (NGOs) use a range of approaches including “life skills” programmes, billboards, booklets and other media. The HIV/AIDS and STD Directorate aims to have 10 000 secondary school teachers trained to initiate peer education programmes at schools. While the focus of these educational activities is aimed at prevention, a key aspect is improving health seeking behaviour among those with an STD. The importance of symptom recognition and early, appropriate treatment seeking must be promoted although this approach will not impact on those with no symptoms.
Promotion of condoms and other barrier methods A key strategy in preventing both HIV infections and other STDs is the promotion of condom use. Although the DOH does not have a barrier methods policy they have been actively distributing condoms with 83% of the over 95 million condoms distributed during the 1996/97 financial year being provided free by the government. While these numbers have been steadily increasing the number currently distributed still only provides an average of 7.7 condoms per person per year for those who are sexually active. Reasons for the relatively low and erratic use of condoms include lack of availability, cultural taboos and a negative perception of condoms. Substantially more effort needs to go into popularising barrier methods (including female condoms) and towards this end the HIV/AIDS and STD Directorate has appointed the Society for Family Planning to develop and implement a barrier methods strategy.
Surveillance Information on the frequency and distribution of STDs across the country is required to enable proper planning and monitoring of an STD programme. These data are collected by a surveillance system but, apart from the annual antenatal HIV seroprevalence survey, South Africa has no such system. In recognition of this shortcoming, the Directorate of Epidemiology has contracted the Medical Research Council (MRC) to design and pilot an STD/HIV/AIDS surveillance system. The outcome of this contract is expected to be a set of detailed guidelines on routine and sentinel surveillance that provinces will be able to implement. Screening of whole communities by detecting asymptomatic infections through laboratory testing may seem a logical idea. However, the high cost of such screening renders this approach unfeasible on a wide-scale basis although it may be possible for selected groups such as pregnant women or sex workers. Another suggested approach has been to mass treat whole communities with antibiotics regardless of whether individuals have symptoms or not. While there is no evidence of the effectiveness of mass treatment for STDs, the results of such a trial currently underway in Uganda are keenly awaited. A modified approach would be to target mass treatment at core transmitter groups only. Opposition to mass treatment is based on the high cost of treating large numbers of people, most of whom are free of infection, with expensive drugs in addition to concerns about side effects and promoting drug resistance.
Sexually Transmitted Diseases 205 CONCLUSION Recognition of the role played by STDs in promoting HIV infection has elevated their importance on the public health agenda. However, it is still too early to determine whether the interventions discussed above are having any meaningful impact. In addition, these interventions will have little impact on the large burden of asymptomatic and untreated STDs in the community. To address this problem innovative approaches will have to be developed and evaluated. Finally, it must be borne in mind that while this chapter highlights the biomedical approach, it is unlikely that this alone will be sufficient to significantly impact on the STD epidemic. Instead, the underlying social conditions that are conducive to its spread, in particular the status of women and the disruption of family life through social strife, labour migration and poverty, need to be addressed simultaneously.
206 NUTRITION 24
South Africa’s broad principles, policies and strategies are described in the White Paper for the Transformation of the Health System.1 Its central feature is the Department of Health’s Integrated Nutrition Programme (INP) which was conceived more than two years ago. The principles and components of the INP have been described in the previous annual health reviews.
POLICY AND NUTRITION PROGRAMME DEVELOPMENTS Multi-sectoral Action One element of the INP is “to provide communication and advocacy directed at other sectors of government to enhance the perceptions and knowledge of politicians and other decision-makers, so that the malnutrition problem is made visible, and perceived as a priority social problem”. Some of the explicit aims are to:1 ➣ develop measures on land reform that will reduce the vulnerability of the landless poor ➣ formulate policies for implementing income transfers that will improve the entitlement package of the urban and rural poor ➣ ensure the availability and equitable distribution of essential food items through a public distribution system ➣ ensure the linkage and adjustment of minimum wages to increases in market prices for food items ➣ develop policies that will empower women through literacy and education programmes. This review does not provide an in-depth assessment of fiscal, economic, land and agriculture policies, all of which have profound influences on the state of household food security and nutrition. However, in 1995, Harrison argued for the need to have a systematic merging of health, agricultural, economic and welfare policies to promote household food security.2 At present, structures for achieving multi-sectoral collaboration include the Inter-departmental Forum on Nutrition and the Working Group on Household Food Security.
Implementation of the Integrated Nutrition Programme (INP) National policy states that nutrition programmes should be integrated, sustainable, environmentally sound, people and community-driven, and should target the most vulnerable groups, especially children and women.1 The Department of Health has structured the INP on the basis of three components: ➣ health facility-based nutrition programmes ➣ community-based nutrition programmes (CBNP)
Authors: David McCoy, Child Health Unit, University of Cape Town Mmipe Saasa-Modise, Goldfields Nutrition Centre, Medunsa 207 ➣ nutrition promotion programme. The challenge to the Department is to now implement this vision. Some of the developments in the implementation of the INP are listed below: ➣ Most provincial departments have been in the process of restructuring the National Nutrition and Social Development Programme, Primary School Nutrition Programme (PSNP) and the Protein-Energy Malnutrition scheme to make them more integrated and targeted. There are a number of reviews and on-going studies to evaluate and make recommendations for these programmes.3,4,5 ➣ In Gauteng, the 1996/97 Business Plan has set out a new provincial decision-making body and a management team comprised of health and education of ficials to oversee the implementation of the PSNP. In Mpumalanga, an Inter-departmental Task Team consisting of representatives from Health, Welfare and Gender Affairs, Education and Agriculture was established to put together a Business Plan for the PSNP. ➣ A R7 million contract for one year has been awarded to the Ernst and Young Management Consultant Services to help design appropriate operational management systems for the INP in all nine provinces. ➣ A draft document on developing mechanisms to fund community based nutrition projects has been developed.6 ➣ A tender for the development of a primary school nutrition education package as part of the national curriculum development process was awarded to Community Life Projects. The Free State and the Eastern Cape have been identified as pilot areas for the project. ➣ In Kwazulu-Natal, the Department of Health has approved the expenditure of R40 million for the implementation of the Valley Trust Nutrition Education Programme in 3 500 schools. ➣ Community-based pilot projects have been established in all nine provinces.7 ➣ The Department of Health (Directorates of MCWH and Nutrition) and the Government of Finland are funding and implementing two parasite control projects in KwaZulu-Natal and Mpumalanga. The experience from these projects will feed into the further development of the draft Policy for Parasite Control. ➣ A policy document on iron supplementation for pregnant women is being developed. A tender has been put out for the development of a brochure on vitamin A deficiency to be used by health workers.8
Food Fortification In July 1996, a national workshop on food fortification recommended that Vitamin A, Folate, Thiamin, Riboflavin, Niacin, Vitamin B6 and Calcium be included in a formal food fortification programme9 (to add to the mandatory iodisation of salt and margarine). Other micronutrients which are to be considered are Vitamin C, Vitamin B12 and Zinc. A number of factors were highlighted at the workshop: ➣ Consideration is needed on what impact food fortification will have on traditional dietary habits; how fortification may affect the economic sustainability of small-scale and home- based food processing industries ➣ Small producers will need technical and financial assistance The Department of Health has established a technical task team to help develop guidelines on food fortification. It will also contract the services of a full-time consultant. At the first meeting of this task group in June 1997, developments in three areas were reported: ➣ a tender has been put out for conducting a national household food consumption survey to assist in the selection of appropriate food vehicles for fortification ➣ the publication of an expert position paper on iron overload ➣ informal discussions have been held with representatives of the wheat, maize and sorghum industry
208 The expert position paper on iron overload commissioned by the Health Systems Trust concluded that a fortification programme which would increase iron absorption by about 1 mg per day in iron deficient subjects would not harm normal individuals. However, between 12 000 to 30 000 white South Africans with hereditary haemochromatosis could be adversely affected. Assuming that a suitable and affordable iron compound and food vehicle is found, it was felt that a well planned iron fortification programme could be introduced. The food vehicle should be able to target young children and women, whilst avoiding exposure to white population groups with a high prevalence of hereditary haemochromatosis.10 In December 1996 the first workshop on the prevention and control of iodine deficiency disease was held in South Africa. Participants at the workshop included the salt industry, research institutions and various representatives from other Southern African countries.
Draft Policy on Vitamin A Supplementation11 A policy on Vitamin A supplementation is seen as an interim measure until the time when all South Africans obtain adequate amounts of vitamin A from natural or fortified foods. The programme will be evaluated in the year 2000 with a view to phasing it out in appropriate areas. The following groups will be targeted for vitamin A supplementation: ➣ post-partum women within four weeks of giving birth ➣ all young children between the age of 6 months and 2 years ➣ children with measles, diarrhoea, protein energy malnutrition, acute respiratory tract infection, and chicken pox ➣ children with clinical manifestations of vitamin A deficiency. The proposed schedule is linked wherever possible to the national immunisation schedule and to growth monitoring visits. In areas where immunisation and health coverage is poor, community-based initiatives will be considered. Guidelines for preventing overdosing are also in the document.
Breastfeeding and the National Breastfeeding Policy This year, a draft National Breastfeeding Policy for Health Workers and Health Facilities was produced.12 Much of the document is based on the Ten Steps of the Baby Friendly Hospital Initiative13 and the principles of the International Code of Marketing of Breast-milk Substitutes.14 To start the process of implementation of the policy, the government, with the assistance of UNICEF have been training provincial personnel in lactation management. Specifically, it aims to: ➣ protect, promote and support breastfeeding ➣ encourage the use of appropriate complementary foods ➣ reduce the impact of practices that negatively affect breastfeeding ➣ ensure that breastfeeding is considered a legitimate reason to grant a mother sick-leave ➣ create a health care system that is free from commercial pressures regarding infant and young child feeding ➣ encourage all health facilities to implement the international Baby Friendly Hospital Initiative guidelines. Some of the proposed policies state that: ➣ admission policies and ward procedures of health facilities should enable infants, young children and mothers to continue breastfeeding ➣ health facilities or health workers, whether private or public, are prohibited from offering or accepting free, subsidised or low-price supplies of breastmilk substitutes, feeding bottles, teats and dummies ➣ health workers are prohibited from selling breastmilk substitutes or otherwise promoting the use of breastmilk substitutes.
