Chapter 3

Financial and Physical Resources

In 1992-93, South Africa spent approximately 8,5% of GDP on health services, both public and private. This represents a very high level of spending for a country at South Africa's level of development. However, the distribution of resources is highly inequitable and wasteful. A small proportion of the population benefits disproportionately from services rendered by the private sector, which are comparable to those offered in more affluent countries. At the same time, the majority of the South African population has very limited access to any form of services.

Moreover, there are considerable inequities and inefficiencies in the distribution of public health resources, spending being weighted heavily in favour of certain provinces, urban areas and curative, hospital-based care.

3.1 THE GOAL: BASIC HEALTH CARE FOR ALL SOUTH AFRICANS WITHIN 10 YEARS

South Africa has well developed, high technology hospitals in the main cities, but underdeveloped basic health services, especially in the former rural homelands. As a consequence, essential health care is deficient for the poorer two thirds of the population.

To rectify this situation, national health policy affords first priority to the development of the district health system, which comprises integrated PHC and district hospital services.

The goal is to provide for an increase in the average number of public PHC consultations per person from a low baseline of 1,8 in 1992/93 to 2,8 by the end of the century and to 3,5 over the following five years (Table 3. 1). Priority will be given to the most underserved areas and the intention is to bring the provision of PHC services for the poorer two thirds of the population up to the level of that for the better off one third by the year 2000.

Table 3.1 : Expected increase in use of public primary health care services

¹Derived from McIntyre, D. et al., Health Expenditure and Finance in South Africa, Health Systems Trust and World Bank, Durban, 1995, Tables 2.5 and 7.4.

3.2 AFFORDABILITY

The Department of Health has developed a medium term expenditure framework for the public health sector. The framework projects public health spending by level of care and in total to the year 2000. It indicates that it is broadly affordable to provide basic health care for all South Africans within a 10 year period, with two provisos. The first is that there is a redistribution of public health resources. The second proviso is that there are new sources of public health finance over and above general government revenue. The main proposed new financial sources are social health insurance and retention in the health service of fees collected by public hospitals. Despite the country's economic constraints, therefore, the Department of Health maintains the policy of providing essential health care to the whole population within 10 years, in line with RDP commitments.

3.3 NEED FOR REDISTRIBUTION OF PUBLIC HEALTH RESOURCES

Because of economic constraints, there is a need to redistribute public health resources, both geographically and by level of care.

Redistribution of health resources from better served provinces to under served provinces has been effected through the Health Function Committee system. In this system, public health finance was allocated by the government nationally and was distributed to provinces on the basis of a weighted capitation formula, which took into account the relative need of provincial populations for public health services. The sector by sector Function Committee system has now been replaced by a system of unconditional block grants to provinces and the central mechanism of health resource allocation is no longer be available. In the new system of fiscal decentralisation, provincial health allocations will be determined by the nine provincial treasuries and governments. Equitable geographical health allocations will be much more difficult to achieve in this context. As a means of defining provincial health resources, it will be important to develop provincial medium term health expenditure plans, which will form the bases for local health service developments.

Because of the unbalanced development of health services in South Africa, it is also necessary to redistribute resources from high technology hospitals to district health services. This policy is one which will require continuous defence in the political arena. The health sector differs from other sectors in that there is major disjunction between established policy and popular demand. Health policy - worldwide and nationally - prioritises prevention and PHC services, because these are the most effective, and the most cost effective, health care means to achieve better health. But everywhere spontaneous demand is mainly for curative and hospital services. Popular demand for high technology hospitals, especially when exerted by urban middle classes, tends to be translated over time into political decisions to use public funds for hospital provision - hence the relative over provision of hospitals all over the world, with South Africa as no exception. Provincial governments will come under the pressure of this urban demand for hospital treatment. It is easy to adopt a PHC policy in theory, but opposition will surface as the process of resource redistribution gets under way and begins to bite. There needs to be a mechanism for ensuring that - in each set of provincial resource decisions - public health resources are allocated in accordance with national PHC priorities and funds for District Health Services are protected from local political pressures acting in favour of high technology hospitals.

3.4 NEED FOR PROTECTION OF FUNDS FOR THE DISTRICT HEALTH SERVICES

Despite the context of economic austerity, health (and other social) services must be improved for disadvantaged populations within the next few years. The key to improving basic health care is the district health system. It was in order to achieve protection of District Health Services funding that the Financial and Fiscal Commission proposed conditional 'minimum standards' grants to provinces for health (and education). The grants earmarked funds for PHC and district hospital services. The FFC grant projections provided for both the priority allocation of resources to the district health system and the phasing in of geographical equity in access to basic health care. To work towards the goal of providing essential health care for all South Africans within 10 years, the FFC projected real growth in District Health Services spending (Table 3.2).

Table 3.2 Financial and Fiscal Commission projection of allocations to the district health system by province (1996 rand - millions)

Source: Financial and Fiscal Commission's Recommendations for the Allocation of Financial Resources to the National and Provincial Governments for the 1997198 Financial Year, May 1996, Table 6.

In the absence of conditional DHS grants from central government, as proposed by the FFC, DHS funding should be earmarked by agreement between provincial health departments and treasuries, in the context of provincial medium term expenditure plans.

The FFC projections may be used as benchmarks of DHS expenditure which would result in basic health care being provided to all South Africans within a 10 year period.

3.5 NEW SOURCES OF PUBLIC HEALTH FINANCE

3.5.1 Retention by health service of public hospital fee revenue

The ability to protect DHS voted allocations would be facilitated by securing additional finance for secondary and tertiary hospitals, making it possible to lessen the demand of the higher levels of care on the health vote. Additional finance would also facilitate improvement in the quality of care in public hospitals.

Revenue generation from user fees is currently at a low level in most public hospitals.

One of the most important reasons for this is the lack of incentive for hospital managers to collect fees, since all generated income accrues to the provincial revenue fund. Also the quality of care in public hospitals is often low and this has resulted in a shift of paying patients to private hospitals (as well as in a demand for new private hospitals, even in small towns).

The Department of Health will work towards improvement in the quality of care and amenities in public hospitals by, inter alia:

• promoting reform in hospital management, including the introduction of decentralised. management in line with government policy on public sector reform; and

In a context of decentralised management and improving care in public hospitals, revenue retention will be introduced to create an incentive for hospital managers to increase the efficiency of fee collection and to provide them with funds which can be used flexibly.

These funds will be utilised to improve the quality of hospital services and the working conditions of hospital staff. These measures should in turn attract further paying patients.

Revenue retention will be phased in over a number of years and the retained funds will be split between the collecting hospitals and provincial health departments. This will provide an incentive for hospitals to collect fees, while allowing provincial health departments to distribute some of the income to needy facilities which are unable to generate significant fee revenue. A greater proportion of the retained funds collected by higher level hospitals will be channelled to the provincial health departments, while a greater proportion of the retained funds generated by lower level hospitals will remain with the collecting facilities.

3.5.2 Social health insurance

Another important means of increasing public health finance will be the introduction of social health insurance. Currently large numbers of employed workers are not members of medical schemes and they, and their families, often attend public hospitals without paying the prescribed fees, even though they can afford to do so. Also medical scheme members and their families may attend public hospitals when their scheme cover is exhausted and again may not pay the prescribed fees. A social health insurance scheme will be introduced which will require all formally employed people to be insured for the costs of treatment of themselves and their dependants in public hospitals. Contributions will be shared between employers and employees, and will be related to income and family size.

3.6 FUNDING OF TERTIARY AND HIGHLY SPECIALISED PUBLIC HEALTH SERVICES

It is expected that, within 10 years, 'routine' tertiary health services will be provided in at least some regional hospitals in all provinces. In the meantime, provinces without such services will have to refer patients to provinces which do provide them. 'Client' provinces will pay 'provider' provinces for these services, but the level of charge in the next several years will take into account the fact that equity in provincial government funding will not yet have been achieved.

By contrast, services which are highly specialised, expensive and relatively rarely needed, would be uneconomical to locate in every province. Most of these services are currently provided in academic central hospitals. Services provided by one or a small number of units in the country will become available, through referral mechanisms, to the whole population. Although academic central hospitals are located in particular provinces, they are national resources and should, in time, treat only appropriately referred patients. Their location and development will be planned centrally in accordance with national health policy and they will be financed from a fund held by the Department of Health. Services at these hospitals are being identified and costed.

3.7 FUNDING OF ACADEMIC RELATED HEALTH SERVICE COSTS

Academic health services complexes incur extra service costs as a result of their academic functions. (The costs of teaching and research as such are met by the universities.) The additional service costs associated with teaching and research have been termed the national increment for teaching, education and research' (NITER).

The NITER grant to provinces with academic health services complexes has been a lump sum estimate based on historical expenditures. A more rational and equitable funding mechanism will now be introduced in the form of a standard allocation for each enrolled medical student. For the time being, the number of medical students will be used as a proxy for all academic activity that requires additional health service provision. More refined methods of estimating academic related service costs based on the numbers of clinical medical, dental and other students (including postgraduates) will be developed.

