Achieving the Health Related Millenium Development Goals (MDGs): Progress & Challenges

Towards achieving the Millenium Development Goals

CONTENTS

1. Introduction
2. Background
3. The Socio-Economic Context
4. The Demographic and Epidemiological Profile

4.1. Some Mortality Trends
4.2. Underlying Causes of Death

5. Health Related MDGs: Achievements

5.1. Goal 1: Eradicate Extreme Poverty and Hunger
5.1.1. Strengthening Nutrition
5.2. Goal 4: Reduce Child Mortality
5.2.1. Immunisation Coverage
5.2.2. Decreasing Infant and Child Mortality
5.2.3. Health Interventions to reduce Child Mortality
5.3. Goal 5: Improve Maternal Health
5.3.1. Health Interventions to reduce Maternal Mortality
5.4. Goal 6: Combat HIV and AIDS, Malaria and Other diseases
5.4.1. Combating HIV and AIDS.
5.5. Combating Malaria and other major diseases
5.6. Goal 8: Develop a Global Partnership for Development

6. Health Related MDGs: Continuing Challenges

6.1. Decreasing Infant and Child Mortality
6.2. Tuberculosis

7. Non-Communicable Diseases

7.1. Interventions to address Non-Communicable Diseases
7.2. Vision 2020 Prevention of Blindness Programme

8. Key Interventions implemented by the Health Sector to accelerate progress towards MDGs

8.1. Development of Service Transformation Plans (STPs)
8.2. Strengthening Human Resource
8.3. Improving Quality of Care
8.4. Strengthening of Provision of infrastructure
8.5. Strengthening priority health programmes

9. Determinants of health that lie outside the Health Sector

10. Conclusions

MINISTER'S FOREWORD

July 2007 marks the midpoint of the timeframe that the United Nations set itself to accomplish the Millennium Development Goals (MDGs). South Africa is a amongst the nations of the world that signed the Millennium Declaration in 2000. This signals the commitment of President Mbeki and the government of this country to devote its resources to eliminating poverty and dealing with the burden of disease that afflicts our people.

Health makes development possible and in turn development contributes to health. This dialectical relationship informs the policies of this government and those of the Department of Health. The creation of the cluster system of government at national and provincial levels as well as the adoption of the integrated development planning process at local government level are concrete mechanisms adopted by government to ensure intersectoral planning and implementation. However, it is well known throughout the world even after the adoption of the Alma Ata Declaration on Primary Health Care, that intersectoral collaboration and community participation are vital but not always easy to practice for a number of reasons.

Given that we are at the midpoint of the MDG period, the Department decided to use this year's National Consultative Health Forum to focus attention on achievements and continuing challenges that we face in attaining the MDGs. This publication reflects a review of these achievements and challenges so that it can provide a common platform for discussion with our partners.

I hope that the meeting of the National Consultative Health Forum scheduled for 19-20 July 2007 will indeed provide an opportunity for the Department of Health, together with other Departments of the Social Cluster as well as our partners in civil society to rigorously review our achievements and continuing challenges with the view of developing concrete proposals on what each partner can do to enable us to achieve the MDGs.

In conclusion, may I wish the Forum well and hope that its deliberations will be productive and innovative.

1. INTRODUCTION

7 July 2007 is the midpoint of the period set by the United Nations for the achievement of the Millennium Development Goals (MDGs) to which South Africa amongst most other members of the UN have signed onto. This report presents progress made by the South African health sector towards the attainment of the health related Millennium Development Goals (MDGs) as well as the current challenges. It is critical that government and its key stakeholders collectively reflect on progress and barriers to the attainment of the MDGs so that together they may focus on what else needs to be done by all partners to realise the attainment of these important goals.

2. BACKGROUND

When the MDGs were adopted by the United Nations in 2000, South Africa was one of the signatories, pledging to work towards the attainment of these goals by 2015. There are eight Millennium Development Goals, 18 targets, and 39 indicators. While there is some agreement that the health related MDGs are incomplete as they focus only on the communicable diseases and not also on non-communicable diseases and injuries and trauma, and that the baseline and targets are arbitrary, there is merit in focusing on them as MDGs, since when all are taken into account, they do relate to issues of development.

South Africa's MDG Country Report submitted in 2005, declared that the country was "well on course to meet all MDG goals and targets" (pg. 3). Two years later, during the midpoint of the agreed upon timeframe, it is imperative to take stock of progress, examine available evidence to assess if the country is still on track, as per its earlier assertion and take corrective action as necessary. Given the link between health and development it is important to also consider what kind of development is necessary to produce good health outcomes. South Africa has adopted the developmental model and seeks to create a developmental state. It is important therefore for the health sector to explore that type of developmental state to achieve the eight health related MDGs.