Nutrition 209 The policy is said to apply to all facilities, organisations and staff that provide maternal and child health care, whether in the public, private or non-governmental sector. In addition, a “Protocol for contact between health workers and health facilities with commerce and industry involved in infant and young child feeding” has been drawn up which stipulates that: ➣ representatives may only visit health workers and health facilities if a written request has been received from the person in charge of that facility ➣ representatives may not visit individual health workers, and may only supply information at meetings of groups of health workers This emphasis on monitoring the promotion of breastmilk substitutes is supported by the findings of a recent survey in four countries, including South Africa, which found that aspects of the International Code of Ethics for the Marketing of Breast-milk Substitutes were being violated in all countries.15 ,16 A number of questions remain unanswered in the document: ➣ Will appropriate legislation be passed to support these policies without contradicting the rights of companies to promote their products? ➣ How can these policies be made to apply to the private sector? ➣ Does the policy mean that mothers will be allowed to room with their hospitalised children free of charge? ➣ How is the policy to be reconciled with the practice of providing breastmilk substitutes as part of public feeding schemes such as the PEM Scheme? Finally, the policy ignores the difficult issue of breastfeeding and HIV. While it states that decisions made about breast-feeding and HIV need to be made on the basis of local information, it does not give clear guidelines and criteria for the development of locally-relevant policy. WHO/UNICEF have recommended that where infectious diseases are not the primary causes of infant death, HIV-infected women should be advised not to breastfeed.17 A workshop held in Durban recommended that breast-feeding should continue to be protected, promoted and supported; but that all women should have access to voluntary HIV testing and that those found to be HIV positive should be counselled about their feeding options.18 However, the content of the advice that front-line health workers should give remains unclear.
The Welfare Sector The Welfare White Paper recognises poverty as an important cause of malnutrition and hunger, and proposes that all Welfare Departments include nutritional objectives and activities into their relevant activities.19 The provision of social security is an important measure to alleviate poverty. There has been much debate around the proposed Child Benefit Scheme that was originally to provide a benefit worth R75 per month (in 1996 Rands). The size of the grant has now been increased to R100 per child but will only cover the poorest 30% of the child population up to the age of six years.
The Wiegand Commission of Inquiry into Nutrition Programmes and Financial Audits The fraud and corruption that has been associated with some of the nutrition programmes has had a damaging effect on the national Nutrition Directorate. A presidential commission has begun to inquire into and report on nutrition programmes and feeding schemes administered by the Department of Health.20 Their brief is to look specifically into the allocation of contracts, the spending of money on contracts and the supervision of the programmes and feeding schemes. In addition to this, the Department of Health has initiated detailed investigations into the books, records and documentation of the PSNP in all provinces. Sixteen of these investigations have been awarded on tender at a cost of R2.1 million. Seven tenders are pending.21
210 THE NATIONAL PRIMARY SCHOOL NUTRITION PROGRAMME (PSNP) EVALUATION Between July 1996 and May 1997, the Health Systems Trust initiated a multi-centred national evaluation of the PSNP in order to provide recommendations for improving the effectiveness of the programme.22
Main findings and conclusions ➣ Because of the poor nutritional status of school children, a primary school nutrition programme is appropriate ➣ However, infants and pre-school children are the priority target groups for interventions designed to prevent and treat malnutrition ➣ The implementation of the PSNP has generally been limited to being a vertical school feeding programme ➣ Support for a vertical school feeding programme costing half a billion Rand each year in the context of inadequate nutrition programmes and services for pre-school children (and in the context of poorly developed school health services) is difficult to justify ➣ Although deworming, nutrition education and micronutrient supplementation are more cost-effective components of a school nutrition programme than feeding, these objectives of the PSNP were not systematically implemented ➣ Many provincial Sub-Directorates of Nutrition have been swamped by the administrative burden of the PSNP. The skewed allocation of resources between the PSNP and other components of the INP has created a mismatch between the stated policy of focusing on the pre-school child and the actual focus of nutrition activities ➣ There have been anecdotal accounts of improved school attendance and classroom performance ➣ In several provinces the coverage of school feeding has been poor and inconsistent ➣ Feeding often happens at an inappropriate time of the day ➣ Food may be of a sub-standard quality and insufficient quantity and some of the selected foods may have a negative impact on healthy eating habits ➣ Restrictive bureaucratic rules hampered progress towards developing a more sustainable and integrated community-driven programme ➣ An important role was played NGOs in administering school feeding in some provinces. They also helped in linking school feeding to other development initiatives ➣ Unfortunately, NGO involvement was discouraged in some provinces on the basis that they inhibit community involvement. Bureaucratic obstacles also limited the full potential of NGOs.
Recommendations ➣ Improve the effectiveness of school feeding. This can be done in a number of ways: ➣ Target the school feeding component of the PSNP to fewer schools ➣ Develop a more needs-based formula for the allocation of funds to schools ➣ Monitoring and evaluation should focus on process and outcome indicators at the school-level ➣ The energy content of the school meal should not drop below the current guideline of 20% to 25% of the recommended daily allowance for energy ➣ Guidelines on the minimum standard of micronutrient content should be established ➣ Discourage the use of fortified commercial foods ➣ Meals must be provided in the morning and must not disrupt teaching and learning time ➣ Transform the PSNP from a vertical feeding programme into a comprehensive school nutrition programme
Nutrition 211 ➣ Integrate the PSNP into a comprehensive school health programme and use it as a catalyst for prioritising the development of effective school health services ➣ Use the PSNP as a spring-board for the development of community-based nutrition programmes, especially around the pre-school population ➣ Develop a programme of pilot projects to model the transformation of the PSNP. Some important aspects which need to be tried out are: - the design of more appropriate management systems, especially at the district and school level - involvement of communities and NGOs - developing a comprehensive human resource development strategy for the INP ➣ The current allocation of RDP funds to the PSNP should remain committed to the funding of the INP, for at least a further three years ➣ School-based mass treatment for parasites and micronutrient supplementation should be implemented in appropriately selected schools, and be extended to cover the pre- school population as far as possible.
CONCLUSION The Department of Health has developed a comprehensive set of policies and objectives in order to address the problems of poor nutrition. There is now a clear policy framework for provincial Departments of Health and other relevant role players in the country. The Department of Health must continue to refine these policies, as well as to implement national level strategies such as food fortification and health promotion. The school curriculum and mass media can be used for health promotion around nutrition. The problems raised by the national PSNP evaluation have highlighted the need to pay greater attention to the actual mechanics of transforming policy into appropriate action. What is lacking are specific, feasible and appropriate plans at the community and district level for the implementation of the INP. The Nutrition Committee that was appointed by the Minister of Health in August 1994 proposed a decentralised network of nutrition units at district level to be tasked with the implementation and monitoring of nutrition plans.23 The nature of these nutrition units was never fully explored. However, the recommendation of a strong and capable implementing arm to the INP at the district level makes good sense. A more bottom-up approach will help to ensure a policy and administrative environment that relates to the real constraints and difficulties at the coalface of public sector delivery. This is especially important in the rural areas where the majority of the under-nourished live, and where the health sector is most challenged by inadequate infrastructure. In this regard, the proposal by the Department of Health to develop pilot programmes in the various provinces should be welcomed. These pilots should be designed with an in-built evaluation mechanism to allow for lessons to be learnt and models to be replicated in other areas. They should also be district based, and be used to strengthen the district health management structure as the focal point around which nutrition activities can be managed and co-ordinated. In order to develop more effective and appropriate implementation of the INP at the community level, a number of issues need to be addressed: ➣ The establishment of well functioning districts ➣ The development of a human resource development strategy to provide the expertise and nutrition programme management skills at the regional and district level ➣ The establishment of effective and sustainable multi-sectoral forums for planning and implementation at the district level ➣ The development of appropriate district health information systems, on which can be built an information-based nutrition programme.
212 INJURY AND 25 TRAUMA
DEFINITIONS Injury refers to all kinds of damage to the body that are manifested within 48 hours, or usually within considerably shorter periods. Intentional injuries are due to violence, and are distinguished from non-intentional injuries. To eliminate the idea that injuries are due to fate, accidents, or other unpredictable and uncontrollable events, the term unintentional injury is preferred over accident. Trauma refers to both the physical and psychological damage that results from an injury, although in this chapter the primary concern is with physical trauma. Deaths due to injury are classified as “non-natural deaths”.
OVERVIEW ➣ An increase in per capita injury rates, precipitating a disproportionate demand for trauma services accompany technological development and urbanisation. ➣ Injury selectively kills young, economically active adults, with males predominating over female victims. ➣ Non-natural causes of death accounted for 32% of all potential years of life lost (PYLL) in 19941 - the single largest category. ➣ Childhood injury mortality rates are some three times higher in South Africa than in the USA. ➣ Violence is the leading cause of fatal injuries in the country - the 1996 homicide rate of 61 per 100 0002 placed SA among the most violent countries in the world. ➣ Road traffic injuries are arguably one of South Africa’s most preventable public health problems and cost society approximately R30 million per day. The hallmark of South Africa’s excessive traffic injury and death rate is the very high pedestrian component. ➣ There is a strong relationship between alcohol abuse and injuries due to violence and traffic, suggesting that this should be an area for priority attention. ➣ Injuries have long been a major contributor to the burden of disease. This chapter discusses the main causes and consequences of injury. In the transformation from apartheid to democracy, there was the belief that because the motives for violence in South Africa were political, democratisation would bring a cessation in violence, and a reduction in violence related injuries. However, while the ultimate causes of violence may lie in factors produced by political strategies of repression,
Authors: Alexander Butchart, Health Psychology Unit, UNISA Margaret Peden, National Trauma Research Programme, Medical Research Council 213 most violence is an outcome of largely unpremeditated interpersonal attacks. The determinants of this violence, such as alcohol, unemployment and over-crowding, are located in the present as a form of social pathology. Contemporary approaches to crime and violence prevention emphasise the need for multi-disciplinary interventions that focus upon prevention in addition to the criminal justice responses. Research by the Harvard Burden of Disease Unit,3 which uses the Disability Adjusted Lost Years of Life (DALY) index as a burden of disease measure, estimated that in 1990 injuries contributed 14% of all DALYs lost to sub-Saharan Africa. Of these 5% were lost to violence and 9.1% to unintentional injury causes. In South Africa, application of the DALY to 1994 mortality data showed external causes (ie. injuries) to account for 32% of the overall disease burden, or twice that of the second major category (Figure 1). In part as a response to such information, research around injury and violence prevention was ranked the top priority by delegates at the 1996 South African Essential National Health Research Congress.1
FIGURE 1 PERCENTAGE ESTIMATED POTENTIAL YEARS OF LIFE LOST IN SOUTH AFRICA 1994 (DALY WEIGHTS)
External Causes 32% Perinatal 12 %
Ill-defined 11 %
Diarrhoeal 7% All Other URI 29% 5% TB 4%
Source: Essential National Health Congress Proceedings, Dept. of Health, 1996
The public health approach redefines injury and violence as the outcome of causal relationships between individuals and other people (such as parents or peers); individuals and products (such as alcohol and guns), and individuals and environments (both physical and socio-cultural). These relationships are the risk factors for injury, which through appropriate research can be identified.