With a per student funding mechanism, any historically determined excessive spending patterns of particular academic complexes will no longer be rewarded.

The current unbalanced distribution of academic health training reflects the country's apartheid history and efforts are being made to distribute medical and related professional training more evenly among universities and provinces. With funding on a per student basis, 'the money will follow the students' and NITER allocations will be distributed more equitably. In addition NITER funds, managed by the Department of Health, will also be used for 'pump priming' of presently under resourced academic health services complexes in advance of an increase in clinical student numbers.

3.8 REVISED PROCEDURES FOR BUDGETING

3.8.1 Aims

Health budgeting procedures have been revised. The aims of the new approach are to:

1. Create awareness of the activities for which a health department is responsible;
2. align health department activities with the goals of the government and establish new activities where current activities do not address all such goals,
3. re-examine the rationale for, and extent of, the need for an activity;
4. determine the cost of each activity from zero;
5. prioritise all the activities of a health department on the basis of cross-cutting criteria which have been established by the Department of Health; and
6. create a database which will -
• - enhance the ability of the government to evaluate spending agencies' requests in a rational manner;
• - provide the information required for policy decisions; and
• - improve strategic financial management in the health sector.

3.8.2 Budget prioritisation

(a) Budgetary controls will promote the following:

1. Shift of expenditures towards primary health care;
2. commissioning of buildings and equipment for the delivery of PHC services;
3. management of patients at the appropriate level of care;
4. improved efficiency with regard to the use of resources;
5. (establishment of, or improved, decision support systems for health care managers at all levels;
6. reduced wastage and loss of drugs;
7. eliminating duplication of facilities and services;
8. limited inappropriate level care in academic hospitals;
9. (reduced number of tertiary care beds;
10. better use of underutilised hospitals; and
11. greater cost recovery at higher level facilities.

(b) Criteria for reprioritisation

The criteria for reprioritisation developed by the Department of Health are the following:

1. Services must be accessible to the majority of the population and focus on the most vulnerable groups, especially women and children, and the rural, peri-urban and urban poor;
2. activities should have maximum impact on the health status of the entire population (with the emphasis on women and children), based on cost-effective interventions targeting those areas with the highest infant, under-five and maternal mortality rates;
3. services should be comprehensive and provided in an integrated manner, and
4. the probability of success, acceptability and participation by communities should be taken into account.

3.9 PHYSICAL RESOURCES SHOULD BE DISTRIBUTED EQUITABLY

The Department of Health is engaged in several processes in an attempt to redress the current imbalances in the distribution and condition of health facilities and equipment in South Africa. These include:

1. A comprehensive audit of community health centres and hospitals, the results of which will form a baseline for future capital allocations and, in close collaboration with other government departments, for ongoing investment in facilities and maintenance; and
2. investment in the expansion of PHC clinics.

3.10 SPECIFIC PROPOSALS FOR PUBLIC/PRIVATE MIX IN SOUTH AFRICA

3.10.1 The current realities of South Africa require a strong Public Health Sector. Such a public health sector will have to accommodate more people and significantly improve the quality of care against a background of limited resources from the fiscus. In this regard a number of strategies are critical. They include the following :

- Changes in management structure in all facilities to promote decentralised decision making which is critical to reform which will facilitate significantly enhanced efficiency operations in the hospital sector, especially if this is linked with the ability to retain revenues generated.

- To raise the degree of cross subsidisation to levels adequate to ensure improved access to good quality care for the millions of unemployed and poor, it will be useful to draw in more paying patients back to the public hospital sector.

3.10.2 (a) At present, South Africa has about 3 beds\1000 of population. Of these 80% are in the public sector and 20% in the private sector. There are a number of proposals in this regard :

- this national ratio of 80:20 be maintained;

- any new licences in future be aimed at correcting historical inequities and also ensure diversification of ownership;

- within the above framework, contractual arrangements be entered into with the private sector based on negotiated tariffs for utilisation of all hospital beds in a province before consideration is made for more beds to be created (be it in the private or public sector). This opens the possibility for the use of the private sector hospital beds for public patients at agreed upon tariffs and vice versa;

- No new licenses for hospital ownership where practising medical practitioners and specialists are shareholders;

3.10.2 (b) There must be licensing of entry of highly specialised equipment based on geographical grids. Greater cross utilisation between public/private sectors should be promoted.

- A closely linked issue is the need for licensing of practices on the basis of certificate of need on a geographical basis. This should aim to promote equitable distribution of our limited resources.

3. 10. 3 Contracting of Services

We have some accumulated experience on the contracting out of services - both clinical and non-clinical. Within the context of provisos outlined in the document, there is a place for selectively engaging in this practice.

The aim of contracting out should be clearly thought through to specifically address the more fundamental need in a particular context. In the more rural and deprived communities of South Africa, the fundamental aim of contracting out should be to extend services to communities where access is hampered by lack of public facilities and where the private sector is in a position to or can be attracted to meet the needs of these communities. This form of intervention may also be appropriate for the peri-urban informal settlements. A possible strategy for this is the accreditation of Private Providers to serve patients who would otherwise depend on public sector facilities. Such private providers may be groups of independent general practitioners or non- governmental organisations.

In the urban areas the central thrust of most contracting out reforms is the introduction of competition in the provision of services, while financing is retained in the public domain. It is argued that such reform would address the pervasive inefficiency problems in the public sector while retaining the positive equity effects of the public sector.

In general, experience suggests that a number of conditions need to hold for contracting to be a viable option. These include:

• range, cost and quality of services under contract should be comparable to direct public provision;
• the public sector should have enough capacity to develop and negotiate contracts, as well as monitor performance of contractors;
• efficiency of contracting depends on a number of factors including the distribution of risk between government and contractor, and incentives in the contract;
• services provided under contract should be consistent with patterns of public services organisation and delivery;
• contractual arrangements should not create sustained dependence and lack of public sector capacity, or inability to seek alternatives to contracting in the future.

3.10.4 Public sources of finance presently account for 40% of health sector funding. Most of this goes to public sector facilities. There is limited money flowing from the private sector sources to the public sector - what exists is largely through user fees (estimated at R650 million in 1992/93).

Furthermore, this amount has been declining over the past few years. If the public sector is to continue providing for the majority of South Africans as envisaged in this document, a number of interventions are necessary and they include the following -

1. greater absorption by the public sector of funds presently utilised in private sector. The policies on revenue retention, managerial autonomy and admission of private patients in public hospitals attempt to address this issue;
2. given the unlikely increase in fiscal allocation, we have to ensure greater payment for hospital care by those who can afford it. The proposal currently being explored of some form of social health insurance attempts to address this issue;
3. Medical Schemes - as a private source of funding will continue albeit in a more regulated environment.

The following set of regulatory mechanisms are required to reverse the recent deregulation of the private health insurance market, which has resulted in serious instability, increasing costs and reduced coverage:

1. medical schemes may not exclude an individual on the basis of health risk. Contribution rates for the full package of benefits will be set according to income and number of dependants.
2. medical schemes are obliged to continue providing health benefits to continuation members (i.e. pensioners, widows, widowers), and to individuals for a limited period after their becoming unemployed. In addition, the practice of transferring private patients to public hospitals once their medical aid benefits are exhausted, should be discontinued.

3.10.5 Regulation of the Private Sector

The regulatory responsibility and capacity of the public sector is probably the single most important determinant of the public/private mix in many countries. Many of the policies mentioned above seek to coordinate public and private sector activities, and to use regulation as a means of influencing private sector behaviour rather than of control. For example, the policy on accreditation of private providers attempts to entice these providers into the public health care system.

A number of regulatory mechanisms are available to the public sector, which include, subject to provisions of the Constitution, controlling prices, quantity, distribution and location of private sector; and mechanisms for regulating quality of services. The existence of a strong regulatory capacity is essential to the success of any policies that encourage private sector participation. In addition, it is important to recognise that government may be only one of may regulatory agents; others could include financing intermediaries, professional groups and patient organisations.

3.10.5.1 Strategies for regulation

It is important to learn some lessons from failures in the implementation of regulatory framework in many countries. Failure can be attributable to a range of factors, including failure on the part of government, which may be more or less benign. Other sources of failure may be due to 'regulatory capture' where the regulatory body is effectively neutralised by the power of the institution which it is supposed to be regulating.

However, a central weakness in the regulatory framework has been the tendency to lay down rigid regulations about what the private sector can and cannot do. It is important that government creates appropriate incentives and disincentive (a carrot and stick approach), to encourage appropriate behaviour. For example, the development of positive regulatory measures which professional bodies find in their interest to adopt may be easier and faster to implement. The public sector should also have the capacity to monitor the professional bodies in their regulatory function.