The health related MDGs are: (i) Eradicate extreme poverty and hunger (ii) achieve universal primary education (iii) promote gender equality and empower women (iv) reduce child mortality (v) improve maternal health (vi) combat HIV and AIDS, malaria and other diseases (vii) ensure environmental sustainability (viii) and develop a global partnership for development.

3. THE SOCIO-ECONOMIC CONTEXT

It is well known that development is related to health outcomes and that poverty and its consequences are related to ill-health. One of the outcomes of this realisation is the establishment of the Social Determinants of Health Commission by the World Health Organisation. Off course, many theorists have made this assertion, notably Virchow, who is known as the father of cellular pathology, who argued in 1848 that poor social conditions resulted in poor health status. Since Virchow, many theorists, including Engels, Allende and Navarro, amongst others, have all pointed to the importance of social conditions to health outcomes. More recently the importance of healthy public policy as articulated by the Lalonde Report in Canada and which resulted in the health promotion movement of the late 1980s, also recognised the importance of social determinants of health. In 2000, the MDGs gave new impetus to this recognition, by emphasising the importance of development to health (and conversely, of health to development).

4. THE DEMOGRAPHIC AND EPIDEMIOLOGICAL CONTEXT

South Africa is undergoing demographic and epidemiological changes. The population increased from 36 million in 1996 to 47.5 million in 2007.

The country is also facing a triple burden of diseases associated with the epidemiological transition namely, communicable diseases associated with poverty (e.g. TB, malaria, sexually transmitted infections including HIV and AIDS); non-communicable diseases associated with lifestyles, and trauma and violence.

4.1. Some Mortality Trends

The overall number of registered deaths increased consistently from 316 507 in 1997 to 591 213 in 2005. The increase from one year to another may be due to the improvement in death registration and population growth.

TABLE 2: DISTRIBUTION OF REGISTERED DEATHS BY YEAR OF DEATH, 1997-2005

Source: Statistical Release P0309.3, Statistics South Africa, 2007

5. HEALTH RELATED MDGS: ACHIEVEMENTS

5.1. GOAL 1: ERADICATE EXTREME POVERTY AND HUNGER

The first health related MDG is Goal 1, eradication of extreme poverty and hunger, which has as its key target, to halve between 1990 and 2015, the proportion of people who suffer from hunger.

5.1.1.   Strengthening nutrition

The Development Indicators Mid-term Review released by the Presidency in June 2007 presents very positive figures with regard to nutrition. According to this report, severe malnutrition amongst children under-5 years of age decreased from 88 971 cases in 2001 to 30 082 in 2005. See Table 3

TABLE 3: SEVERE MALNUTRITON UNDER 5 YEARS

Source: Development Indicators Mid-term Review, The Presidency, June 2007

The health sector has over the years made a significant contribution to the decline in malnutrition amongst children under-5. Health sector interventions have included the provision of Vitamin A supplementation to children and mothers, which exceeded set targets. By the end of March 2007, 96.4% of children aged 6-11 months (who were seen at health facilities) had received these supplements, which exceeded the 2006/07 target of 90%. Furthermore, 53.7% of post-partum mothers were also provided with the supplements, which reflected progress towards the set target of 75% for 2006/07. While 24.3% of infants aged 12-59 months also received Vitamin A supplementation, this was lower than the target of 40%. It is clear therefore that additional effort needs to be made to increase vitamin A coverage for infants aged 12-59 months in particular. .

South Africa has also made great strides towards food fortification. On 7 October 2003, the regulations for the mandatory fortification of all maize meal and white and brown bread flour, with six vitamins and two minerals, (i.e. vitamin A, thiamin, riboflavin, niacin, pyridoxine, folic acid, iron and zinc) came into effect. The fortification programme was implemented in response to the findings of the 1999 National Food Consumption Survey which showed that one out of two children aged 1-9 years did not meet half their daily requirement for several nutrients".

Ensuring compliance monitoring of the fortification regulations is the responsibility of the Environmental Health Practitioners (EHPs), employed by Local Authorities. During 2005/06, the public health sector developed a monitoring system for tracking the impact of the food fortification programme, with financial support from the Global Alliance for Improving Nutrition (GAIN), UNICEF and the Micronutrient Initiative. By December 2005, a total of 1 590 of the targeted 1600 EHPs (99.4%) had undergone training in the monitoring of this programme. Sixty-nine dietitians and nutritionists had also been trained.