Work informed by the public health approach has involved the epidemiology of neurotrauma; prospective, hospital based studies of all injuries presenting in major metropolitan areas; focused analytic studies of risk factors such as alcohol and firearms; population-based surveys of injury and perceived injury causes, and the initiation of a fatal injury surveillance system in Cape Town. Data from this system was obtained only in Johannesburg and Cape Town. However, the information from such research has impacted on local and national policy; been incorporated into health promotion campaigns; and implemented in pilot community-based injury and violence prevention programmes.
Despite these initiatives, the local injury prevention and control field continues to be limited.
214 INJURY IN SOUTH AFRICA: CRITICAL ELEMENTS Two causal categories dominate the South African injury profile. First, violent or intentional causes, which have consistently been shown to account for between 45 and 55% of all injuries. Second, transport-related unintentional causes, which account for between 20 and 25% of all injuries. The bulk of the remaining 20% result from unintentional causes occurring for the most part in the home, where injuries to children are of critical concern.
Mortality Data In the absence of comprehensive injury morbidity information, mortality data offers the only, perspective on the contribution of injury to the national public health burden. In 1992, the Central Statistical Services (CSS) reported that injuries accounted for 25 273 deaths, or 14% of all mortality. Of these deaths, 18 395 (73%) were due to violence (including suicide), 13% were transport related, and the remaining 14% to other unintentional causes.4 The Births and Deaths Registration Act of 1992 stipulated that details about the cause of a non-natural death may not be reported on the medical certificate. As a result, the national mortality data which should be the cornerstone of an injury surveillance system are non-existent. This is clearly a policy issue of great concern and, a number of efforts are being undertaken by different stake holders to have cause of death information reinstated on the death certificate. The 1992 mortality data showed that violence was the leading cause of death among males aged 15-34 years. For females, violence was the second leading cause of non-natural death for women aged 10-44.4 CSS mortality data for 1994,5 show that there has been little change in the predominance of injury as a cause of death, especially among young adults. Despite their value, mortality statistics reflect only the tip of the injury iceberg. One study showed that for every death in Cape Town there are more than 80 non-fatal injuries.6
Morbidity Data Injuries Due to Violence Most injuries are caused by violence. According to the WHO,7 three broad categories of violence can be identified: ➣ Interpersonal violence, which subdivides into intimate violence, acquaintance violence and stranger violence; ➣ Self-directed violence, which subdivides into suicidal violence and self-mutilation; ➣ Organised violence. Evaluated in respect of these three categories, the South African violent injury profile is the inverse of that seen in developed countries. In these countries, self-directed violence predominates over interpersonal violence with negligible levels of organised violence. In South Africa, interpersonal violence is predominant, followed by organised violence with self-directed violence a much smaller problem. The two major epidemiological studies on non-fatal injury in South Africa to date are those conducted in Johannesburg-Soweto8,9 and Cape Town.6 A comparison of their findings suggest that while intentional injuries are a major source of morbidity in both cities, Johannesburg is the more violent with intentional injuries accounting for 50% of all new cases seen in hospitals,9 as against 34% of patients presenting to facilities in Cape Town10 (see Figure 2).
Injury and Trauma 215 FIGURE 2 DIFFERENCES IN INJURY PROFILES BETWEEN JOHANNESBURG AND CAPE TOWN
60
50
40
30
Percentage 20
10
0 Violence Traffic “Accidents” Other
Johannesburg Cape Town
The observation that Johannesburg is more violent finds confirmation in police statistics for violent crimes such as rape, assault, and homicide.2,11In both cities it was found that for every non- fatal violent injury reported to the police many more are seen by medical services only.
Victim profiles In both the Johannesburg12 and Cape Town13 studies, persons classified as “coloureds” were found to be at greater risk than blacks, who in turn were some four times more likely than whites and Asians to be injured violently. Ratios of 5 and 2.7 males per female victim were observed in Johannesburg and Cape Town respectively.12 ,14 The Cape survey indicated that about two thirds of the victims had been assaulted at least once in the previous five years.15 Both studies yielded very similar age distributions, with a peak in the age range 25 - 34 years.
Motive for attack Both studies indicated that only around one in 10 of all victims reported being injured in instances of organised conflict between political groupings. For the remaining 90% of victims, perceived motive of attack varied with gender. For males, the violent incident was believed to emanate from an attempted robbery in one fifth of all cases, with the remaining 80% attributing their victimisation to ill-defined arguments and quarrels, mostly with strangers. For females, the studies showed that approximately 40% of victims related the attack to an argument, most frequently with someone they knew.12,14
Weapons and alcohol In both studies, sharp instruments were found to be the most frequently used weapons (Cape Town, 60%; Johannesburg, 51%), followed by blunt objects, fists and feet. In Johannesburg guns were used in 13% of cases, against only 1.4% in the Cape, with the largest proportion of firearm related injuries occurring among men. Provisional data from Durban indicates that the majority of violence-related fatalities result from firearm injuries.16 Alcohol use emerged as a prominent feature of the aggressive incident.17 In Cape Town, 60% of all cases were clinically judged to be alcohol related.13 Emerging data also shows that cannabis and Mandrax are strongly related to violence-related mortality.18 In summary, it is true to say of intentional injuries in South Africa that the majority of cases do not result from any clearly identifiable “traits” or overtly political motives. Instead, an increasing body of research locates their origin within the violence of everyday life, where they are the explosive spillover of disrupted community structures and failed interpersonal relationships.
216 Policy and Planning Developments, 1995-1997 The shift over the last few years from understanding violence as a predominantly political issue to viewing it as a public health problem is reflected in a number of policy and research developments: ➣ The 1995 establishment of a WHO Collaborating Centre for Violence and Injury Prevention in Johannesburg. The first such centre in Africa, its linkage through WHO to other violence prevention centres around the world helps to consolidate global experience in respect of violence and injury prevention, and provides a conduit for the delivery of international expertise to assist in developing local injury prevention capacity. ➣ The 1995 introduction into the SA Technikon Community Police Training Curriculum of modules on public health and violence, and strategies for the implementation of safe community programmes at police station level. ➣ The 1996 formulation of the National Crime Prevention Strategy.19 This explicitly identified violence prevention as a medium to long term goal, and advocated that health sector involvement, along with that of other sectors and disciplines, was essential to the formulation of effective prevention programmes. ➣ The May 1996 endorsement by the World Health Assembly (WHA) of Resolution 49.25 Prevention of Violence: Public Health Priority. Introduced to WHA by the South African Minister of Health, this resolution imposes a moral obligation on member countries to initiate violence prevention activities within the health sector. ➣ The February 1997 conclusion of an agreement for technical co-operation between the US and SA Governments to develop the violence prevention capacity of local agencies. ➣ In March 1997, an amount of just over one million Rand was approved for health and violence research towards the refinement of the national Crime Prevention Strategy. This is the most substantial state investment to date in health and violence research, and if successfully utilised could lead to increasing state support for an area that remains almost wholly dependent on donor funding to sustain its activities. As of March 1997 these policy and planning developments had found little expression in changes at the level of information management and service delivery by the national and provincial health agencies. However, they do indicate that the context of policy making has shifted, and it is now reasonable to expect that some success will be achieved over the next year in respect of two priority areas. ➣ Development of a national strategy for health sector involvement in violence prevention. This should address prevention at the primary, secondary and tertiary levels, and should aim at consolidating existing expertise within government, non-governmental and private components of the health care sector. The development of mortuary and hospital-based information systems covering all injuries (both intentional and non-intentional), will be a crucial component of this strategy, as will the training of health professionals at all levels in how to identify and deal with victims of violence. ➣ Implementation of the national health and violence prevention strategy. Only once a timetable for implementation and delivery is available, will it become possible to more rigorously evaluate the progress of violence prevention against projected achievements and clearly defined milestones. Hampering the development and implementation of a systematic violence and health programme is the lack of co-ordination between government departments, and in particular between safety and security, health, and welfare. All three sectors continue to maintain their own disciplinary boundaries. The effect is that the problem of violence remains analytically fragmented and thus inaccessible to concerted interdisciplinary action. Alongside the need to reinstate the recording of external cause of death information, and its collation at national, provincial, and local levels, the development of an effective strategy for the promotion of intersectoral collaboration around violence prevention is an area of crucial concern.
Traffic Injuries Traffic is the second leading cause of injury in South Africa. South Africa’s 1991 road death rate of 11.7 per 100 million kilometres travelled is more than 10 times that of the USA.20 According
Injury and Trauma 217 to the Directorate of Traffic Safety, nearly half a million collisions occurred in South Africa in 1993. Over 9 000 people were killed, more than 33 000 seriously injured and and nearly 85 000 slightly injured. 21 But these summary statistics obscure what can be considered the hallmark of South Africa’s excessive traffic injury and mortality rates, namely the very high pedestrian component.22 Every year approximately 4 500 pedestrians are killed and a further 26 000 are injured on South African roads.
Traffic and alcohol Alcohol is strongly associated with traffic related injuries. Multi-centred, random alcohol surveys have been done bi-annually for the Directorate of Traffic Safety since 1975, and offer an index of alcohol usage in the background population of at-risk drivers and pedestrians. These surveys are conducted on pedestrians between the hours of 17h30 and 19h00, and on drivers between 20h00 and 24h00. Since 1990 these surveys have consistently shown that approximately 12.5% of adult pedestrians (uninjured, walking on the side of the road), and 5.5% of drivers (uninjured, stopped at road blocks) have blood alcohol contents (BACs) in excess of the legal limit (0.08 g/ 100ml).23 There is a sharp increase in the proportion of those with elevated BACs when injuries are examined, thus confirming the centrality of alcohol as a risk factor for traffic injury.24-26 Other intoxicants may also be implicated in the factors contributing to the risk of traffic injury. A study of all traffic-related trauma patients (drivers, passengers and pedestrians) presenting to Addington Hospital, Durban, assessed 530 patients for alcohol intoxication and marijuana use at the time of presentation to the hospital.27 The results indicated that 52% of all the patients were over the legal limit for alcohol, 35% had traces of marijuana in their urine and 19% were positive for both substances. A study on fatally injured pedestrians indicated that of the 60 cases examined, 78% were BAC positive and of these latter 47 cases, 30 (64%) tested positive for cannabis and/or Mandrax as well.18
The cost of traffic trauma An estimate for the unit cost of road traffic collisions in South Africa for 1991 was calculated.28 When these unit costs are increased by inflation29 to 1993 and the 1993 vehicular collision statistics are used, calculations show that approximately R30 million was spent per day in 1993 on road traffic collisions.
Initiatives to Decrease Traffic Accidents New Traffic Safety Board The goal of the new board is to achieve a 10% reduction in traffic injury fatalities by the year 2000, through implementation of a new Road Traffic Management Strategy. The Board involves key national and provincial ministers and other role-players.