In addition, government may want to review the activities of existing regulatory agencies and mechanisms, and may need to develop new agencies and mechanisms. Regulatory reform should be supported by research which identifies possible poor practises (eg excessive referrals and inappropriate use of expensive technology). Ultimately, the need for information and better data will be critical if government is to better manage the interface with the private sector.

Chapter 4

Developing Human Resources for Health

Human resource development is a critical factor in the implementation of health and social development. A policy should provide guidelines for the recruitment, selection and placement of health personnel, based on national needs and affirmative action; design education programmes aimed at developing competent personnel- promote the optimal use of globally competent, caring and critically-minded personnel functioning within a multidisciplinary team; and promote a new culture of change management in the health sector, based on participatory leadership.

4.1 PLANNING HUMAN RESOURCES

4.1.1 A NATIONAL FRAMEWORK FOR THE TRAINING AND DEVELOPMENT OF HEALTH PERSONNEL WILL BE ESTABLISHED

(a) Implementation strategies

1. A national audit of the numbers and distribution of trained health personnel will be undertaken.
2. An audit of training institutions and their capacities will be undertaken, and the relevance of existing curricula assessed.
3. On the strength of (i) and (ii) above, guidelines for future training and upgrading of personnel will be formulated, based on a principle of excellence.

4.1.2 THE SKILLS, EXPERIENCE AND EXPERTISE OF ALL HEALTH PERSONNEL SHOULD BE USED OPTIMALLY TO ENSURE MAXIMUM COVERAGE AND COST-EFFECTIVENESS

(a) Implementation strategies

(i) Composition of basic primary health care teams (PHCTs)

Basic PHCTs should include a mix of health personnel with appropriate skills to deal with common conditions and execute prompt and appropriate referral to the next level of care. Such a team should be based at a basic health unit (BHU) such as a clinic, community health centre or a doctor's rooms (public/private).

A PHCT should include community health nurses, midwives, doctors, primary health care nurses, enrolled nurses and nursing auxiliaries oral hygienists/therapists, clerical and support staff and rehabilitation personnel.

Problems that cannot be dealt with at the primary level must be referred to the secondary level. At each of these levels, an appropriate health personnel mix will be available. The existing PHCT population ratio of 1: 30000 should be reduced to 1: 15000 over a five year period. This increased availability of health personnel will provide coverage for the additional 1000 primary care clinics required.

(ii) Composition of referral teams at the district level

The referral team should consist of medical and nurse practitioners, clinical nurses with advance training, e.g. psychiatric nurses, pharmacists, dentists, clinical psychologists, environmental health officers and assistants, enrolled nurses and nursing auxiliaries, advanced midwives and supplementary health personnel, according to the needs of the community.

Specialist personnel will be stationed at the secondary and tertiary levels for referral care. These will include specialist nurse clinicians, super and subspecialists and more specialised allied health workers, such as orthopaedic technicians and educational psychologists.

(iii) Upgrading the skills of mid-level health workers

Consideration should be given to supporting existing categories of mid-level workers through distance learning in order to upgrade their skills. Those with two years of training, be they monovalent or polyvalent in their range of clinical skills, should be provided with a career path with appropriate exit points. Staffing in the peripheral areas should be aimed at nurturing skilled generalists; separate categories of mid-level workers should be avoided.

(iv) Training of doctors

The existing number of medical schools (8) should be retained and the intake should reflect the demographic composition of the country. The number of admissions and graduates should be based on an assessment of the country's needs, as determined by the National Human Resource Audit, with regular reviews to meet the changing needs. In addition, South Africa's role in the human resource development initiatives of the region should be considered.

(v) Medical assistants

Medical assistants, most of whom are returned exiles, should be admitted to a closed register under the control of the Interim National Medical and Dental Council (INMDC). Returned exiles only should be accommodated, and no further training of medical assistants should be approved.

• The cut-off date for registration should be 1 January 2000.
• Medical assistants should be appointed on appropriate salary scales.

(vi) Relationship between community health workers and the public health system

The incorporation of community health workers with the public service should not be considered at this stage. Where necessary, training should take place at the district level, with accountability to the provincial health authority. The feasibility of district financial support for such training should be investigated. Community rehabilitation health workers and health carers should only be trained through the addition of skills to physiotherapist or occupational therapist assistants, where a distinct career path with exit points has been identified, and not on an ad hoc basis.

(vii) Traditional practitioners and birth attendants

Traditional practitioners and traditional birth attendants (TBAs) should not, at this stage, form part of the public health service, but should be recognised as an important component of the broader primary health care team.

The regulation and control of traditional healers should be investigated for their legal empowerment. Criteria outlining standards of practice and an ethical code of conduct for traditional practitioners should be developed to facilitate their registration. Where TBA's are utilised, they should be educated and supported by the public health sector.

(viii) Foreign health graduates

The distribution and competency levels of foreign graduates working in South Africa should be monitored at the national level. Clinical competence and the ability to communicate in at least one South African language will be a prerequisite for registration. They should be recruited to serve in under-served areas. Foreign doctors from countries with an oversupply should be permitted to practice, once they have been certified and registered by the INMDC, conditional upon a job offer from a provincial health authority. Government-to-government programmes should enjoy preference over individual applications. The registration of volunteer medical doctors should be considered by the INMDC.

(ix) Review of legislation

Legislation pertaining to the health professions must be reviewed. Health-related legislation pertaining to the scope of practice of optometrists and the prescription of certain medication by psychologists should also be reviewed including -

• the Medical, Dental and Supplementary Health Service Professions Act. 1974 (Act No. 56 of 1974), Ethical Rule 9(ii),
• the Medicine and Related Substances Control Amendment Act (Act No. 94 of 1991); and
• Section 38A of the Nursing Act (Act No. 50 of 1978), with reference to the "diagnosing, prescribing and treatment" in the Regulations regarding the Scope of Practice for Nurses.

(x) Role of training institutions

Appropriate, multidisciplinary community-problem and outcome-based education programmes in accordance with the National Qualifications Framework (NQF) should be developed to support and enhance the PHC approach.

(xi) Vocational Training

Consideration should be given, as part of curricula review, for the introduction of vocational training to improve the competence of our health professionals.

This process will be introduced for medical doctors beginning January 1998. The period of vocational training must equip our professionals to better confront the challenges of independent practice. This necessitates that such training be carried out also in Primary Care Settings.

(xii) South African-trained health professionals abroad

South African-trained health professionals abroad should be recruited and J-1 visa holders, based on a concept of need, should be followed up to honour their commitment to return to South Africa.

4.1.3 HEALTH PERSONNEL SHOULD BE DISTRIBUTED THROUGHOUT THE COUNTRY IN AN EQUITABLE MANNER

(a) Implementation strategies

(i) National planning system

A new, uniform system for the distribution and financing of personnel at all levels of health care will be developed at the national level. Norms and standards will be developed for the selection and appointment of health professionals, thereby determining a profile of human resources in relation to the skills and competencies required, and to conduct quality assurance and personnel performance appraisal.

(ii) Addressing the maldistribution of personnel

The maldistribution of human resources should be addressed primarily through an incentive-driven process, with service requirements of a maximum of two (2) years in an underserved area after completion of graduate or post-graduate studies.

Incentives should be developed, the magnitude of which should be based on the level of inhospitability of the working environment. AN categories of professional staff should benefit from such incentives.

New bursary schemes linked to districts and provinces should be established for health science students, while existing bursary and other training schemes with service obligations should be retained. Students resident in identified underserved areas should receive preferential consideration.

Professional nursing students should be excluded from bursary schemes and the current system of being paid a salary during their training, should be continued.

Urgent attention should be given to upgrading clinics, to ensure adequate staff recruitment.

(iii) Obligatory service requirements

All health professionals, generalists and specialists, should spend at least two years in a public sector non-tertiary institution, prior to entering health practice. Registrars' training should include one year's public sector experience in an underserved area, which should form an integral part of such training.

(iv) Remuneration packages

The Government should review the salary packages of all health personnel. The Remuneration of Town Clerks Act, 1984 (Act No. II 5 of 1984), Sections 8 and 9, should be reviewed and the Government should adopt the best salary equalising option that is financially viable.

4.2 EDUCATION AND TRAINING

4.2.1 EDUCATION AND TRAINING PROGRAMMES SHOULD BE AIMED AT RECRUITING AND DEVELOPING PERSONNEL WHO ARE COMPETENT TO RESPOND APPROPRIATELY TO THE HEALTH NEEDS OF THE PEOPLE THEY SERVE

Education and training programmes should comprise relevant, reality-based curricula which are aimed at attaining competence within the psychomotor and affective domains of education objectives; should provide comprehensive, integrated, community problem-based health care delivery education for competent practice within a multidisciplinary team ideology; and should be coordinated, reviewed and rationalised to meet the health needs of the country.