In order to assist millers to comply with the fortification regulations, the Department of Trade and Industry has agreed to support millers with the purchasing and installation of fortification equipment according to the size of the mill. This assistance to millers will become available in the second half of 2007.

Other interventions included the provision of food parcels and the establishment of food gardens at health facilities, schools and communities. It is acknowledged that whilst the provision of micro and macro nutrition supplementation was important, it was more important to ensure food security for poor households in particular.

5.2. GOAL 4: REDUCE CHILD MORTALITY

The second health related MDG is Goal 4, which is to reduce by two-thirds (66%), between 1990 and 2015, the under-5 mortality rate. There are several factors that contribute to the attainment of this goal, including good immunisation coverage, access to water and sanitation as well as good nutrition and maternal education.

5.2.1. Immunisation Coverage

South Africa's MDG Report in 2005 reflected an overall immunisation coverage of 78%, based on 2002 estimates. Routine data subsequently indicated that the national immunisation coverage had increased to 83% as at the end of 2006. Notwithstanding this achievement, there are still districts and sub-districts with low immunisation coverage, which require focused intervention. These have been identified, and the public health sector has begun implementing the WHO strategy known as Reach Every District (RED), aimed at improving coverage and protecting South Africa's children against vaccine preventable diseases.

For children of school going age, school health services were also expanded. By the end of March 2007, 94% of health districts were implementing Phase One of school health services, which entails screening and assessment for basic health conditions, and referral to the health services where this is required.

The contributions made by the provision of free basic services, including primary health care services, water, electricity, and sanitation, will also have contributed to the improvement in health of infants and children.

According to the Development Indicators Mid-term Review released by the Presidency in June 2007, since 1994, the percentage of households with access to water at equal or above the Reconstruction and Development Programme (RDP) standard, increased from 61.7% to 84.7%. This rate of delivery had been achieved in the face of a 26% increase in household numbers. With regard to the provision of housing, the Mid-term Review indicated that between 1994 and March 2006, a total of 2.3 million houses were built by the government. In terms of electricity supply, the Development Indicators Mid-term Review reflected that a total of 3.5 million households were electrified since 1994.

Progress was also made towards addressing the sanitation backlog. According to the Development Indicators Mid-term Review, households with access to basic sanitation increased from 50% in 1994, to 71% in 2006. It was also stated that progress was being towards eliminating the bucket system in established settlements by the end of June 2007.

However, the Review also indicated that in April 2006, the backlog of access to sanitation infrastructure was more than 3.7 million households, and stated that the delivery rate will have to be accelerated, in order to achieve the set targets.

In addition, further strengthening the Prevention of Mother-to-Child transmission of HIV also contributed to improved child health.

It is important for the health sector to identify those districts with high infant and child mortality and to focus on strengthen health and related services to decrease mortality in these districts. The importance of intersectoral collaboration and community participation in this regard cannot be overstated.

The expansion of the Comprehensive plan for HIV and AIDs as well as early diagnosis and completion of TB treatment will also contribute to a decline in maternal mortality.

5.4. GOAL 6: COMBAT HIV AND AIDS, MALARIA AND OTHER DISEASES

The fourth health related MDG is Goal 6, which is to combat HIV and AIDS, malaria and other diseases. The first target related to this goal is to have halted by 2015, and begun to reverse the spread of AIDS by 2015. The second target is to have halted by 2015, and begun to reverse the incidence of malaria and other major diseases.

5.4.1. Combating HIV and AIDS

As reflected in Table 5 below, the 2006 antenatal survey results show a statistically significant decrease in the prevalence of HIV amongst pregnant women who use public health facilities. It is for the first time after several years of relative stability, that the survey results show evidence of a decline in HIV prevalence.

TABLE 5: PROVINCIAL HIV PREVALENCE ESTIMATES:SOUTH AFRICA 2005-2006

Source: Summary Report: National HIV and Syphilis Prevalence Survey, South Africa, 2006

Furthermore, as shown in Table 6, HIV prevalence in the age group less than 20-years old, decreased from 15.9% in 2005 to 13.7% in 2006. This reduction implies a reduction in new infections (incidence) in the population.

As reflected in Table 6, HIV prevalence in the 20-24year age group also decreased from 30.6% in 2005 to 28.0 in 2006. This is a significant decline.