Reduction of BAC level New legislation to lower the blood alcohol limit for drivers from 0.08 g/100ml to 0.05 g/ 100ml and for public and goods vehicles to zero is about to be promulgated in Parliament. It will, however, have little effect on the frequency of traffic injuries unless pre-collision law enforcement is significantly improved.
The KwaZulu-Natal Traffic Safety Pilot Study Following the prevention success of the Victorian Road Safety Project in Australia, that project has been amended and is being piloted in KwaZulu-Natal. Among its key elements are: ➣ traffic camera enforcement for speeding ➣ random, continuous and full-time breath testing using Alco-vans
218 ➣ the allocation of traffic officers to schools to promote road safety. Depending on the outcome of this pilot project the concept will be extended to the whole of South Africa as has been done in Australia.
Traffic Safety Today magazine The private sector has shown a willingness to accept responsibility by becoming more involved in promoting traffic safety. It has brought out a magazine aimed at promoting road traffic safety which was officially launched at the BP Traffic Safety Campaign in September 1996.
National Pedestrian Committee - Walk Alive Manual Organisations such as the CSIR and Transportec have long been involved in research into the pedestrian problem. As a counterpoint to the Drive Alive campaign, the National Pedestrian Committee has published a Walk Alive manual, aimed at reducing the number of pedestrian injuries on our roads. The primary purpose is to assist provincial and local authorities in identifying problems and improving the management of pedestrian safety. The priority areas for traffic safety in the next year include: ➣ The establishment of legislation and implementation of enforcement to govern the behaviour of drunk pedestrians. ➣ Strategies to address fatigue-related collisions in both commercial and private transport vehicles. ➣ Investigation into the relationship between traffic injuries and cell-phone use by drivers. ➣ Assays of drug use in traffic.
Childhood and Adolescent Injuries Injuries to children, under 14 and adolescents aged 15 - 19, demand special attention. Because young children cannot be expected to take responsibility for their own safety, innovative approaches to the design of passive, environmental approaches to prevention in the home, school, leisure and public environments are required. Also special attention should be given to the education and training of parents and other adults in appropriate methods of supervision.
Age, gender and racial distribution Children aged 1 to 4 years returned an annualised injury rate of 90 per 1 000 population, as against 66 for children aged 5 - 9 and 81 in the age range 10 -14.31,32 Male children are more at risk in all age ranges. The ratio of male to female victims range from a low of 1.2 males per female among children of less than one year old, to a high of 2.8 males per female in the age range 15 - 19 years. In a Cape Town study “coloured” children were over-represented, accounting for 60% of all childhood injury victims against the 50% of the background population that were “coloured”.33
Causes of injury In Cape Town in the age range 0 - 14 years, falls (46%), sharp instruments (14%), traffic (11%), blunt instruments (10%) and burns (9%) were the leading causes of injury.34 In the age range 15 - 19, and correlated with a stepwise increase in the incidence of violence at around 14 years of age, sharp instruments accounted for 40% of the injuries, blunt instruments 21%, falls 13%, traffic 11% and fists and feet 7%. Although there are major difficulties in ascertaining whether injuries to very young children are intentional or not,37 this age-related shift in the causal profile would suggest that the adult injury profile where violence predominates until age 35 is crystallised by early adolescence. Work on childhood and adolescent injuries in other parts of South Africa is scanty, but the article by Zwi and others35 on injuries presenting to a Johannesburg township health centre provides some basis for comparison to the Cape Town findings. The aetiology of childhood injury is extremely complex and its prevalence is a symptom of the poor standards of health, housing, child care and economic status. The influence of inadequate adult supervision and informal housing on childhood injury has been documented,36-37 giving some indication of the many factors which need to be addressed in the formulation of appropriate
Injury and Trauma 219 safety strategies. Although primary prevention will be the only long-term solution to the childhood injury epidemic, “secondary prevention” of death and disability through improved medical and paramedical care - particularly in rural districts - is essential in South Africa.
Trauma Services and Rehabilitation Facilities Clinical services at a primary level are at present over loaded and very few health workers are trauma trained. Tertiary trauma facilities are inundated with inappropriate attenders. It is likely that this will continue until primary and secondary trauma care facilities are made more accessible and acceptable to the general public. It is important here to note that the only direct references to injury and trauma appearing in the Department of Health’s Year 2 000 Goals: Objectives and Indicators for South Africa, concern the provision of improved emergency medical services, and to improved access for the disabled to comprehensive health services. The absence of any reference to primary prevention modalities, and of any reference to violence, suggests that a great deal more has to be done in planning for the future of injury prevention in South Africa.
OBSTACLES AND OPPORTUNITIES Framing the achievements and challenges specific to each of the injury categories reviewed above, are a series of macro-level factors specific to injury prevention in developing country settings and common to most causal categories. In most developed countries where injury prevention programmes have been successful,38 the threat of infectious disease has largely been removed, and injury prevention has unfolded in the relatively open space of competition with other non-communicable diseases. In South Africa the situation is more complex. Injuries here occur in a mixed economy of disease alongside high levels of infectious illness and poverty-related conditions such as malnutrition. Unlike infectious diseases and environmental hazards that are seen as threats to the well being of everyone, the causes and effects of injury are highly specific and different for different people. As a result, it is difficult to secure the levels of popular and political concern required to establish a sustained injury prevention response, and the injury problem in South Africa has yet to receive anything approaching the levels of financial and policy-making support enjoyed by problems of a more dramatic nature (eg. HIV/AIDS). Accordingly, the first challenge to injury prevention in South Africa is to overcome this perceptual barrier by raising awareness among policy makers as to the extent of the problem and the range of potential solutions. The dominant framework for understanding injury derives from the experience of highly developed societies. Within such societies, consumer control over the technologies most likely to affect safety enable the effective implementation of simple injury prevention solutions. For many problems, these can be introduced at the point of product design and manufacture (eg. motor vehicle airbags), and for others through the enforcement of appropriate legislation (eg. wearing of seatbelts). By contrast the causes of injury in South Africa are far more complex. They are therefore resilient to attempted solutions derived from developed country models. For example, the high frequency of informal liquor outlets mitigates against the likelihood of legislation-based interventions succeeding. In respect of firearm-related injuries a similar barrier is provided by the prevalence of unlicensed weapons and a flourishing illegal arms trade. The second challenge for injury prevention in South Africa is therefore to build a locally relevant model of injury analysis and prevention that draws on the experience of developing countries and is keyed to safety promotion in our own more complex setting. The strong relationship between socio-economic status, environmental conditions and the amount and severity of injury means that in addition to discrete interventions which target dangerous products, situations and behaviours, structural interventions are required to stabilise communities through improvements in housing, sanitation, access to employment and the provision of education.
220 Particularly in respect of injuries due to violence, it may well be that it is only through such structural interventions that a significant decrease will occur. To achieve such changes requires strong mechanisms of civil ordering and accountability by which community leaders and residents can lobby for and ensure that development takes place. However, these mechanisms are absent or underdeveloped in the poorest communities at highest risk for injury and violence. This is largely due to the transience of residents and leaders. Successful safety promotion demands continuity of leadership and the medium to long-term maintenance of a unified goal. Until these conditions are achieved safety promotion through injury prevention will remain elusive.
CONCLUSION Injury prevention and control has come of age in the industrialised world, which has produced many examples of startling success in reducing unintentional injury rates. Less convincing are the results to date in respect of intentional injuries, although extension of public health measures to cover them occurred only recently relative to other injury categories. If South Africa adapts some of the measures used in other countries and learns from the successes, then there is every reason to believe that the same level of success can be achieved here, and that even the levels of violence can be reduced through the positive techniques of public health. It is hoped, therefore, that research and development in the field of injury management is set to become one of the major public health sector activities in South Africa.
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References 237 HEALTH AND RELATED INDICATORS
DEMOGRAPHY BY PROVINCE South Africa South Africa Total/Average Total/Average Mpumalanga Mpumalanga Northern Northern Province Province South Africa Total/Average Eastern Cape Eastern Cape Northern Northern Cape Cape Mpumalanga Northern Province South Africa South Africa Total/Average Total/Average Eastern Cape Northern Cape Mpumalanga Mpumalanga Northern Northern Province Province North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal Free State Free State Eastern Cape Eastern Cape Northern Northern Cape Cape North West Western Cape Gauteng KwaZulu- Natal Free State Free State Free State North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal
Total poulation 19967 (in thousands) 5 865 2 646 7 171 7 072 746 4 128 3 043 2 470 4 118 37 859 % Pop per province 19941 16.1 7.2 17.0 21.2 1.9 12.4 8.3 6.9 9.0 100 19952 15.7 7.3 17.1 21.1 1.8 13.1 8.2 6.7 9.0 100 19967 15.5 7.0 18.9 20.3 2.0 10.9 8.0 6.5 10.9 100 Annual pop. Growth rate (1985-1993)3 2.6 3.0 1.3 2.8 0.8 4.0 3.1 1.5 1.7 2.4 Crude birth rate 1994 (based on hospital deliveries)4 17.3__21.6_ _15.8__ _ Crude death rate5 5.7 3.2 6.1 3.5 8.5 2.6 5.7 5.8 6.8 4.9 Total fertility rate 19913 4.6 4.3 3.0 4.3 2.9 5.8 4.5 3.7 2.7 3.3 19969 _ 4.3______3.5 Teenage birth rates 19913 13.1 13.5 12.9 15.3 12.8 16.4 12.6 14.9 11.8 14.6 Average household size 19901 5.2 4.6 3.5 5.7 4.3 5.2 3.8 3.9 3.9 4.5 19946 4.9 4.8 3.9 5.0 4.1 4.7 4.5 4.0 3.9 4.5 19958 4.7 5.0 3.6 5.0 3.7 5.0 4.2 3.7 3.8 4.3
Sources: 1 Chimere-Dan in Demographic patterns in South Africa, South African Health Review, 1995. 2 Central Statistics Service. RSA Statistics in brief 1995. Pretoria, 1996. 3 Development Bank of South Africa. South Africa’s nine provinces: A human development profile. Halfway House 1994. 4 Health (and Welfare) in Eastern Cape: Implications for Planning, 1996. Durban, 1996 KwaZulu-Natal: Implications for Planning, 1996. Durban, 1996 North West: Implications for Planning, 1996. Durban, 1996. 5 Bradshaw et. al. Estimated cause of death profiles for the nine new provinces based on 1990 data. Medical Research Council. 1995. 6 Central Statistics Service. October Household Survey 1994. Pretoria, 1995. 7 Central Statistics Service. Census ‘96: Preliminary estimates of the size of the population of South Africa. Pretoria, June 1997. 8 Central Statistics Service. October Household Survey 1995. Pretoria, 1996. 9 South African Institute of Race Relations. South Africa Survey 1996/97. Johannesburg, 1997.