(a) Implementation strategies

(i) Training appropriate to the level of care

The ability of health professionals to deliver approved health service packages at various levels of health care should be developed. The following categories of health workers should be regarded as a training priority:

• PHC nurses and advanced midwives
• community psychiatric nurses and psychologists
• paediatric nurses
• nutritionists - environmental health officers and assistants
• epidemiologists
• district health managers.
• chronic disease managers
• psychologists
• occupational therapists and physiotherapists.

(ii) Co-ordination of training

The large number of health personnel education programmes offered by a variety of institutions should be coordinated and, if necessary, rationalised. The Human Resources Development Directorate of the Department of Health should establish a coordinating education committee (CEC which should include representatives of universities, technikons, nursing colleges, the Departments of Education and Health, health service providers, health science students, nongovernmental organisations and the public, to facilitate an interdisciplinary approach.

The function of the CEC for health care training and education programmes will include the selection of training of all professionals, curriculum review, community-based education, integration of educational experiences for different professionals, continuing education, recertification and accreditation.

The activities performed at this level should include the planning, implementation, monitoring, evaluation, review and co-ordination of ail health personnel education programmes.

(iii) Career path development and continuing education

The development of career paths and continuing education for all health professionals should be promoted. The system of visiting consultants should be structured in such a way that specialist categories function as educators at the primary health care level.

(iv) Ability assurance and registration

Recertification for competency and safe practice and the updating of health professions should be the responsibility of the interim professional councils or their successors in title.

(v) Training of oral health personnel

The training of all oral health personnel, including dental technicians and dental assistants, should be undertaken in academic oral health services complexes.

4.2.2 PARTICULAR EMPHASIS SHOULD BE PLACED ON TRAINING PERSONNEL FOR THE PROVISION OF EFFECTIVE PRIMARY HEALTH CARE

(a) Implementation strategies

(i) PHC-orientated curricula

Health sciences curricula should be restructured to reflect community needs more accurately, and teaching should place greater emphasis on community and outcome-based programmes. The fundamentals of a community needs-based health sciences curriculum are primary health care, social sciences, health promotion, ethics, basic management, community participation, conflict resolution and communication, basic counseling, epidemiology, research methodology and information use, and first aid (emergency care).

Provision should also be made for the development of educational programmes on the rational use of essential generic drugs. Nutrition support, monitoring and rehabilitation should be incorporated with the training of all primary health care providers.

Health personnel at all levels should receive training in the analysis and use of data collected in terms of the National Health Information System for South Africa (NHIS/SA).

(ii) Primary health care orientation of existing personnel

An understanding of, and emphasis on primary health care should be instilled in all existing health personnel through appropriate reorientation programmes with ongoing evaluation and monitoring components.

(iii) Emphasis on generalist training

Training offered by academic health services complexes should reflect the emphasis on generalist as opposed to specialist training. An expert task group should be established to evaluate post-graduate education in view of this emphasis.

(iv) School of Public Health

There exists a need for a National School of Public Health to complement the existing schools of public health initiative. The Department of Health will support the development of a National School of Public Health which - as a school without walls - will use the resources of all academic, service and research organisations, and complement other public health programme initiatives in the country.

4.2.3 NEW POLICIES AND STRATEGIES FOR HUMAN RESOURCE DEVELOPMENT SHOULD ADDRESS PRIORITY EDUCATION AND TRAINING NEEDS

(a) Implementation strategy

The subsidy system for educational institutions should reflect priority education and training needs. This system should be reviewed by the Departments of Health and Education, and make provision for a more equitable allocation of subsidies, especially for historically Black tertiary institutions.

4.3 CREATING A CARING ETHOS

(a) Implementation strategies

(i) Charter of Community and Patients' Rights

A Charter of Community and Patients' Rights should be designed in consultation with health service providers and users in support of the democratisation of society.

(ii) Rights of health care personnel

The rights of health care workers should be defined and respected, so that an ethos of caring is nurtured, and not undermined or exploited. The security and safety of staff should also be ensured.

(iii) Campaign of caring

An active campaign to engender a "culture of caring" throughout the health services should be launched by senior officials at all levels, including the Ministry. The following are among the activities which should be undertaken:

• Health care providers should be rewarded for compassionate and caring service.
• The selection of health sciences students should include criteria for caring and compassion. - Ethics courses on health care, properly supervised, should feature prominently in training programmes.
• Peer pressure could be used as a means of ensuring compassionate and caring attitudes among health personnel.
• Competency in the major South African languages should be encouraged by health training institutions, and appropriate training should be offered in conjunction with professional courses. A mandatory African language should be considered.
• Clinical examinations for all health sciences students should include credit for compassion and caring displayed.
• Guidance for a career in the health professions should be offered at schools.

(iv) Support of health care personnel

An efficient and effective support system for health care personnel, particularly those in rural areas, should be developed and the following implemented:

• An improved system of communication for health care workers in rural areas should be developed as a matter of urgency.
• Funds should be made available at the national level for the improvement of physical health care structures and equipment.

4.4 CHANGING THE NATURE OF MANAGEMENT

4.4.1 MANAGEMENT AUTHORITY SHOULD BE DECENTRALISED TO THE PROVINCIAL AND DISTRICT LEVELS TO ALLOW FOR A GREATER DEGREE OF AUTONOMY

(a) Implementation strategies

(i) Decentralised management

Capacity will be built to ensure effective management at the provincial, district and local levels. Such decentralisation will be aimed at promoting innovation and efficiency where a health management team (HMT) constitutes the structural unit. Such a team should consist of a health service manager, a chief nurse, medical practitioners and other appropriate staff, co-opted as the needs of the community served are determined. However, monitoring and assessment of upholding of norms, standards and guidelines will be conducted at the national level.

(ii) District health management teams

District health management teams should be trained and empowered to develop and supervise integrated comprehensive health services, using the primary health care approach.

4.4.2 HEALTH SERVICE MANAGERS SHOULD BE SUPPORTED IN ACQUIRING THE SKILLS REQUIRED TO MANAGE A DECENTRALISED HEALTH SERVICE

(a) Implementation strategy

1. A health management training committee comprising representatives of selected educational and training institutions, the health services, student organisations and consultants should be established.
2. An inventory of all health services management training should be compiled by this committee, with a view to optimising and, where necessary, rationalising such training.
3. Formal and in-service courses in health systems management emphasising democratic management principles should be developed.
4. Qualification requirements for senior and mid-level management posts should be reviewed.
5. A particular effort should be made to recruit management trainees reflecting the demographic structure of the population.

4.4.3 A PARTICIPATIVE, DEMOCRATIC MANAGEMENT STYLE AND MANAGEMENT BY OBJECTIVES SHOULD BE ENGENDERED

(a) Implementation strategies

(i) National Human Resource Development Consultative Forum

The Consultative Forum will consist of all stakeholders in the health sector. The purpose of the Forum will be to share information, discuss matters of mutual concern, such as personnel and education needs, resource distribution and referral systems, and ensure that policy-makers are aware of the needs of and challenges facing health professionals. It will be managed and facilitated by the Human Resource Development Directorate of the Department of Health.

(ii) Training in participative management and conflict resolution

Senior health care personnel should receive training in participative management, negotiation, labor relations, conflict resolution and management by objectives.

4.4.4 EFFECTIVE EVALUATION TECHNIQUES AND PROCEDURES SHOULD BE INTRODUCED TO ASSESS MANAGEMENT EFFICIENCY AT ALL LEVELS OF THE HEALTH SERVICES

(a) Implementation strategy

Existing tools for personnel evaluation should be reviewed by a multi-professional committee consisting, amongst others, of representatives of the Public Service Commission, the departments of health at the national, provincial and district levels, employees, the communities and labour relations experts.

4.5 BUILDING CAPACITY

4.5.1 THE CLINICAL SKILLS OF HEALTH WORKERS SHOULD BE UPGRADED

(a) Implementation strategy

The clinical skills of health professionals should be developed in accordance with approved health care packages in existence at the various levels of service delivery. Particular attention should be given to the training of PHC nurses, advanced midwives, community psychiatric nurses, paediatric nurses, chronic disease nurse-clinicians, psychologists, nutritionists and health managers.

In view of the reliance on nurses and PHC nurses in both primary care and referral teams, an investigative committee, representative of all the stakeholders, should be appointed to -

1. review the existing one and four year nursing courses in terms of cost-effectiveness and appropriateness;
2. investigate whether nursing education should be offered by universities or technikons, and whether responsibility for training should reside at the national or the provincial level; and
3. examine the existing one year training programme for nursing auxiliaries with a view to creating a separate, non-professional category of nursing which would later progress along a career path to the professional nursing programme.