TABLE 6: PROVINCIAL HIV PREVALENCE ESTIMATES:SOUTH AFRICA 2005-2006

Source:  Summary Report: National HIV and Syphilis Prevalence Survey, South Africa, 2006

However, HIV prevalence in the older age groups (30-34 years; 35-39 years; 40+) remained at levels similar to 2005, and in some instances reflected some increases, although these were not statistically significant.

In order to strengthen its efforts to combat HIV and AIDS, South Africa produced the Comprehensive Plan for HIV and AIDS, as well as the intersectoral Strategic Plan for HIV and AIDS for 2007-2011, which builds on the gains of the Strategic Plan for 2000-2005. The Strategic Plan serves as a framework for South Africa's response to the major challenge of HIV and AIDS.

At present 90% of health facilities provide VCT and PMTCT . Furthermore, by April 2007, a cumulative total of 282 200 patients had been put on antiretroviral treatment, in 316 sites of the Comprehensive Programme for HIV and AIDS Management, Care and Treatment (CCMT) across the nine provinces. Additional sites are found in correctional services facilities as well as in the private for profit and not for profit health sectors.

Nutrition packages are also distributed to people living with HIV and AIDS, TB and other debilitating conditions. The proportion of eligible people living with these conditions who received nutrition supplements increased from 56% in 2005/06 to 81.8% in 206/07.

The treatment of opportunistic infections has also been strengthened. By March 2007, a national STI partner notification rate of 98.3% had been achieved. However, the National STI partner tracing rate was much lower, at 23.3%. This is being continuously addressed.

Life skills programmes were also provided to the youth at various health facilities. By March 2007, 41% of PHC facilities were implementing Youth Friendly Services and 15% of these had been accredited as Youth Friendly Services.

5.4.2. Combating Malaria and other major diseases

The management and control of malaria is one of the key areas of success of the public health sector in South Africa.

As shown in Table 7, the number of malaria cases declined over a five year period, from 51 444 cases in 1999 to 12 098 cases in 2006. As shown in Table 8, the malaria case fatality rate fluctuated during this period, from a peak of 0.8 in 1999, to a lowest level of 0.4 in 2001, and to 0.7 at the end of 2006.

TABLE 7: MALARIA CASES IN SOUTH AFRICA 1999-2006

Source; Communicable Disease Control Directorate, National Department of Health, March 2007

TABLE 8: MALARIA CASE FATALITY RATES  IN SOUTH AFRICA 1999-2006

Source; Communicable Disease Control Directorate, National Department of Health, March 2007

Factors behind the successes in malaria control include: (i) An increase in indoor residual spraying using DOT, with an overall coverage of more than 80%, and the completion of spraying before the peak in malaria transmission; (ii) The use of artenumisin-based combination therapy by the malaria affected provinces, which reduces parasite carriage; (iii) Intensified surveillance leading to early detection of any increases in malaria cases in high risk areas; (iv) epidemic preparedness teams capacitated to respond to seasonal outbreaks; (v) Advocacy with mass community mobilisation and training of healthcare workers in the malaria affected areas; (vi) Collaboration amongst African countries in improving the effectiveness of malaria control programme since malaria vectors (mosquitoes) have no regard for national borders.

South Africa has worked with three neighbouring states, Mozambique, Swaziland and Zimbabwe, in two separate cross-border malaria control initiatives. The cross border collaboration between Limpopo Province in South Africa and the Matabeleland South Province in Zimbabwe is ongoing and the two countries are currently finalising the malaria elimination strategic plan. Also, the Lubombo Spatial Development Initiative on malaria control involving SA, Swaziland and Mozambique has contributed significantly to the decline in malaria cases in all three countries.

5.5. GOAL 8: DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT

The fifth health related MDG is Goal 5, which is to develop a global partnership for development. The target for this goal is: in cooperation with pharmaceutical companies, provide access to affordable drugs in developing countries.

Over the last few years, South Africa has made concerted efforts to ensure access to safe and affordable drugs, dispensed by appropriately trained personnel.

During 2005/06, the public health sector reduced the stock outs of medicines in both the Essential Drug List (EDL) , as well as anti-retrovirals at accredited Comprehensive HIV and AIDS Management and Treatment Plan sites, to almost zero level.  Most of pharmacies and dispensers that applied for licenses during 2005/06 and met all requirements, were licensed.

A revised dispensing fee was published for public comment on  10 March 2006. During 2006/07, the pricing regulations were also reviewed and published for public comment. However, the pharmaceutical companies instituted litigation against the public health sector on this matter.