238 DEMOGRAPHY BY RACE
White Coloured Indian African South Africa Average / Total
% Pop per province 19941 12.8 8.5 2.6 76.1 100 19952 12.7 8.5 2.5 76.3 100 19966 12.4 8.4 2.5 76.7 100 (%) Ave annual population growth rate 19941 0.7 1.5 1.5 2.5 2.1 19952 0.7 1.4 1.4 2.4 2.1 1991-19966 0.5 1.45 1.31 2.35 2.02 Crude birth rate 19941 13.7 21.7 18.1 25.3 23.4 Crude death rate 19941 6.7 7.2 7.3 10.2 9.4 Total fertility rate 19901 1.8 2.7 2.3 3.7 3.3 19943 1.6 2.3 2.2 3.7 - 4.3 2.9 1991-19966 1.8 2.4 2.2 4.0 3.5 Contraceptive prevalence rate 19901 75.1 69.5 70.1 50.7 — 19941 80.0 74.0 77.0 66.0 — % Teenage pregnancy 19901 6.3 14.8 6.1 10.7 — 19931 — 8.5 — 15.2 — Ave. household size 19901 3.0 4.7 4.4 4.8 4.5 19944 2.7 5.3 4.5 5.3 4.5 19955 2.9 4.6 4.2 4.7 4.3
Sources: 1 Chimere-Dan. Demographic Patterns in South Africa in South African Health Review, 1995. Durban, 1995. 2 Central Statistics Services. RSA Statistics in brief. Pretoria, 1995. 3 Central Statistics Services. 1994 October Household Survey. Pretoria, 1995.. 4 CASE. A National Household Survey of Health Inequalities in South Africa. 1995 5 Central Statistics Services. 1995 October Household Survey. Pretoria, 1996.. 6 South African Institute of Race Relations. South Africa Survey 1996/97. Johannesburg, 1997.
239 SOCIO-ECONOMIC INDICATORS BY PROVINCE South Africa South Africa Total/Average Total/Average Mpumalanga Mpumalanga Northern Northern Province Province South Africa Total/Average Eastern Cape Eastern Cape Northern Northern Cape Cape Mpumalanga Northern Province South Africa South Africa Total/Average Total/Average Eastern Cape Northern Cape Mpumalanga Mpumalanga Northern Northern Province Province North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal Free State Free State Eastern Cape Eastern Cape Northern Northern Cape Cape North West Western Cape Free State Gauteng KwaZulu- Natal Free State Free State North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal
Area as a % of tot area of SA1 13.9 6.7 1.5 7.5 29.7 9.8 9.7 10.6 10.6 100 Pop density (persons per km2) 19942 38.0 37.3 365.2 92.3 2.0 42.2 28.0 21.1 28.1 33.0 19953 38.2 38.4 374.7 94.5 2.0 43.8 28.8 21.5 28.8 33.8 Functional urbanisation % Urban 19933 55.4 43.2 99.6 77.9 78.2 12.1 43.9 73.7 95.1 65.5 % Urban 19944 35.0 31.6 96.0 38.0 73.1 8.0 30.0 54.0 86.4 48.8 % Rural 19944 65.0 68.4 4.0 62.0 26.9 92.0 70.0 46.0 13.6 51.2 % Urban 19967 37.3 38.3 96.4 43.5 71.1 11.9 34.8 69.6 89.9 55.4 % Rural 19967 62.7 61.7 3.6 56.5 28.3 88.1 65.2 30.4 10.1 44.6 Literacy rate % 19911 59.0 54.6 69.0 58.7 67.6 52.7 55.8 60.0 71.9 61.4 19955 59.0 55.0 69.0 59.0 68.0 53.0 62.0 59.0 72.0 — 19969 — ————————71.0 % non school attendance 19911 9.4 8.5 8.7 11.3 7.3 8.6 13.7 9.7 6.4 9.6 Unemployment rate 19911 23.6 16.3 16.6 25.2 16.7 24.8 22.3 15.3 13.3 19.4 19946 45.3 36.4 28.7 32.2 32.5 47.0 36.6 24.4 17.3 32.6 19959 14.4 33.4 20.9 33.1 27.0 41.0 32.8 26.1 18.6 29.0 Dependency ratio 19941 3.7 2.1 0.9 2.3 1.6 4.8 1.6 1.4 1.2 1.9 Average annual household income (R 000) 199710 24 30 71 37 31 31 30 25 53 — % house-holds with tap water in dwelling 19946 White 97.5 96.6 98.6 99.1 98.9 91.4 99.7 97.4 99.4 98.4 Coloured — — 93.7 — 29.2 — — — 85.5 76.0 Indian — — 99.5 — — — — — — 97.7 African 16.3 20.1 57.2 25.9 20.2 12.9 21.1 19.1 39.5 27.4 19958 White 92.6 96.5 96.7 96.0 98.3 93.1 99.7 98.3 98.9 96.9 Coloured 53.3 91.4 95.3 91.2 44.4 92.7 84.8 52.1 76.7 72.2 Indian 100 100 99.8 95.9 87.7 100 92.8 — 100 96.8 African 16.0 41.2 64.2 26.6 27.0 16.6 27.0 26.6 36.9 32.7 % households using electricity as main energy source 19946 White 95.8 99.1 98.4 99.4 81.9 97.9 99.7 99.8 99.4 98.2 Coloured 53.7 — 93.5 — 37.1 — — — 83.9 75.7 Indian — — 99.8 — — — — — — 98.5 African 12.0 20.0 64.6 31.7 29.9 14.0 25.1 31.7 46.5 30.5 19958 White 94.3 99.8 99.5 98.8 90.7 98.6 99.6 98.2 96.8 98.2 Coloured 56.3 88.4 97.7 90.0 49.0 98.4 90.9 66.1 78.5 74.9 Indian 98.9 100 99.7 98.2 87.7 100 100 — 91.8 98.3 African 16.4 31.0 84.1 37.2 48.0 21.6 36.0 45.1 53.9 42.1 % without sanitation facilities 19946 White 0.1 — — 0.0 — — 0.0 0.0 — 0.0 Coloured 5.8 — 0.1 — — — — — — 2.4 Indian 28.8 16.8 2.6 8.9 — — 13.0 12.7 — 12.6 African — — 0.1 — 0.5 — — — 0.1 0.1 19958 White — — 0.1 — 0.5 — — — 0.1 0.1 Coloured 6.9 — — 0.4 8.4 — 0.5 3.5 2.2 3.2 Indian — — — 0.1 — — — — — 0.0 African 19.9 11.4 1.2 15.7 11.5 14.7 5.5 11.9 1.8 10.9
Sources: 1 Development Bank of South Africa. South Africa’s nine provinces: A human development profile. Halfway House 1994. 2 Chimere-Dan in Demographic patterns in South Africa 1995. 3 Central Statistics Service. RSA Statistics in brief. 1995. Pretoria, 1996.
240 4 Health (and Welfare) in the: North West: Implications for Planning, HST Durban, 1996. KwaZulu Natal: Implications for Planning, HST Durban, 1996. Northern Province: Implications for Planning, HST Durban, 1996. Free State: Implications for Planning, HST Durban, 1996. Eastern Cape: Implications for Planning, HST Durban, 1996. Northern Cape: Implications for Planning, HST Durban, 1996. 5 Portfolio of South Africa, 1995. Gauteng, 1995. 6 CSS October Household Survey 1994. (Provincial Reports). Pretoria, 1995. 7 CSS Census 1996: Preliminary estimates of the size of the population of South Africa, July 1997. 8 CSS October Household Survey 1995. (Provincial Reports). Pretoria 1996. 9 Joint Education Trust. A Survey of Adult Basic Education in South Africa. In, South Africa Survey 1996/97. SAIRR, Johannesburg, 1997. 10 Central Statistics Service. Earning and Spending in South Africa : selected findings of the 1995 Income and Expenditure Survey. Pretoria, 1997.
SOCIO-ECONOMIC BY RACE
White Coloured Indian African South Africa Average / Total
% Urbanised 19931 91.1 83.2 96.2 35.8 48.3 % Literate 19932 99 66 84 54 — 19967 —— —— 71 Unemployment rate 19943 6.4 23.3 17.1 41.1 33.(40)4 Age dependency ratio5 49.0 57.1 48.7 61.6 — Monthly income per capita (R)8 7 108 5 727a 5 727a 1 252 2 579 % of Pop with electricity 19943 98.2 75.7 98.5 30.5 36.6.6
a individual groups too small to report.