4.5.2 THE SKILLS OF MANAGERS AT ALL LEVELS SHOULD BE DEVELOPED, IF SUBSTANTIVE HEALTH REFORM IS TO BE SUSTAINED

(a) Implementation strategy

The development of management skills development in the following areas should be accelerated:

1. management by objectives
2. participative and change management
3. leadership development
4. community participation
5. financial and fiscal management
6. strategic and operational planning
7. programme management and evaluation
8. policy development and implementation (ix) policy analysis.
9. monitoring and evaluation

4.5.3 INSTITUTIONAL CAPACITY TO SUPPORT HUMAN RESOURCE PLANNING AND MANAGEMENT SHOULD BE DEVELOPED

(a) Implementation strategy

Structures and systems should be developed to support the effective and efficient delivery of health services:

1. A human resource development unit should be established within the HRD Directorate at the national level.
2. A nationally uniform system of planning the personnel establishment at service delivery points should be established.
3. A national information management system should be established.
4. The communication skills of all health professionals should be developed to enhance communication and understanding between patient and practitioner. Communication skills should also be a factor in promotion and advancement.
5. Job descriptions of health professionals at all levels of service delivery should be so specified that duplication and/or fragmentation is avoided.
6. Human resource development units and programmes should be rationalised to promote cost-effectiveness and efficiency in the development of human resource capacity.
7. New and vacant posts should be filled in all the health services. This must be done through the reallocation of budgets and personnel from under-utilised to under-served areas and health services.
8. Additional posts should be created at the point of delivery at all levels of health of care in critical instances.
9. A policy to enable greater mobility of personnel between positions in the district, provincial and national health services should be developed.
10. Managers should be appointed on a contractual basis, ensuring equal rank at the district, provincial and national levels until full-time posts are created, and adequately trained personnel are available.

4.5.4 RESEARCH CAPACITY FOCUSING ON ESSENTIAL HEALTH RESEARCH STRATEGY SHOULD BE IMPLEMENTED TO SUPPORT HEALTH SECTOR DEVELOPMENT

(a) Implementation strategy

The funding of human resource development research be based on the priorities of the RDP. A national register of all health-related HERD research should be established.

4.6 AFFIRMATIVE ACTION

4.6.1 AFFIRMATIVE ACTION POLICIES SHOULD BE AIMED AT TRANSFORMING THE PUBLIC HEALTH SERVICES INTO A NON-RACIAL, NON-SEXIST ORGANISATION

(a) Implementation strategy

A strategic change management programme should be developed at the national level to facilitate a process of institutional change at all levels, thereby ensuring a spirit of openness and involving all stakeholders prior to the implementation of policy. This will ensure-

1. the integration of the health services;
2. the development of skills to promote effectiveness and efficiency, while increasing representativeness at the administrative, managerial, supervisory, professional and technical levels; and
3. that imbalances of the past in the composition of the labour force with regard to race and gender are addressed.

4.6.2 THE PERSONNEL PROFILE OF THE HEALTH SYSTEM SHOULD REFLECT BROADLY THE COMPOSITION OF THE RELEVANT LABOUR MARKET AT ALL ORGANISATIONAL LEVELS

(a) Implementation strategy

(i) Affirmative action in appointments

• A realistic affirmative action policy, linked directly to recruitment, job description and career advancement, performance appraisal, training and study programmes and promotion should be developed.
• -Sound human resource systems should be established to ensure an adequate supply of suitably qualified health personnel, while also improving the representativeness of the public health service.
• The present criteria governing appointment to management positions and the determination of remuneration packages should be reviewed, in order to advance disadvantaged persons with potential.
• A special effort should be made to train Black health service managers.
• Mechanisms should be established to review the representation of women in the higher echelons of management at all levels of health care.
• Gender sensitivity should be applied in recruitment and promotion practices, conditions of service and retirement practices, e.g. housing subsidies for married women and equalising pension schemes and ages of retirement.
• A standing committee should be established to monitor the process of affirmative action.
• To set benchmarks that will serve to guide and monitor adherence to the time frames set for the implementation.

(ii) Affirmative action in education and training, and in health research

Racial, gender and geographic inclusivity should be ensured in all health personnel education and training programmes.

• A representative staff structure should be promoted at academic health complexes.
• The admission of students to training and educational institutions should reflect national demography.
• Student selection should be coordinated at the national level in order to implement and monitor affirmative action policies.
• The process of capacity-building will require strict monitoring.

Essential National Health Research

Essential national health research (ENHR) is an integrated strategy for organising and managing health-related research. it is not a particular type of research or research methodology, but rather a process whereby a country can direct its research towards its greatest health problems. Its goal is to promote health and development in a way that achieves equity and social justice. The ENHR strategy aims to utilise the full range of health research methodologies including epidemiology, social and behavioural, clinical and biomedical, health systems and policy analysis.

5.1 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

The process of setting priorities should be all-inclusive and allow all role-players jointly to determine the agenda. The major role-players are community researchers and health service providers. The process should identify the research agenda that will address the country's health problems. The following guidelines should be used in the priority-setting process:

1. Burden of disease (as measured by disability-adjusted life years);
2. Cost-effectiveness of interventions aimed at the burden of disease-,
3. Institutional human resource availability to implement interventions at the community level; and
4. Health priorities that reflect the communities' needs.
5. Health profiles

5.1.1 Implementation strategies

(a) Task force

It is recommended that a task force be formed which - together with the Chief Directorate: Health Information, Evaluation and Research of the Department of Health - should promote and facilitate the development of the ENHR process and mechanism.

(b) Identification of stakeholders

All role-players must be identified and intersectoral functional networks developed, based on common interest and functionality.

(c) Consultation in determining priorities

A central information centre for health, which collects and collates research data from all available sources inside and outside the country, should be established.

5.2 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

To address the priorities identified successfully, a concerted effort in the various disciplines will be required. Any single problem will require an integrated approach, so that the most cost-effective solutions can be achieved. To achieve these goals, the research agenda will have to be goal-orientated, and human resources will have to be developed to articulate the communities' needs.

5.2.1 Implementation strategies

(a) Capacity development

1. Education in the health and basic sciences for the majority of the population is regarded as a priority investment.
2. A culture of research and technology is essential for the future development of the country. Well-trained scientists and technologists are a prerequisite for general development.
3. Government should make a concerted effort to ensure that the present research infrastructure is maintained and developed to be more appropriate to needs.
4. South Africa should build capacity, through the training of the technologists required to address health priorities.
5. Mentorship, modelling and linkages between historically advantaged and disadvantaged institutions and researchers should be promoted.

(b) Research agenda

The research agenda should -

1. be action-orientated focused, and relevant to the health needs of the country to inform the country of the strategies to be followed;
2. be cost-effective and aimed at improving the efficiency of the health services; and
3. develop effective health delivery, planning, management and policy through informed research and other forms of information.

(c) Funding

1. The Department of Health should co-ordinate public health research activities, to ensure that research results and recommendations are disseminated and implemented.
2. A system of tendering for research identified as a priority should be implemented, to allow for the fairly rapid redistribution of resources for health research.
3. An incentive-driven process should be developed to encourage more public health research.

5.3 RESEARCH SHOULD BE RELEVANT TO HEALTH NEEDS AND AIMED AT INFORMING HEALTH PLANNING, EFFECTIVE DELIVERY, MANAGEMENT AND POLICY DEVELOPMENT

Health Systems Research will be an important field of research in developing the health system and services. Research will aim at identifying mechanisms for improving health delivery, quality of care, patient and systems management and policy development.

Through Health Systems Research the concept of the Department of Health being a 'Learning Organisation' will be promoted by embracing evidence or information based decision making.

5.3.1 Implementation Strategies

1. Capacity building and training in basic skills associated with collecting and using available information
2. Foster a culture of using information for making decisions
3. Health service providers should contribute substantially to defining research agendas that impinge upon health care delivery
4. Research agenda should be fully aligned with most important health problems.

Health Information

The lack of reliable health information is one of the major obstacles to the effective planning of health services in South Africa. The health sector has, therefore, given priority to the development of a new national health information system and aims to contribute to the promotion of an information culture in South Africa. The Minister of Health established a Committee in 1994 to facilitate the development of a national strategy for the implementation of a comprehensive National Health Information System for South Africa (NHISSA). The Committee consists of representatives of the provincial MECs for Health, the Department of Health, other relevant Government departments, academic and research institutions, and the private sector.

Analysis of the 1994 status of health information systems in South Africa conducted by the NHISSA Committee, found that existing information systems were fragmented and incompatible.

They were uncoordinated and not comprehensive; software and hardware were incompatible and not user-friendly; most systems were manually driven, with minimal computerisation; and there was inadequate analysis interpretation and use of data at the local level.

It is anticipated that new attitudes and tools will have to be developed to improve the collection and use of data for the effective management of available resources.

6.1 THE NATIONAL HEALTH INFORMATION SYSTEM (NHISSA) SHOULD BE NATIONALLY CO-ORDINATED IN ORDER TO SUPPORT THE EFFECTIVE DELIVERY OF SERVICES AT ALL LEVELS OF THE HEALTH SYSTEM

For the NHISSA to fulfill its objectives - which include ensuring the availability of information on cost, efficiency, volume and coverage as well as the measurement of the South African population's health status - it will have to be coordinated at all levels.