The public health sector also gazetted a draft International Benchmarking Methodology in December 2006, which compared medicine pricing policies and practices in five countries namely: South Africa, Canada, Spain, New Zealand and Australia. The methodology provided for South African prices to be compared and benchmarked against prices of medicines in these countries, to ensure that local people do not pay more for their medicines compared to the citizens in these countries.

The other four countries were chosen on the basis of three criteria namely: existence of sound policies on the pricing of medicines; membership of OECD countries; and existence of recognised and reputable medicines registration authorities.

The public health sector has also strengthened its collaboration with the traditional health sector. With regard to the development of pharmacopoeia, (i.e. standards for individual entities of African traditional medicines), the Medical Research Council (MRC) is in the process of producing 60 monographs on medicinal plants for inclusion in the pharmacopoeia. A database of African Traditional Medicines is also being developed.

6.  HEALTH RELATED MDGs: CONTINUING  CHALLENGES 6.1. Decreasing Infant and Child Mortality

There is no consensus amongst the scientific community about the exact figures for under-5 mortality. The Development Indicators Mid-term Review released by the Presidency in June 2007, cites figures from the Medical Research Council (MRC), which estimated the Under-5 mortality to be 104/1000 live births in 2003. Figures from the Health Systems Trust (HST) for the same period reflected Under-5 mortality for 2003 as being 49.3/1000. However, the fact that two reputable research institutions presented under-5 mortality figures with a 100% difference is a cause for concern. The Department's own SADHS (2003) put under-5 mortality at 58/100 live births as noted in the section above.

With regard to infant mortality, as already stated, the SADHS 2003 indicated a decrease in the Infant Mortality Rate (IMR) from 45/1000 live births in 1998, to 43/1000 live births in 2003. While this is positive, it is another area of contention amongst the scientific community. The Presidency's Development Indicators Mid­term Review quotes at least five reliable sources of data, which yield the inconsistent and contradictory IMR figures reflected in table 9.

For planning and implementing appropriate interventions, the health sector uses figures from the SADHS 1998 and 2003. It is clear however, that consensus is needed around a more reliable set of figures.

However, whatever the true figure, additional efforts are needed to further reduce infant and under-5 mortality. These include health sector initiatives as well as the contributions of other sectors as noted above.

TABLE 9: INFANT AND CHILD MORTALITY RATES FROM DIFFERENT SOURCES

Source:  Development Indicators Mid-term Review,   the Presidency,   June 2007

6.2. Tuberculosis

In keeping with the World Heath Organisation (WHO) AFRO resolution of 2005, South Africa has implemented a national tuberculosis (TB) crisis management plan in 2006, in three provinces namely, Eastern Cape, Gauteng and KwaZulu-Natal. Four of the worst performing districts in these provinces were identified namely, Amathole District and Nelson Mandela Metro (Eastern Cape), City of Johannesburg (Gauteng) and Ethekwini Metro (KwaZulu-Natal). They were provided with systematic and targeted support in accordance with their locally developed plans. The aim of the interventions was in the short term, to increase the number of TB patients testing negative for TB within three months of treatment, and to increase the cure rates in the medium term.

The advent of extreme -drug resistant TB in 2006 posed yet another challenge. During the planning cycle 2007/08-2009/10, areas of focus will include improving smear conversion rates in the four worst performing districts, strengthening of laboratory services, revision of the MDR TB Treatment Guidelines, training of health care providers and a range of activities designed to better understand and treat extremely drug resistant TB. However, it is acknowledged that to decrease both MDR and XDR-TB, that the national TB Control Programme must be strengthened. The South African health sector has also made a P4 laboratory available for SADC Countries.

7. NON-COMMUNICABLE DISEASES (NCDs)

The incidence of non-communicable diseases has significantly increased in developing countries, including South Africa, thus contributing to the burden of disease. These diseases include various types of cancer, diabetes and hypertension.

Self reported data from the SADHS 1998 indicated that 2.4% of men and 3.7% of women (15 years+) reported they had diabetes (type unspecified). StatSA has also reported an increase in deaths due to diabetes in the three year period 2002-2004.

The mortality figures increased from 15 705 deaths in 2002 to 16 718 deaths in 2003, and to 16 902 deaths in 2004.

A study on amputations conducted at Groote Schuur and draining hospitals reflected an increasing number of amputations between 1997 and 1999. The number of amputations conducted increased from 179 in 1997; to 211 in 1998; and to 238 in 1999. Of these amputations, approximately 40% were above knee; about 35% were below knee and approximately 25% were big toe and toectomy (other toes).

A systematic assessment of the contribution of non-communicable diseases to the national burden of disease study will be conducted in the next planning cycle.