Sources: 1 Yach D, and Harrison D in Public Health in North-South Perspective 1994. 2 Development Bank of Southern Africa in Race Relations Survey, 1993/94. SAIRR, Johannesburg, 1994. 3 CSS October Household Survey 1994. Pretoria, 1995. 4 Lund F and Patel Z. in South African Health Review. 1995 5 Key Indicators of poverty in South Africa. 1995. 6 Medical Research Council. Electrification and Health. A South African perspective. Unpublished. 1994. 7 Joint Education Trust. A survey of Adult Basic Education in South Africa. In, South Africa Survey 1996/97. SAIRR, Johannesburg, 1997. 8 South African Institute of Race Relations. South Africa Survey 1996/97. SAIRR, Johannesburg, 1997
241 HEALTH STATUS BY PROVINCE South Africa South Africa Total/Average Total/Average Mpumalanga Mpumalanga Northern Northern Province Province South Africa Total/Average Eastern Cape Eastern Cape Northern Northern Cape Cape Mpumalanga Northern Province South Africa South Africa Total/Average Total/Average Eastern Cape Northern Cape Mpumalanga Mpumalanga Northern Northern Province Province North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal Free State Free State Eastern Cape Eastern Cape Northern Northern Cape Cape North West Western Cape Free State Gauteng KwaZulu- Natal Free State Free State North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal MORTALITY
Infant mortality rate 19901 44.7 45.1 32.3 44.9 42.9 52.9 40.1 45.8 24.4 40.2 Infant mortality rate 1991-1996, per 1 000 live births17 56.3 55.2 60.3 54.5 55.3 56.5 55.7 54.6 53.4 56.1 Neonatal deaths per 1 000 public hospital deliveries 19952 15.0 8.0 — 7.0 9.8 14.7 9.8 12.2 — — Perinatal mortality rate23 — ————————3.5 Child mortality rate 19903 19.4 14.8 13.1 14.3 19.6 8.3 24.7 23.3 12.3 — Maternal mortality rate4 — ————————32.0 19942 63.0 — — 44.0 — 52.8 70.0 61.0 — — Still born per 1 000 deliveries2 22.0 35.0 — 19.0 — 17.3 26.5 21.3 — — Caesarian section (as a % of total medically assisted deliveries)2 10.0 10.4 — 20.9 10.1 8.7 8.7 8.2 — — % of clinics with comprehensive MCH services2 41.4 44.0 — 12.8 79.2 70.0 57.0 41.0 — — Ratio of antenatal visits to deliveries2 — 6.1 — 6.4 3.4 4.5 5.5 3.9 — — Potential years of life lost 19905 1 039 876 191 076 778 771 638 198 139 750 231 919 635 889 383 383 385 045 — Life expectancy at birth 19901 (M / F) 61 / 68 63 / 69 63 / 69 62 / 69 60 / 65 62 / 68 64 / 70 61 / 66 63 / 68 62 / 68 1991-199624 (years) 63.7 64.1 65.8 64.3 64.3 63.5 63.9 64.4 64.9 64.4
MORBIDITY
Communicable Diseases Incidence of TB 19937 280.6 84.2 191.9 115.3 417.2 53.2 83.0 472.0 72.6 224.9 Incidence of TB per 100 000 pop 199619 504 286 375 381 340 260 271 282 559 362 % TB patients successfully treated 199516 65.6 80.2 70.4 71.6 64.3 68.9 69.1 67.4 75.5 71.9 Incidence measles 19928 51.7 93.4 69.0 44.5 115.5 47.8 27.8 105.5 40.2 57.2 Per 1 000 pop 199618 1.4 24.4 9.1 26.0 9.2 23.5 8.0 18.7 17.7 15.8 Incidence malaria 19939 0.1 131.0 9.0 45.1 2.9 42.7 4.4 0.5 0.5 27.5 Per 1 000 pop 1996/9725 — 573.4 — 221.1 — 163.4 — — — 70.2 Incidence typhoid 1993 3.0 7.7 2.4 5.2 0.3 11.4 0.2 0.9 0.6 — 199410 1.3 9.6 1.5 1.4 0.0 3.7 0.3 0.5 0.6 2.0 per 1 000 pop 199618 0 4.4 0.5 0.6 0 2.4 0 0.03 0.3 0.9 Incidence viral hepatitis per 1 000 pop 199618 0.2 2.1 4.3 1.9 4.2 1.5 0.2 1.9 10.7 2.7 Incidence meningococcal infection 199211 0.9 0.8 0.5 0.4 2.2 0.6 0.3 0.6 8.5 1.3 199618 0 0.2 1.1 0.07 0.1 0 0.3 0.03 5.7 0.8 Incidence congenital syphilis 199211 4.8 0.4 1.9 0.4 2.4 0.9 0.2 0.2 7.0 2.0 Prevalence gonorrhoea % 199622 ————— — ——— 8 Antenatal and family planning clinic attenders: Incidence chlamydia % 1996 — — — — — — — — — 16 HIV no. of cases 1996/9721 ——466 000 750 000 22 000 — ———2.4million HIV (antenatal) (%) 199412 4.5 12.2 6.4 14.4 1.8 3.0 6.7 9.2 1.2 7.6 199513 (%) 6.0 16.2 12.0 18.2 5.2 4.9 8.3 11.0 1.7 10.4 199621 (%) 8.1 15.8 15.5 19.9 6.5 7.9 25.1 17.5 1.6 14.1 Tetanus 199618 (no. of cases) 04040 8 01118
* No. of reported cases generally lower than actual no. of cases, especially malaria and TB.
242 South Africa South Africa Total/Average Total/Average Mpumalanga Mpumalanga Northern Northern Province Province South Africa Total/Average Eastern Cape Eastern Cape Northern Northern Cape Cape Mpumalanga Northern Province South Africa South Africa Total/Average Total/Average Eastern Cape Northern Cape Mpumalanga Mpumalanga Northern Northern Province Province North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal Free State Free State Eastern Cape Eastern Cape Northern Northern Cape Cape North West Western Cape Gauteng KwaZulu- Natal Free State Free State Free State North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal DISABILITY20 Sight (serious eye defect) % 2.0 1.7 2.2 2.6 3.3 2.2 2.5 4.4 2.0 2.4 Hearing / Speech % 0.7 0.4 0.7 0.8 1.2 0.7 0.8 1.5 0.6 0.8 Physical % 1.6 1.0 1.0 1.8 1.6 1.1 1.2 2.3 1.4 1.4 Mental % 0.5 0.2 0.3 0.4 0.6 0.3 0.5 0.4 0.5 0.4
RISK TAKING BEHAVIOUR
Smoking (1995)14 % adults who smoke 29 23 37 33 55 14 46 40 48 34 % men 48 42 52 56 72 35 62 56 51 52 % women 12 6 20 8 33 4 31 23 45 17
NUTRITIONAL STATUS
% Wasting Primary school children in sub-standards 1&2 19944 2.5 1.8 2.1 1.9 5.4 3.1 4.4 1.8 2.8 2.6 Children 6-71 months15 3.2 1.7 1.2 0.7 2.5 3.8 4.5 4.5 1.3 2.6 % Stunting Primary school children in sub-standards 1&2 19944 16.8 11.4 7.1 11.8 19.2 13.4 14.1 11.2 13.8 13.2 Children 6 - 71 months15 28.8 20.4 11.5 15.6 22.8 34.2 24.7 28.7 11.6 22.9 % Under-weight Primary school children in sub-standards 1&2 19944 9.2 6.2 436 5.6 20.9 10.4 12.0 8.0 12.0 9.0 Children 6-71 months15 11.4 7.3 5.6 4.2 15.6 12.6 13.2 13.6 7.0 9.3 % Low birth weight babies2 4.3——— ——————
Sources: 1 Chimere-Dan in Demographic patterns in South Africa 1995. 2 Health (Care)(and Welfare) in Eastern Cape, Northern Cape, Northern Province, North West, Mpumalanga and Free State: Implications for Planning, 1996. Health Systems Trust, Durban, 1996 and 1997. 3 Bradshaw D et.al unpublished report. Medical Research Council, 1990. 4 Department of Health. Epidemiological Comments; Vol 22 (4). Pretoria, 1995. 5 Bradshaw D et.al Estimated causes of death. Profiles for the nine new provinces based on 1990 data. MRC, 1995. 6 Fourie J, and Steyn K. Chronic Diseases of Lifestyle in South Africa. Medical Research Council, 1995. 7 Department of Health. Epidemiological Comments; Vol 22 (1). Pretoria, 1995. 8 Department of Health. Epidemiological Comments; Vol 21 (5). Pretoria, 1994. 9 Department of Health. Epidemiological Comments; Vol 21 (6). Pretoria, 1994. 10 Department of Health. Epidemiological Comments; Vol 22 (2). Pretoria, 1995. 11 Development Bank of Southern Africa, 1994. 12 Department of Health. Epidemiological Comments; Vol 22 (5). Pretoria, 1995. 13 Department of Health. Annual Report, 1995. Pretoria, 1996. 14 MRC / HSRC Survey, 1995. 15 The South African Vitamin A Consultative Group. 1995. 16 Weyer K. Unpublished Report. Medical Research Council, 1995. 17 Institute for Futures Research, University of Stellenbosch. In, South African Institute of Race Relations. 1996/97 Survey, 1997. 18 Department of Health. Number of reported cases of notifiable diseases. In, South African Institute of Race Relations. 1996/97 Survey, 1997. 19 South African Institute of Race Relations. Information supplied by Ms Courtenay Singer, Dept of Health, 27 Feb, 1997. 1996/97 Survey, 1997. 20 Central Statistics Service. October Household Survey 1995.Pretoria, 1997. 21 Department of Health Seventh National HIV Survey amongst women attending antenatal clinics in South Africa - Oct/Nov 1996. Pretoria, 1997. 22 Pham-Kanter GB, Steinberg MH, Ballard RC. National AIDS Research Programme, Medical Research Council, Johannesburg. Sexually transmitted diseases in South Africa. Genitourinary Medicine. 72(3):160-71, 1996 June. 23 Department of National Health. Proceedings of the First Essential National Health Research Congress on Priority Setting. Pretoria, November 1996. 24 South African Institute of Race Relations. 1996/97 Survey. Johannesburg, 1997. 25 Department of Health, Communicable Disease Control Section. Malaria in South Africa During 1996 - July 1997. Pretoria, 21 August 1997. 26 Directorate of Traffic Safety. Provinces to accept traffic safety challenges. Nuusbrief 1994; December 1-2: 1. In, Butchart A and Peden M. South African Health Review, Health Systems Trust, 1997.
243 HEALTH STATUS BY RACE
White Coloured Indian African South Africa Average / Total
MORTALITY
Infant mortality rate 19901 7.4 28.6 15.9 48.3 40.2 19942 7.3 36.3 9.9 54.3 48.9 1991-9618 19.3 60.5 34.1 59.0 56.1 Perinatal mortality rate 1994 (%)16 —— —— 3.5 Under 5 Mortality rate % of deaths < 5 years (1990)3 12 19 13 20 — Maternal mort. rate 19904 330152332 19922 8 22 5 58 — Trauma related deaths: Motor vehicle accidents (no. of cases) 1993 — — — — 9445 Unintentional/Intentional Violence (%)17 —— —— 19.2 Life expectancy at birth 19901 Males 69 59 64 60 62 Females 76 65 70 67 68 1991-1996 73.0 62.5 68.8 63.2 64.4 1996-200118 73.6 64.4 70.2 64.5 65.6 % deaths due to respiratory causes: children <5yrs per 100 000 (1990)3 7.0 15.7 7.4 12.0 —
MORBIDITY
Communicable Diseases Incidence TB per 100 000 pop 19935 18.8 712.5 50.8 206.6 224.9 Incidence malaria per 100 000 19936 15.3 0.3 0.9 32.8 27.5 Ave annual Incidence of typhoid per 100 000 pop 1985-19947 0.6 0.7 2.1 10.1 7.8 % HIV +ve (antenatal) 19948 0.4 1.3 7.0 7.3 7.6 Non communicable diseases Prevalence of dental caries % amongst 6 yr olds (1989)9 59.5 79.2 76.3 65.3 66.3 DMFT scores for 12yr olds 198910 1.8 2.1 1.3 1.7 —
RISK TAKING BEHAVIOUR
% of adults who smoke (1995)11 35 59 36 31 34 % of men who smoke12 40 63 48 46 47 % of women who smoke12 34 49 8 6 13
NUTRITIONAL STATUS
Wasting (%) Children in substandards 1 & 2 (1994)13 0.9 4.1 5.2 2.4 2.6 Under-weight (%) Children in substandards 1 & 2 (1994)13 1.1 16.9 6.2 8.7 9.0 Stunting (%) Children < 6 years (1994)14 4.9 19.1 6.1 28.3 — Children in substandards 1 & 2 (1994)13 1.8 18.2 4.1 14.6 13.2 % Prevalence of Obesity (BMI > 30) adults aged 15-64 (1994)15 Male 14.7 6.1 3.2 7.9 — Female 18.0 25.9 21.6 34.4 —
244 Sources: 1 Chimere-Dan in Demographic patterns in South Africa, 1995. 2 Department of Health. Annual Report 1995. Pretoria, 1996. 3 Department of Health. Health Trends in South Africa, 1993. Pretoria, 1994. 4 Department of Health. Health Trends in South Africa, 1992. Pretoria, 1993. 5 Department of Health. Epidemiological Comments; Vol 22 (1). Pretoria, 1995. 6 Department of Health. Epidemiological Comments; Vol 21 (6). Pretoria, 1994. 7 Department of Health. Epidemiological Comments; Vol 22 (2). Pretoria, 1995. 8 Department of Health. Epidemiological Comments; Vol 22 (5). Pretoria, 1995. 9 National Survey Data, 1988 / 89 in Health Status Chapter. South African Health Review 1995. Durban, 1995. 10 Department of Health in Health Status Chapter, South African Health Review 1995. Durban, 1995. 11 Medical Research Council and Human Sciences Research Council Survey, 1995. 12 Community Agency for Social Enquiry. A National Household Survey Health Inequalities in South Africa. 1995. 13 Department of Health. Epidemiological Comments; Vol 22 (4). Pretoria, 1995. 14 SALDRU/ World Bank Report 1993-1994. South Africa Rich and Poor: Baseline household statistics. 15 Walker ARP in Fourie J and Steyn K. (Eds) Chronic Diseases of Lifestyle in South Africa. MRC, 1995. 16 Department of Health. Annual Report 1996. Pretoria, 1997. 17 Department of Health. Annual Report 1996. Pretoria, 1997. 18 South African Institute of Race Relations. South African Survey 1996/97. Johannesburg, 1997.