6.1.1 Implementation strategies

(a) Establishment of a comprehensive national health information system

A comprehensive NHISSA will be developed as an overall parent system comprising various components. Individually and collectively, these components will provide the various types of information needed to support the health care delivery system in South Africa.

At the national level, an NHIS Advisory Committee will be established to strengthen stakeholders' involvement in the development and implementation of the NHISSA. The Committee will also promote the use of NHISSA data at all levels and Raise closely with the strategic planning sections of the departments of health at the national and provincial levels.

At the provincial level, committees will be established to facilitate the implementation of a streamlined health information system, based on the national guidelines. The provinces have a key role to play in the development of the NHISSA and promoting the use of data for planning. They will also be responsible for facilitating the development of a district health information system. In so doing, the provinces should consult all key role-players including NGOs, the private sector and academic and research institutions.

(b) Components of the NHISSA

The NHISSA was conceived as a parent system that encompasses various subsystems. The following component systems are envisaged:

(i) Management information

• National Health Care Management Information System
• Human Resources Management Information System
• Financial Management Information System
• Facilities Management Information System
• Equipment Management Information System
• Transport Management Information System
• Pharmaceutical and Other Consumables Management Information System
• Service Coverage (i.e. utilisation, coverage, access).

(ii) Surveillance

• Socio-demographic Surveillance
• Environmental Surveillance
• Disease Surveillance
• Nutrition Surveillance
• Health Systems Surveillance

Provincial and district level working groups will be established to facilitate the development and implementation of these systems on an incremental basis. In addition, community level surveillance will be developed and implemented with the communities' active participation. District health teams will assist the communities to develop the capacity to assess their own problems and identify appropriate remedial actions.

(c) The private sector

The system developers will collaborate with the private sector to ensure that its information systems are included in the NHISSA.

(d) Provincial variations

The NHISSA will accommodate provincial variations in accordance with specific needs at the provincial and district levels.

(e) Piloting the NHISSA

The NHISSA will be piloted nationally on an incremental basis.

6.2 THE NHISSA SHOULD BE USED TO MONITOR THE IMPLEMENTATION AND SUCCESS OF THE HEALTH PRIORITY PROGRAMMES, BOTH OF THE DEPARTMENT OF HEALTH AND THE RECONSTRUCTION AND DEVELOPMENT PROGRAMME (RDP)

6.2.1 Implementation strategies

(a) Minimum data set and indicators

A minimum data set will be established at the national level, in accordance with international indicators. The ICD-10 system, which has been adopted by the NHISSA Committee, will be used.

(b) A user-friendly NHISSA

Minimum standards for technology, coding systems, application software, the database management system, etc. will be adopted in the course of developing the NHISSA to ensure its user-friendliness, and facilitate the collation, analysis and use of data.

(c) National Nutrition Surveillance System

A National Nutrition Surveillance System will be implemented as part of the NHISSA. A research strategy and surveillance system for growth monitoring (especially community-based), which will address the nutritional status of pregnant and lactating women, preschool children, levels of micronutrient deficiency and food consumption, will be developed and implemented.

Nutritional status, especially that of young children, will be among the key indicators of social well-being and an outcome measure of RDP projects.

(d) Mortality and morbidity data

Cause-specific mortality and morbidity data (especially for children and women) will be gathered and published widely. They will serve as indicators of development, thereby ensuring that priority health problems are addressed continuously.

(e) Use of NHIS data

Emphasis will be placed on the use and feedback of data at all levels, especially at the point of collection. Regular NHISSA bulletins will be produced at the national level. It is envisaged that mechanisms for data dissemination will be established at the provincial and district levels. It is essential that data be made available to decision-makers, planners and communities, and that it is used to influence resource allocation and reduce inequity.

6.3 REPORTING OF NHISSA DATA AT ALL LEVELS SHOULD BE TIMEOUS, ACCURATE AND COMPLETE

6.3.1 Implementation strategies

(a) Training

Health workers will be trained appropriately, to ensure the accuracy, timeousness and comprehensivity of reporting NHISSA data.

(b) Monitoring timeousness and comprehensivity of reporting

Monitoring forms will be developed and built into the system, to facilitate the monitoring of timeous and comprehensive reporting. At the provincial and district levels, supervisory checklists should include questions related to this activity.

Nutrition

Nutrition is a basic human right, and a prerequisite for the attainment of a person's physical and intellectual potential. Nutrition is an outcome of developmental processes in society, and not simply a service to be delivered. Improving nutrition is thus an ethical imperative and a sound economic investment which is politically rewarding.

Malnutrition in South Africa has two major components:

The first is undernutrition, which manifests itself in infants and young children, and pregnant and lactating women. South Africa has a high incidence of low birth weight babies (LBW) - about 16%. The 1994 survey conducted by the South African Vitamin A Consultative Group found that one in three children in South Africa had marginal Vitamin A deficiency status; one in five had iron-deficiency anaemia; one in four were stunted and one in ten were underweight for age.

The second component comprises chronic diseases of lifestyle, which manifest typically in adulthood as obesity-related diseases, ischemic heart disease, hypertension, diabetes and certain cancers.

The Department of Health is committed to taking the lead in advocating optimal nutrition. It is also committed to developing and implementing an integrated nutrition strategy based on human right, developmental in orientation, monitored for impact, sustainable, environmentally sound, people and community-driven, and which targets the most vulnerable groups, especially women and children. The guiding principles and implementation mechanisms of such an integrated nutrition strategy are elaborated below.

7.1 SOUND NUTRITION FOR ALL SOUTH AFRICANS SHOULD BE PROMOTED AS A BASIC HUMAN RIGHT AND AN INTEGRAL COMPONENT AND OUTCOME MEASURE OF THE COUNTRY'S SOCIAL AND ECONOMIC DEVELOPMENT.

Effective nutrition interventions are social and economic investments, vital for economic growth. They have been shown internationally to yield high economic returns. Since adequate nutrition is necessary for and an essential outcome of development in a country, nutrition interventions should be viewed and monitored within the overall guiding principles of the Reconstruction and Development Programme (RDP). Because nutritional status, especially of young children, is a sound indicator of overall development and social well-being, the nutritional status of young children should be one of the outcome measures of the RDP.

7.1.1 Implementation strategy

The RDP highlights the Government's commitment to addressing problems of undernutrition and hunger. As a lead agency, the Department of Health must play a key role, not only in developing a strategy within its own line function, but also in terms of advocacy. This will ensure that nutrition is specified and monitored as an outcome of the RDP and other socioeconomic programmes being planned within Government departments, intergovernmental organisations (IGOs), NGOs and the private sector.

7.2 NUTRITION PROGRAMMES SHOULD BE INTEGRATED, SUSTAINABLE, ENVIRONMENTALLY SOUND, PEOPLE AND COMMUNITY-DRIVEN, AND SHOULD TARGET THE MOST VULNERABLE GROUPS, ESPECIALLY CHILDREN AND WOMEN

An Integrated Nutrition Strategy has been developed, the objective of which is to set in motion fundamental processes leading to a sustained improvement in the nutritional status of children, especially those under five years of age. The strategy will also improve the quality of fife of women through an adaptive process of assessment, analysis and action.

Effective nutrition intervention programmes are dependant on political commitment, intersectoral collaboration and community participation. They should also be environmentally sound and target the most vulnerable groups.

Political commitment, although already embodied in the RDP, requires continued advocacy to sustain it. Integrated nutrition programming takes into account three underlying clusters of factors which determine nutrition status: household food security, the malnutrition-infection syndrome and the caring capacity of households.

From the Department of Health's perspective, a three-pronged integrated nutrition programme should be set in place, giving particular attention to -

• issues of intersectoral linkages and collaboration;
• community mobilisation and participation;
• targeting of the most vulnerable groups;
• effective response to specific problems;
• monitoring, evaluation and management information systems;
• development of human resources and institutional capacities; and
• sustainability in terms of processes, resources and impact.

7.2.1 Implementation strategies

Within the Department of Health, three major components of an integrated nutrition strategy should be implemented, namely:

• a health facility-based component;
• a community-based component; and
• a nutrition promotion programme, comprising communication, advocacy and relevant legislation; and
• a national nutrition surveillance system.

(a) Health facility-based nutrition programme

In keeping with the emphasis on an integrated, comprehensive primary health care (PHC) service, a health facility-based nutrition programme should be established as an integral part of the PHC package. This will address the major problems of undernutrition and micronutrient deficiencies and prevent the chronic diseases of lifestyle through an optimal dietary approach. Because of the high rates of undernutrition in young children and women, special attention will have to be given to the maternal, child and women's health component of PHC.