7.1. Interventions to address Non-Communicable Diseases

The public health sector has spearheaded a number of Healthy Lifestyle activities to reduce the burden of disease from non-communicable diseases during 2005/06 and 2006/07 and these will continue to expand into the future. During 2005/06, more than 120 000 community members participated in a range of healthy lifestyles activities, including physical activity; health screening, establishment of food gardens and programmes to reduce risky behaviour such as smoking, alcohol and drug abuse. The cataract surgery project was also strengthened by the arrival of Tunisian doctors, who were allocated to the Eastern Cape Province, and performed 187 cataract surgery operations within a short period of their arrival.

7.2. Vision 2020 Prevention of Blindness Programme

Within the Vision 2020 Prevention of Blindness Programme, the health sector previously focused on cataract surgery but the programme has been expanded to include refractive services, with a further expansion to make low vision services available in one district per province by March 2008. Significant progress was made with sight restoration, with a total of 1 030 cataract surgeries per million people performed during 2005/06, which exceeded the target of set by the Department.  During 2006/07, a cataract surgery rate of 1 146 per million people was achieved.

8. KEY INTERVENTIONS IMPLEMENTED BY THE HEALTH SECTOR TO ACCELERATE PROGRESS TOWARDS MDGs

Key health sector interventions have been interwoven with the foregoing discussion, outlining how the health sector has tackled the challenges it has faced during 2000-2007.

The achievements for this period have also been reflected, which include: improved immunisation coverage; training of health workers in IMCI and orientation of families and community members to the IMCI strategy; implementation of a comprehensive response to the challenge of HIV and AIDS, increasing the proportion of public health facilities offering VCT and PMTCT services; expansion of the Comprehensive Plan for HIV and AIDS Programme; provision of nutrition supplements to infants and post-partum mothers, and people living with debilitating conditions; reduction of malaria incidence and deaths in the three malaria-endemic provinces (KwaZulu-Natal, Limpopo and Mpumalanga) as well as strengthening malaria control in the Maputo and Lubombo corridors, amongst others.

Looking ahead, the National Health Council (NHC) has adopted a set of five priorities for implementation during the period 2007/08 and 2008/09, with a view to accelerate progress towards attainment of the health-related MDGs and other priority health programmes. These priorities are: development of provincial service transformation plans; (ii) strengthening human resources for health; (iii) improving quality of care; (iv) strengthening the provision of infrastructure for both clinics and hospitals; and (v) strengthening priority health programmes, with specific focus on healthy lifestyles, national TB crisis management plan, accelerated HIV prevention, and strengthening Maternal Child and Women's Health programmes with a special focus on the Expanded Programme on Immunisation (EPI) and implementing the recommendations of the Report on the Confidential Enquiry into Maternal Deaths.

8.1. Development of Service Transformation Plans

With the assistance of the National Department of Health, provinces have developed

Service Transformation Plans (STPs) that are intended to assist them to re-shape and re-size their health services, and to develop appropriate, adequately resourced and sustainable health service delivery platforms which are responsive to current health challenges facing each province and the country. The STPs have been costed to determine the extent to which new resources are required to meet service gaps.

8.2. Strengthening Human Resources

The provision of sufficient numbers of adequately skilled, well-motivated, and

appropriately remunerated human resources for health, is critical for the attainment of the health-related MDGs.

Against this background, The National Human Resources for Health (HRH) Strategic Framework was launched on 6 April 2006, which was designated as International Day for Human Resources for Health by the World Health Organisation. The National Department of Healh has guided the development of Provincial HRH Plans, and 4 provinces have produced draft Plans. Moving into the next planning cycle, the National Department of Healh will support the remaining 5 provinces, and the 52 health districts to develop their HRH Plans.

Over the last few years, the health sector has also implemented a variety of recruitment and retention strategies, including rural and scare skills allowances.

During 2006, the new Nursing Act was passed which provides, inter alia for community service for nursing graduates. This will commence in July 2007. With regard to the review of remuneration of health professionals, a task team set up between the National Department of Healh, Treasury and DPSA to address the issue of conditions of service for health professionals completed its work during 2006/07.  It is envisaged that revised remuneration packages will be awarded to health professionals in the public sector, in a phased manner as from the 2007/08 final year commencing with nurses.

8.3. Improving Quality of Care

A number of measures have been implemented to strengthen Quality of Care

(QoC). To entrench health as a human right, the public health sector launched the Patients' Rights Charter on the in November 1997, to inform users of health services of their rights to health, as well as their responsibilities. Extensive training of health workers on the Charter was conducted across health facilities, and non-governmental organisations commissioned to inform patients on these right.