245 HEALTH SERVICES PROVISION BY PROVINCE South Africa South Africa Total/Average Total/Average Mpumalanga Mpumalanga Northern Northern Province Province South Africa Total/Average Eastern Cape Eastern Cape Northern Northern Cape Cape Mpumalanga Northern Province South Africa South Africa Total/Average Total/Average Eastern Cape Northern Cape Mpumalanga Mpumalanga Northern Northern Province Province North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal Free State Free State Eastern Cape Eastern Cape Northern Northern Cape Cape North West Western Cape Gauteng KwaZulu- Natal Free State Free State Free State North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal EXPENDITURE
Per capita public health expenditure (rands) 1992/931 227.0 136.6 381.7 236.9 221.2 164.1 178.9 226.5 491.1 262.6 1997/19987 444 263 773 418 543 309 417 510 707 468
HUMAN RESOURCES
Doctors per 100 000 pop 1992/933 30.7 28.3 127.4 53.5 37.6 15.5 22.7 46.5 143.8 60.2 19942* 9.6 12.6 43.9 18.0 14.2+ 6.6 1.01 11.0 34.7 — 19956 — — — — — — — — 65.7 Nurses per 100 000 pop 1992/933 321.3 265.8 618.4 431.4 432.3 293.2 273.5 382.3 686.3 421.5 19942** 130.7 28.3 — 151.0 116.0 107.9 100.0 70.5 — — 19956 — — — — — — — — — 412.1 Therapists per/100 000 pop 19956 Occup Therapists — — — — — — — — — 4.9 Physiotherapists — — — — — — — — — 8.6 Speech Therapists — — — — — — — — — 2.9 Dentists per 100 000 pop 1992/933 3.05 4.17 23.6 5.4 7.9 1.4 3.2 5.0 22.1 9.4 19942*** 0.7 1.4 2.7 1.7 0.3 0.5 1.2 0.9 1.9 — 19956 — 0.4 — — — — — — — 9.7 Pharmacists per 100 000 pop 1992/933 20.1 23.1 109.8 28.7 28.5 7.8 22.8 38.8 79.8 42.6 19942 1.4 2.1 3.6 2.6 1.5 1.1 1.7 1.6 4.9 — 19956 — 1.8 — — — — — — — 23.2
FACILITIES
Hospital beds per 1000 pop 1992/934 3.5 2.1 6.0 3.8 4.0 2.5 3.3 4.1 5.4 4.0 Distribution of hospital beds by type of hospital Academic hospitals (%) 6.8 — 57.6 8.2 — — — 31.0 37.5 18.5 Tertiary hospitals (%) 22.0 5.5 9.2 30.7 — 29.2 19.4 9.6 14.5 19.7 Secondary hospitals (%) 12.6 38.4 19.8 20.9 44.4 5.2 17.9 17.5 18.1 18.4 First level hospitals (%) 58.6 56.1 13.4 40.2 55.6 65.6 62.7 41.9 29.9 43.4 Acute beds per 1 000 pop 19942 2.2 1.9 — 1.6 2.7 2.4 1.6 2.3 — — Chronic beds per 1 000 pop 19942 1.0 0.6 — 0.2 0.7 0.8 0.7 0.5 — — Bed occupancy rate (%)19942 64.0 96.3 — 79.0 66.6 52.0 58.0 41 — 81.5 Average length of stay (days) 19942 7.0 3.7 — 9.0 5.9 5.3 7.8 7.0 — — Bed turnover rate 19942 34.0 — — 32.0 44.5 24.4 27.2 — — — Theatre utilisation per day 19942 1.0 — — — 1.04 2.0 1.4 — — — No. of hosp. deaths per 1 000 admissions 19942 25.0 30.8 — 36.0 33.8 32.4 19.0 19 — — No. of hosp beds per professional nurse 19942 2.8 2.4 — 3.1 3.7 3.2 3.3 2.7 — — No of hosp beds per doctor 19942 — — — — 25.2 44.1 25.7 — — — No of admissions per doctor 19942 1 011 — — 32 764 ——1 154——— No of admissions per professional nurse 19942 44— — —— —150—— —
246 South Africa South Africa Total/Average Total/Average Mpumalanga Mpumalanga Northern Northern Province Province South Africa Total/Average Eastern Cape Eastern Cape Northern Northern Cape Cape Mpumalanga Northern Province South Africa South Africa Total/Average Total/Average Eastern Cape Northern Cape Mpumalanga Mpumalanga Northern Northern Province Province North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal Free State Free State Eastern Cape Eastern Cape Northern Northern Cape Cape North West Western Cape Gauteng KwaZulu- Natal Free State Free State Free State North West North West Western Western Cape Cape Gauteng Gauteng KwaZulu- KwaZulu- Natal Natal
Immunisation (%) 19915 % of PHC facilities with refrigerators2 53.4 72.0 — 80.6 72.3 79.0 42.0 61.0 — — Measles5 — ————————85 DPT5 — ————————81 Polio5 — ————————82 BCG5 — ————————63 % of clinics and health centres with basic amenities 19942 Adequate water supply 54 — — 80 93 70 70 93 — — Grid electricity 48 — — 89 88 77 58 91 — — Waterborne sewerage 45 — — 59 43 51 42 73 — — Telephone 62 — — 85 87 77 57 90 — —
Sources: 1 ReHMIS Survey in Health Expenditure Review. Durban, 1995. 2 Health (Care) (and Welfare) in : Eastern Cape; KwaZulu Natal; Northern Cape; Northern Province; North West; Mpumalanga and Free State: Implications for Planning, 1996. Health Systems Trust, Durban, 1996. 3 Development Bank of SA quoted in Health Expenditure Review. Durban, 1995. 4 Chetty in Health Expenditure Review, Durban, 1995. 5 Department of Health. Health Trends in South Africa. Pretoria, 1995. 6 Pick W, Kunene H, Jikwana S, and Ntishingila L. Planning Human Resources for Health Care in South Africa -A Document for Discussion. Dept of Community Health, University of the Witwatersrand. December 1996. 7 Van Den Heever AM and Brijlal V. South African Health Review 1997. Health Systems Trust, Durban, 1997. Notes: * General Practitioners and interns ** Professional Nurses in public sector *** Dentists and Dental specialists (public sector) + General Practitioners only
247 Index
Abortion ...... 30, 147 Commission of Inquiry into Safety and Acute flaccid paralysis surveillance ...... 141 Health in the Mining Industry...... 172 Acute respiratory infection ...... 143 Community-based health workers . . . . . 135135, 95 Ad Hoc Select Committee on Abortion Community-based rehabilitation ...... 186 and Sterilisation ...... 30 Community Partnerships in Health Personnel ...... Adolescent Health Project ...... 150 Education ...... 96 Adolescent mortality rate ...... 16 Community rehabilitation workers...... 184 Adolescent services ...... 160 Community service ...... 32, 64 Adult mortality ...... 7, 16 Condoms ...... 192, 205 Age dependency ratio...... 16 Congo Fever...... 12 Age distribution ...... 1 Constitution of the Republic of South AIDS Training Information and Counselling Africa ...... 29, 45, 50, 81, 179 Centres ...... 193 Consumer price index ...... 40 Alcohol ...... 13, 159, 213, 216 Contract tracing ...... 205 Assault ...... 5, 22, 216 Convention on the Rights of the Child ...... 144 Assistive devices ...... 183 Co-operative governance ...... 50 Audit of Health Care Personnel for South Africa . . 91 Co-ordinating Education Committee ...... 92 Core package of PHC services ...... 57, 143 Basic Conditions of Employment Act ...... 149 Cost centre ...... 79, 80 Bilharzia ...... 10 Council on Hospital Accreditation of SA ...... 73 Breastfeeding ...... 209 Crime ...... 5, 22 Budgeting ...... 83 Cryptosporidium ...... 10 Budget Council ...... 83 Cuban doctors ...... 64, 95 Burden of Disease ...... 9, 14, 16, 114, 214 Culture of caring ...... 97
Cancer ...... 11, 141, 166 Decentralised Hospital Management ...... 61 Census ...... 1 Democratic Nursing Organisation of South Central Bargaining Chamber ...... 6464, 47, 72 Africa ...... 30 Central Mark Control System ...... 101 Demographic transition ...... 5 Centre for Health and Social Studies ...... 96 DENOSA ...... 30 Cervical screening ...... 141 Dental caries ...... 14 Chancroid...... 10 Dental Schools ...... 166 Charter of Community and Patient Rights . . . 92, 97 Dental Technicians Amendment Bill. . . 29, 30, 168 Child Health Policy Institute ...... 142 Dental Technicians’ Council...... 31 Child mortality rate ...... 7, 16 Dental Therapists ...... 168 Chlamydia ...... 10, 203 Dentists ...... 94, 168 Choice on Termination of Pregnancy Depression ...... 13 Act ...... 131131, 29, 30, 96, 147 Diarrhoeal disease...... 143 Chronic diseases ...... 11 Directly Observed Treatment, Short-course . . . . 200 Chronic illnesses ...... 150 Disability ...... 1313, 179179, 181 Chronic obstructive airways diseases ...... 13 Disability adjusted life year ...... 16, 214 Civil society organisations ...... 130 Dispensing doctors ...... 32 Clinic Upgrading and Building District Council ...... 57 Programme ...... 125125, 124 District financing ...... 86 Clinical Psychologists ...... 159 District Health Councils ...... 132 Cochrane Centre ...... 117 District Health Service ...... 160 COMED ...... 101 District Health System ...... 5858, 46, 53, 54, Commission on Gender Equality ...... 144 ...... 59, 81, 85, 96, 131 Commission of Inquiry into Health Doctors ...... 94 Services (1980) ...... 54 Drug pricing committee ...... 100