Essential elements of a health facility-based programme should include:

1. Provision of disease-specific nutritional support and counseling;
2. growth monitoring and promotion through the universal use of standardised growth cards for all infants and young children at clinics;
3. nutrition education for care givers of infants, young children, and pregnant and lactating women, the emphasis being on -
• measures that render health facilities baby and woman-friendly, and protect and promote breast-feeding and its successful management;
• the introduction of appropriate and locally available complementary foods;
• child feeding practices during periods of diarrhoea, other infections and immunisations; and
• the importance of regular growth monitoring.
4. follow-up and assessment by health staff through visits to community resource persons providing advice, counseling or referral to other supportive services;
5. provision of food supplementation to malnourished children and pregnant women, including -
• - through the protein-energy malnutrition (PEM) scheme; and
• - reducing the number and types of food supplements available from clinics, to reflect foods forming the bulk of the normal diet within a community,
6. addressing micronutrient deficiencies - particularly iron and sub-clinical vitamin A deficiencies in infants and young children, and iron and folic acid deficiencies in women, especially during pregnancy - through education, micronutrient supplementation and fortification of staple foods; and
7. ensuring appropriate nutritional management of diarrhoeal and other infectious diseases.

To do this effectively, PHC staff should devote sufficient time to nutrition-related activities. In addition, adequately trained and dedicated nutrition staff should be developed.

(b) Community-based nutrition programme

A community-based nutrition programme has several advantages:

1. Sustainability is more likely,
2. information, education and communication (IEC) is more focused, targeted and relevant, ensuring the incorporation of new ideas and practices;
3. external dependency is lessened; and
4. implementation will be contextual.

Instead of developing predesigned programmes, the Department of Health will provide gender-sensitive, multisectoral support to communities in solving their own nutrition problems. The Department will achieve this through the facilitation of the fundamental processes of assessment, analysis and action cycles in a capacity-building and empowering fashion. It will also be achieved through the multisectoral mobilisation of relevant structures at community level; developing projects that will strengthen household food security; care of children and women-, and providing health services - while promoting a healthy environment.

An important objective of this programme will be the achievement of positive behavioral change regarding knowledge of attitude towards and practice in respect of health and nutritional well-being, including the allocation of resources by individuals, households, the community and decision-makers at large. Appropriate labour-saving technologies will be promoted. The programme will also be linked to other community initiatives that promote child survival, protection and development.

Although the provision of services will target the most vulnerable individuals and communities - especially the poor - in a simple, flexible and adaptive way, the programme will be aimed at mobilising all members of households as well as community leaders and structures, both public and private. All people: women and men, children and adults, the affected and the unaffected, the vulnerable and the non-vulnerable will thus be mobilised to participate. Growth monitoring and promotion through the weighing of children will be an important tool in such mobilisation.

The community-based nutrition programme should combine the relevant projects of the Primary School Nutrition Programme (PSNP) and the National Nutrition and Social Development Programme (NNSDP) within the context of the RDP. Links of the PSNP with the Department of Education should be strengthened, to establish nutrition education in primary schools, and links with the Department of Agriculture to promote household food security.

While the major thrust of the community-based programme will be aimed at ensuring the active participation of individuals, families and communities in assuming responsibility for the improvement of their nutrition status, community participation should be complemented by awareness, commitment and the support of leadership in the higher levels of Government, relevant NGOs and external support organisations. Nutrition personnel, together with community development resource persons, community-based organisations and NGOs should assist communities in identifying and implementing key intervention strategies.

Once the new community-based nutrition programme has been established, it is expected to become a true community development strategy, with nutrition surveillance as the primary management and monitoring tool.

(c) Nutrition promotion: communication, advocacy and legislation

Promoting the realisation that nutrition is an outcome of complex intersectoral processes in society and that poverty is the basic determinant, is fundamental to building a broad alliance which will support nutrition strategies that combat poverty, while drawing on trans-sectoral collaboration. In order to achieve national consensus, the definition of common nutrition-related goals and effective policies, strategies, programmes, actions and legislation, it is necessary to influence the perceptions, understanding and demands of policy-makers, civil servants and the general public. The highest level decision-makers are especially critical to this process.

A nutrition promotion programme which leads to positive behavioral change in policy and among decision-makers and the general public should, therefore, be a key part of an integrated nutrition strategy. The aim is to build national awareness and consensus about the nutritional situation in South Africa, the most critical causes of undernutrition and the course of action to promote and protect optimal nutrition.

The strategy will consist of three major components:

(i) A focused approach to a programme of communication and public information will be adopted, using the mass media and health staff. They will have to be trained in communication skills and have a sound understanding of the major causes of malnutrition in the groups with whom they communicate. Seminars or retreats for senior staff to inculcate a sound vision of nutrition and lay a firm foundation for official strategies and intersectoral programmes should be arranged. The consistency of messages communicated will be of paramount importance.

Priority areas of programme communication will be:

• Breast-feeding: its successful initiation, management and protection, as well as the development of a Code for the Marketing of Breast Milk Substitutes;
• sound infant and young child-feeding practices: frequent feeding, increased energy dense foods, feeding during diarrhoeal bouts and other illnesses;
• the major disease causes of childhood undernutrition: their prevention and treatment;
• areas in which there is controversy or in which popular perceptions are in conflict with up-to-date technical information, e.g. food handouts and the dangers of creating dependency, and focus on nutrients (food groups) rather than food as a whole; and
• the prevention and control of diseases of lifestyle.

(ii) Advocacy will be initiated to -

• develop consensus among policy-makers at the national, provincial and district levels concerning issues of nutrition and the major cause of undernutrition. (The focus will be on controversial areas, or those in which perceptions are in conflict with up-to-date technical knowledge);
• formulate public policies to improve nutrition, with emphasis on responses to poverty alleviation, the care of vulnerable groups over the short and long term, and linking strategies to health and RDP programmes, especially the RDP's Lead Projects;
• develop a comprehensive nutrition policy for South Africa, based on sufficient consensus on the nature of nutrition problems, their causes and appropriate actions;
• incorporate nutrition considerations and components into developmental and intersectoral policies, plans and programmes. (This will ensure that the nutritional status of children is adopted as an outcome measure of the RDP at the national, provincial and district levels, and that information generated by the nutrition surveillance systems is disseminated);
• ensure the strengthening of food safety, security and quality;
• develop measures on land reform that will ensure that the vulnerability of the landless and the landless poor is reduced;
• formulate policies for implementing income transfers that will improve the entitlement package of the rural and urban poor,
• develop policies that will ensure the availability and equitable distribution of essential food items through a public distribution system;
• develop a formula based on basic food prices and their nutritional adequacy. (This will be incorporated in policies that will ensure the linkage and adjustment of minimum wages to increases in market prices, as well as the strict enforcement and timely revision thereof),- and
• develop policies that will ensure the empowerment of women through literacy and education programmes.

(iii) Legislation relevant to nutrition will be reviewed, strengthened, implemented and enforced -

• to protect breast-feeding, and to control the marketing of infant foods-,
• for the mandatory iodisation of all salt for human and animal consumption;
• for the mandatory fortification of appropriate staple foods, e.g. fortification of maize meal with riboflavin, nicotinamide, thiamine, folate, vitamin B6, and other nutrients; and exploration of the fortification of a food vehicle with vitamin A;
• to ensure food safety and quality; and
• for the expansion of the Food Legislation Advisory Group (FLAG) to be representative of all stakeholders.

7.3 NUTRITIONAL WELL, BEING SHOULD BE PROMOTED AND MONITORED WITHIN NATIONALLY-DEFINED GOALS; THERE SHOULD BE A CLEAR NUTRITION INFORMATION STRATEGY

There is a need for the development of an integrated nutrition information system in South Africa to identify the trends, nature, extent and severity of the different types of nutrition problems and their causes. Such a system would also assist in monitoring and evaluating the impact of nutrition programmes and facilitate informed decision-making processes at various levels for policy, strategy and programme development and implementation.

Apart from facilitating the improved targeting of nutrition programmes and analysis of the possible causes of malnutrition, the system also has a fundamental role to play in monitoring and evaluating the nutritional goals of the RDP. Nutritional status can provide an overall indicator of the success of the Programme. In a people-driven process such as the RDP, decision-makers at all levels must have a clear understanding of problems to be addressed and employ a common framework within which the progress made towards achieving the desired goals can be gauged. A nutrition information system (NIS) provides such a framework. An NIS can thus be considered a priority for South Africa.

The aim of the system is to improve decision-making at all levels, with a view to solving the problems of malnutrition in vulnerable groups, especially young children and pregnant women. This can be done through the provision of timely, appropriate, accurate and relevant information on an ongoing basis. The emphasis should be on information for action, and efforts should be made to avoid paralysis of action through overzealous analysis.

7.3.1 Implementation strategies

In defining an effective NIS for South Africa, national process and impact goals should be defined in keeping with the strategies of the RDP, World Summit for Children (WSC) and International Conference on Nutrition (ICN).