At PHC level, clinic supervisors, based at health district level were required to conducted regular clinic visits, with each clinic visited at least once a month, and a report compiled on the findings of the visit.

During 2005/06, a national hospital improvement plan was launched and the National Infection Control Policy was finalised. Fourty percent of hospitals conducted morbidity and mortality meetings during 2005/06. In 2006/07, public hospitals continued to conduct clinical audits as required. During 2007/08, clinical audits will be routinely monitored in all hospitals, especially regional and tertiary hospitals. The management of complaints in hospitals will also be strengthened with the view to reduce the time it takes to satisfactorily address complaints. In addition, all public hospitals will be assisted to conduct and publish annual patient satisfaction surveys.

8.4. Strengthening the provision of infrastructureHospital Infrastructure

In accelerating progress towards MDGs, Primary Health Care (PHC) services must

be supported by a network of state of the art hospitals, providing good quality services. South Africa has a hospital revitalisation programme, which consist of 4 components:  improving infrastructure and health technology (equipment); improving quality of care; improving management and organisational development; as well as strengthening project management, within the each of specific target hospitals.

Since the inception of the programme, the following 8 hospitals were revitalized:

• Madikana KaZulu Hospital (former Mary Theresa) in the Eastern Cape;
• Jane Furse and Lebowakgomo in Limpopo Province;
• Colesburg and Calvinia in the Northern Cape;
• Piet Retief in Mpumalanga
• Swartruggens in the North West
• George Hospital in the Western Cape.

A total of 43 hospital projects were active during 2006/07. The National DoH will accept an additional 20 business cases from the provinces. However these will only be activated subject to the availability of funding from the National Treasury. In 2007/8 there will be 39 active projects. This is because the rest had to be temporarily stopped due to the unavailability of funds. Some of these were at the stage of completing earthworks this current financial year.

Primary Health Care (PHC) Services

Well functioning PHC services are a cornerstone of the mission to accomplish the MDGs . The health sector has continued to provide PHC services through the District Health System (DHS) and has strengthened planning and monitoring of service utilisation. Access to PHC services, as measured by headcounts, increased from 67,021,961 in 1998/99 to 99,365,898 in 2004/05, and to 101,758,377 in 2005/06. Planning processes at district level were strengthened, with 90% of health districts producing District Health Plans (DHP) for 2006/07, based on DHP Guidelines developed by the National Department. Key focus areas during 2007/08 will include conducting a PHC audit of services and infrastructure to assess the extent to which the full package of PHC services is delivered and the physical condition of facilities, particularly at sub-district and facility levels.

Emergency Medical Services (EMS) Infrastructure

A key objective during the current planning and implementation period will be to reduce the response times of EMS in both urban and rural areas. The Department will assist provinces to implement the national EMS Strategic Plan. With the 2010 FIFA World Cup within sight, the health sector will over the next three years, finalise the operational plan for the Health and Medical Logistics for this international event. Working jointly with other government departments and key stakeholders, the Department will soon complete an intersectoral operational plan for the 2010 World Cup. Of key significance will be the implementation of improved Emergency Medical Services, with an adequate fleet of reliable ambulances, appropriately trained and qualified personnel, and state of the art equipment.

In relation to the MDGs, some Provinces have implemented innovations such as allowing EMS vehicles transporting pregnant women to bypass normal referral routes.  In addition, additional ambulances have been purchased and fixed and rotor arm aircraft have been used to both transport patients and health workers (as part of outreach programmes) to further strengthen the health system's responsiveness.

8.5. Strengthening priority health programmes Maternal, Child and Women's Health and Nutrition

The health sector will continue to build on the milestones already reached, and progressively strengthen interventions to reduce morbidity and mortality amongst children and mothers. This includes accelerating the training of midwives and advanced midwives. A systemic and scientific assessment of the impact of the IMCI strategy on infant and child mortality will be undertaken. Similar studies must be conducted to assess the improvement in maternal mortality rates as a result of the implementation of the 10 recommendations of the Confidential Enquiries into Maternal Deaths (CEMD) Reports.

School health services should continue to be expanded. The provision of safe termination of pregnancy services for women must be strengthened at both hospitals and community health centres.

Beyond the health sector, it is crucial that poverty alleviation programmes be expanded to reach the currently marginalized and poor. In addition, safe water and proper sanitation must be provided to those in need.