248 Housing ...... 21 Ebola ...... 12 Human Development Index ...... 18, 27 Education ...... 18 Human Sciences Research Council...... 117 Electricity ...... 22 Employment ...... 18 Illiteracy ...... 18 Employment Standards Act ...... 149 Immunisation...... 142 EquityEquity...... 84 Impairment ...... 181 Equity Project ...... 142 Income ...... 18 Essential Drugs List ...... 100, 101 Independent Development Trust ...... 124, 130 Essential National Health Research . . . . 113, 161, 186 Independent Practitioner Associations ...... 43 Expenditure ...... 84 Infant Mortality Rate ...... 7, 16 Inflation ...... 41 Fee for service ...... 40, 42 Infrastructure ...... 6, 21, 57 Female-headed households ...... 20 Initiative for Sub-District Support ...... 134, 142 Fertility ...... 4 Injuries ...... 1212, 213 Fertility rate ...... 4 Integrated Management of Childhood Fetal Alcohol Syndrome ...... 13, 143 Illnesses ...... 143 Financial Administration Standards ...... 47 Integrated Nutrition Programme ...... 207 Financial and Fiscal Commission ...... 83 Interim National Medical and Dental Firearms ...... 13 Council ...... 30, 39, 91 Flouridation ...... 167167, 165 Interim Nursing Council South Africa ...... 91 Foreign Doctors ...... 64 Interim Pharmacy Council ...... 30 Fortification...... 208 Intestinal parasitic infections ...... 10 Foundation for Research Development ...... 117 Iodine deficiency ...... 10 Free State Hospital Bill ...... 34 Iron overload ...... 209
Generic Substitution ...... 32, 43, 100 Khulumani Group ...... 158 Gluckman Commission Report ...... 54 Goitre ...... 10 Labour Relations Act ...... 43, 149 Gonorrhoea ...... 10, 203 Legislation ...... 29, 43, 87, 149, 159, 176 Green Paper for restructuring local Life expectancy at birth ...... 16 government ...... 56 Lifeskills Programme ...... 190 Growth, Employment and Redistribution Local authorities...... 53 Programme ...... 2525, 24, 129 Local government ...... 49 Local Government Transition Act (1993) . . . . 56, 57 Handicap ...... 181 Lund Commission on Child and Family Health Act 63 of 1977 ...... 54 Support ...... 140 Health care expenditure ...... 37 Health, Developmental Social Welfare and Malaria ...... 10, 143 Hospital Governance Institutions Act ...... 34 Malnutrition ...... 1010, 9, 143 Health Goals, Objectives and Indicators ...... 106 Managed Care ...... 3939, 42, 66, 101 Health Information Systems Pilot Project ...... 110 Mandrax ...... 218 Health Insurance ...... 39 Marijuana ...... 218 HealthLink ...... 116 Masakhane campaign ...... 57 Health Professions Council ...... 31, 93 Maternity leave ...... 149 Health Rights Campaign...... 40 Measles ...... 143 Health Systems Research ...... 115 Media ...... 137, 149 HIV/AIDS ...... 187187, 10 Medicines Control Council...... 32, 99 HIV infection ...... 197, 203 Medicines and Related Substances Hookworm ...... 10 Control Act ...... 99 Homicide ...... 13, 216 Medical, Dental and Supplementary Health Hospital Establishment Review ...... 72 Service Professions Amendment Hospital insurance ...... 87, 88 Bill ...... 29, 30, 31, 93 Hospital Strategy Project ...... 48, 61, 63, 85, 131 Medical Research Council ...... 116, 117
Index 249 Medical savings accounts ...... 39 Norms and standards ...... 87, 146 Medical schemes ...... 38, 41, 42, 82, 87 Nurses ...... 94 Medical Schemes Act ...... 4343, 81 Nursing Amendment Act ...... 29, 30, 91, 131 Medical Specialists ...... 94 Nursing EducationEducation...... 93 Medicines and Related Substances Control Nutrition ...... 207 Amendment Bill...... 29, 30, 100, 159 Medium Term Expenditure Occupational Diseases in Mines and Framework ...... 8686, 61, 65 Works Act ...... 175 Mental health ...... 13, 153 Occupational health ...... 171 Mental Health Act ...... 159 October Household Survey ...... 12, 81, 84 Metropolitan local councils ...... 57 Oliver Tambo Fellowship Programme ...... 96 Migration ...... 5 Oral Health ...... 1414, 165 Mine Health and Safety Act ...... 175175, 172, Oral hygienist...... 168 Multidrug resistance ...... 200 Out of pocket payments ...... 39 Municipal health services ...... 56 Murder ...... 5, 22 Parallel importation ...... 32, 43, 100 Parasite infestation ...... 145 Narcotic drugs ...... 13 Parliamentary Portfolio Committee on Health . . 100 National Affordability Guidelines...... 62 Partner notification ...... 205 National AIDS Convention of South Africa . . . . 188 People With AIDS ...... 192 National Assembly Portfolio Committee Perinatal Education Programme ...... 146 on Health ...... 29, 32, 33, 130 Perinatal Problem Identification Programme . . . . 141 National Audit of Health Human Resources . . . . 94 Periodontal disease ...... 165 National Cancer Registry ...... 11 Pharmaceutical industry ...... 40 National Centre for Occupational Health ...... 175 Pharmaceuticals ...... 40 National Commission on Higher Pharmaceutical Manufacturers Association . . . . 100 Education ...... 92, 169 Pharmacists ...... 94 National Consultative Health Forum ...... 130 Pharmacy Amendment Bill...... 29, 30, 32, 100 National Council of Provinces ...... 29, 33 Pharmacy Council ...... 32, 100 National Development Agency ...... 130 PHC / INFO Project ...... 110 National Drug Policy ...... 30, 31, 32 PHC nurse ...... 95, 159 National Education Health and Allied Planned Parenthood Association ...... 146, 150 Worker’s Union ...... 30 Pneumoconiosis ...... 13, 176 National Health Act...... 33 Pneumonia...... 143 National Health Care / Management Population ...... 1 Information System ...... 105, 107 Population density...... 16 National Health Information System ...... 15, 105 Population growth rate ...... 1, 16 National Health Facilities Audit ...... 119119, 61 Population Policy ...... 1 National Health Plan ...... 54 Potential years of life ...... 8 National Health Services (Gluckman) PovertyPoverty...... 2020, 17, 181 Commission ...... 54 Presidential Lead Projects ...... 24 National Health Services Facilities Plan...... 54 Pricing Committee ...... 100 National Human Resources Audit ...... 168 Primary School Nutrition National Nutrition and Social Development Programme ...... 134, 208, 211 Programme ...... 208 Private hospital ...... 40 National Programme of Action for Children . . . . 144 Private sector ...... 37 National Progressive Primary Health Care Protein-Energy Malnutrition ...... 208 Network ...... 130 Psychiatrists ...... 159 National Qualifications Framework . . 100, 102, 184 Psychiatric disorder ...... 13 National School of Public Health ...... 96 Psychiatric nurses...... 159 National Youth Commission ...... 151 Public Administration Standards ...... 47 Neonatal tetanus ...... 141 Public Health Act of 1919 ...... 53 Non-governmental Public Service Commission ...... 47 organisations . . . . . 25, 130, 182, 191, 195, 205
250 Rape ...... 5, 22, 216 Transitional National Development Trust . . . 26, 130 Reconstruction and Development Transvaal School of Public Health ...... 96 Programme ...... 24, 129, 140 Truth and Reconciliation Commission . . . . 140, 158 Rehabilitation ...... 182 Tuberculosis ...... 10, 13, 176, 197, 200 Regional Health Management Tuberculosis Register ...... 198, 200 Information System ...... 105 Tuberculosis Review ...... 200 Regulatory framework ...... 47 Regulatory policy...... 44 Unemployment ...... 18 Report of the National Commission on Higher Education ...... 91 Vaginal infections ...... 203 Reproductive Health ...... 149 Valley Trust Nutrition Education Programme . . . .208 Risk rating ...... 4141, 44 Vertical integration ...... 41 Risk selection ...... 81 Violence ...... 13, 22, 213, 215 Robbery ...... 23, 216 Vital registrationregistration...... 109109, 6, 215 Roundworm ...... 10 Vitamin A ...... 208, 209 Vocational training ...... 9393, 31, 63, 64, 130, 168 Science and Technology White Paper...... 117 Voluntary Severance Package . . . . 48, 66, 79, 95, 97 Sentinel surveillance system...... 10, 13, 205 Sexuality ...... 146 Wages ...... 19 Sexuality education ...... 191 Water ...... 22 Sexually transmitted diseases . . . . 10, 189, 191, 203 Well Child Initiative ...... 144 Shigella dysentery ...... 141 Western Cape Committee on Public Smoking ...... 12 Health Education ...... 96 Social Health Insurance ...... 8888, 65 White Paper on the Transformation of the Health Social pensions ...... 19 System in South Africa 33, 42, 45, 91, 139, 153, 166, Social workers ...... 159 173, 179, 184 South Africa Act (1910) ...... 53 White Paper on Higher Education ...... 91, 92, 97 South African Drug Action Programme ...... 102 Whipworm ...... 10 South African Journal of Public Health ...... 117 South African Managed Care Coalition ...... 101 Year 2000 Goals: Objectives and South African Medical and Dental Council ...... 31 Indicators for South Africa ...... 220 South African Nursing Council ...... 30 Youth Health ...... 150 South African Qualifications Authority ...... 93 “Soul City” ...... 149 STD/AIDS Review ...... 196 Standard Conditions of Employment Act ...... 43 Standard Treatment Guidelines ...... 101 Substance AbuseAbuse...... 1313, 159 Suicide ...... 215 Supplementary Health Professionals ...... 94 Supra-regional services ...... 85 Syndromic management of STDs ...... 204 Syphilis ...... 10, 203
Teenage birth rate ...... 16 Theft ...... 23 Third party payment ...... 42 Traffic injury ...... 12, 217 Trauma ...... 213 Tobacco ...... 11, 150 Tooth decay ...... 165 Total Fertility Rate ...... 16 Traffic injuries ...... 213
Index 251