Tuberculosis

A National Strategic Plan for Tuberculosis management has been developed, and finalised. The Plan is based on an adaptation of the WHO's Stop TB Programme and include aspects that focus on prevention, early and reliable diagnosis as well as treatment.

It is imperative though, that TB is not viewed as an exclusive health sector challenge. Lessons from other countries generated across decades, reflect that the provision of housing, jobs and reduction of poverty and unemployment are central to turning the tide against TB. These are as important as adequate clinical skills, good case management, and effective monitoring of treatment outcomes amongst health workers, as well as compliance with TB treatment amongst TB patients.

HIV and AIDS

An intersectoral National Strategic Plan for HIV and AIDS was completed, which focuses on the 5-year period, 2007-2011. This process has drawn together key role players including government, business, civil society, trade unions, youth organisations, traditional leaders and healers and community leaders. The main priority areas in the Strategic Plan for HIV and AIDS are: prevention; treatment, care and support; human rights and legal issues; and monitoring and evaluation, research and development. A restructured and re-invigorated South African National AIDS Council (SANAC), chaired by the Deputy President of South Africa, will provide leadership in the implementation of the National Strategic Plan for HIV and AIDS Plan. The Ministry of Health will provide technical and administrative support to the implementation of this plan.

Implementation of the accelerated prevention of HIV will also continue, in keeping with the WHO/AFRO resolution of 2005, focusing on both intersectoral and health components. As was the case in 2006/07, the intersectoral aspects will entail: promoting development, alleviating poverty, and addressing gender inequities. The health aspects will consist of: strengthening social mobilisation, including a greater focus on youth; expanding and improving treatment of sexually transmitted infections; offering group counselling in addition to individual counselling; and increasing access to female condoms.

It is critical that the implementation of HIV and AIDS programmes not be seen as vertical or stand alone programmes but that they contribute to the further strengthening of the national health system at all levels of care, and strengthen support systems and partnerships.

9. DETERMINANTS OF HEALTH THAT LIE OUTSIDE THE HEALTH SECTOR

The reduction of IMR, under 5 MR and MMR, as well as HIV and TB rates are not solely dependent on health sector interventions, but are equally determined by factors that lie outside the health sector, such as access to education, water and sanitation amongst others.   Data from the Provincial Annual Performance Plans (APPs) for 2007/08-2009/10 reflect that, inter alia:

• 1.3 million people in the Free State (35% of the population) have no access to basic sanitation;
• 34 urban schools and 464 rural schools in the Free State (11% of schools) have no sanitation facilities;
• 22% of households in Limpopo do not have access to piped water; 23% of households in Limpopo do not have access to proper sanitation
• 8% of the population of Mpumalanga older than 20 years have no formal education.

It is therefore evident that intesectoral action is required to accelerate progress towards achievement of the health-related MDGs.

10.  CONCLUSIONS

10.1. Progress towards the health-related MDGs cannot be accelerated without strengthening the delivery of health care services to South Africans, especially women and children, the marginalised and poor.

10.2. South Africa has many plans both in the health sector and in other sectors. Health sector plans exist in sufficient types and numbers, for instance, the National Strategic Plan; Nine Provincial Annual Performance Plans; Annual National Health Plans; Government Programme of Action (PoA) for 2007/08; Presidential Priorities for 2007-2009, and District Health Plans. In addition we have programme specific plans such as the Strategic Plans for HIV and AIDS and Tuberculosis, and the CEMD Reports.

10.3. What is required is for all partners to lift out of these plans a set of key interventions which if carefully resourced, implemented and monitored, will yield measurable progress towards the health-related MDGs.

10.4. An added sense of urgency will also be required in the implementation of this key set of interventions. Regular monitoring and reporting of progress towards MDGs to oversight structures such as the NHC Technical and Policy Committees should be institutionalised. Similar structures at provincial and district levels should be charged to do the same.

10.5. Advisory structures such as the National Consultative Health Forum and the Provincial Consultative Health Forums should also assist in monitoring progress and identifying innovative ways of accelerating progress.

10.6.   Good quality and reliable data should be generated to illustrate the gaps in health service provision, and used to mobilise more resources for the health sector from the Fiscus, and other sources of funding.

10.7. Linked to this, consensus needs to be built around the figures for Infant Mortality Rate (IMR) and Under-5 mortality in South Africa. The scientific and research community needs to generate one set of reliable estimates that can be used as a baseline, and for monitoring purposes.

10.8.   With regard to intersectoral interventions to ensure that the country races towards achievement of the MDG targets, concrete proposals must be developed and presented to the Government Social Cluster and Cabinet for approval.

National Department of Health, July 2007