(a) Critical strategic factors

For a nutrition information system to be effective, it must address the five critical and strategic factors that ensure its success. Thus, it should -

1. enhance the perceptions and knowledge, particularly of politicians and other decision-makers, so that the malnutrition problem is made "visible" and perceived as a "priority social problem";
2. increase effective demand for nutrition-relevant information to motivate action,
3. improve the capacity to assess, analyse and design resource-relevant actions-
4. ensure adequate resources for maintaining the Nutrition Information System (NIS) over a reasonable period of time (5-10 years), and
5. ensure adequate resources for action.

It is important to note that, while it is frequently possible to mobilise resources to solve half the problem, this often creates the climate for solving the entire problem. Thus, three strategies will be implemented simultaneously at three levels: household, community/district/provincial and national. In implementing these main strategies, the Department of Health will develop sub-strategies to cover the following aspects:

1. Appropriate and standard tools such as road-to-health cards and charts can be used by communities for growth monitoring and promotion of children under three years. They can also be used to measure the nutritional status of pregnant women.
2. Monitoring of pre-school children of three years and older, and of school entrants;
3. monitoring and evaluation of the management and impact of nutrition programmes; and
4. surveys on specific nutrition issues, such as micronutrient deficiencies.

(b) Nutrition information strategies at household and community level

The primary objectives of a household and community level nutrition information strategy are threefold. The first is to increase household and community level awareness of the nutritional needs of the most vulnerable individuals, particularly the promotion of children's growth.

The mother constitutes the first line of protection and support, the father and/or care givers and children the second and the community the third. The type of decisions which can and should be taken at the household and community levels depends on the use of resources within the household, those accessible within the community or obtainable from higher levels of society. Normally, the mother assesses and analyses the problem, sometimes with the aid of an outsider, e.g. the village or community health worker. Here, communication is informal and interpersonal.

However, the mother is frequently the "assessor, analyst and actor" at the same time. A nutrition information strategy can be developed at this level, which should improve the perception of the problem and make it more visible. Growth monitoring and promotion (GMP) assists in this effort. This necessitates GMP sessions taking place as close to the household level as possible. Though more efficient than clinic-based GMP, household/community-level GMP should complement rather than replace clinic-based GMP. At the household and community levels, GMP should be used not only to direct the required action, but also to justify such actions.

(c) Nutrition information strategy at the district/provincial level

The objectives of a nutrition strategy at these levels are similar to those at the household and community levels but here the main users of nutrition information will be the relevant decision-making systems. These levels have more human, organisational and economic resources at their disposal than households and communities. A community, district or provincial growth chart could be used to make the malnutrition problem more visible and mobilise resources for more targeted action. At these levels, the nutrition information strategy will comprise GMP and nutrition surveillance based at the community level and in PHC, notably at clinics and health centers.

(d) Nutrition information strategy at the national level.

At the national level, the decision-making process is far more complex. Two categories of decisions affect nutrition. The first are those related to direct actions like supplementary feeding, micronutrient supplementation or fortification, nutrition education, promotion of breast-feeding, community-based GMP, etc. The second are decisions and actions which have an implicit consequence for nutrition, like interventions in agriculture, on wages and prices, on marketing and social services or on cost recovery and fiscal, trade and monetary policies. Both categories are important for improving nutritional well-being, and nutrition information systems should strive to link up with them.

The primary objectives of a nutrition information strategy at the national level are threefold. First, to improve decisions on targeting nutrition-relevant services. Secondly, to improve decisions on the use of existing resources for nutrition improvement, thereby improving their availability and access. Thirdly, to build consensus on the nature of and trends in the nutrition problem, and to monitor the impact of interventions.

(e) Linking the different levels of nutrition information strategies

Since decision-makers participate in both horizontal and vertical decision-making processes, it is a challenge to the nutrition information system to link the many decision-making assessment, analysis and action processes at the different levels so that they can become mutually reinforcing. Thus, to improve decision-making processes with potential impact on nutritional status, nutrition-relevant information emanating from the different levels has to be shared.

A strategy should be developed to build capacity and capability for information analysis at each level, thereby enabling each level to provide information about the following:

1. When and where support is needed at the next lowest level: a targeting mechanism that will reach communities and households that need extra support on a selective basis;
2. how to use the resources controlled at that level: improving resource utilisation to reach such households; and
3. when to seek assistance and support from the next highest level: linking up with higher levels for technical and resource support.

Child growth monitoring in the formal health care system should be complemented by community-based growth monitoring to ensure universal coverage, and by nutrition information systems developed to incorporate data from both these sources. Community-based growth monitoring and promotion is an essential element of a community-based nutrition programme, which assists communities with their own planning, programme management and evaluation.

The nutrition information system (NIS) should be closely linked to the health information system (HIS) and other information systems, for example, the household survey programmes of the Central Statistical Service (CSS). This will not only permit the assessment of nutrition status over time, but also the possible causes of changes in the situation. The Nutrition Directorate is responsible for the timely acquisition of nutrition information in order to provide reports to the Minister of Health and the Office of the RDP at regular intervals.

Maternal, Child and Women's Health

In restructuring South Africa's health services from a largely curative-based and fragmented system to a more community-orientated one - based on primary health care principles - the emphasis will be on improving preventive, promotive and curative services for children and women.

The Department of Health is committed to achieving universal access to health services for children including infants, children under five, adolescents and women, while improving the quality of services provided. This will enable the health sector to make its contribution to the reduction of infant, child and maternal morbidity and mortality in keeping with the goals of the RDP. The principles that will apply are stated below:

8.1 MATERNAL, CHILD AND WOMEN'S HEALTH (MCWH) SERVICES SHOULD BE ACCESSIBLE TO MOTHERS, CHILDREN, ADOLESCENTS AND WOMEN OF ALL AGES, THE FOCUS BEING ON THE RURAL AND URBAN POOR AND FARM WORKERS

The provision of MCWH services in South Africa hitherto has been fragmented and poorly coordinated, with inadequate resources being provided. Furthermore, inadequate planning, implementation, supervision, monitoring and evaluation of these services has occurred. As a result, there is unequal access to MCWH services, especially in the rural areas, as well as high-density and peri-urban areas, informal settlements and among workers in farming communities.

8.1.1 Implementation strategies

(a) Reorganising MCWH services

MCWH services will be reorganised at all levels to facilitate the planning, implementation, supervision, monitoring and evaluation of services, and ensure the effective coverage of the majority of children and women.

(i) National level

A MCWH Directorate will be established by the Department of Health at the national level. It will co-ordinate and facilitate the reorganisation of MCWH services, formulate policy, set norms and standards, undertake national level planning and support provincial activities.

(ii) Provincial level

MCWH units will be established at the provincial level to oversee the planning, implementation, supervision, monitoring and evaluation' of integrated MCWH services in the various districts. The national Directorate and provincial MCWH units will be adequately staffed with people trained in the planning and management of MCWH services.

(iii) District level

The planning and implementation of MCWH programmes (child and reproductive health) will be district-focused and community-based. District health teams will be trained to enhance their capacity for planning, implementing, supervising, monitoring and evaluating MCWH services. The co-ordination of MCWH activities will be undertaken within the framework of local government structures.

(iv) Community level

At the community level, households and communities will be targeted for relevant information. In addition, community health promoters will be trained to facilitate community action.

The role of nongovernmental and other grassroots organisations in promoting community participation and involvement in health development will be recognised. Health workers in the various facilities will be expected to be familiar with their catchment population and participate in community- based MCWH activities.

(v) Intersectoral collaboration

Intersectoral collaboration, and the mobilisation of all stakeholders to support services aimed at the improvement of children's and women's health, will be undertaken.

(vi) Advisory committees

MCWH advisory committees will be established. They will comprise members with technical expertise as well as community and non- governmental representatives. Integrated primary health care advisory committees, whose responsibilities will include MCWH, will be established at the district level.

(b) Resource allocation

The Department of Health and provincial health departments will ensure the allocation of adequate resources, to provide comprehensive and integrated MCWH services.

The health sector aims to provide access to community health centres and clinics in rural, peri-urban and urban areas at a coverage rate of 1:20000 by the year 2000. Where necessary, such facilities win be constructed, equipped and provided with adequately trained staff.

(c) Human resource development

Health workers will be orientated towards primary health care concepts and principles. Their skills will be upgraded, and they will be trained and encouraged to develop a caring ethos towards their patients.

In addition, health workers will be encouraged to become involved in community-based health care activities. They will be orientated to expand their responsibility beyond patients attending their own facility.

(d) Monitoring and evaluation

District health teams' capacity for monitoring and evaluating MCWH services will be built through training, and streamlining the health information system. The focus will be on the use of data at all levels, especially at the point of collection.

8.2 MCWH SERVICES SHOULD BE COMPREHENSIVE AND INTEGRATED

In most South African health facilities, MCWH services are provided at separate locations within the same health facility. Furthermore, the services are often not comprehensive, especially at clinic and community health centre levels. MCWH will form an integral part of primary health care services.

8.2.1 Implementation strategies

(a) One-stop, "supermarket" approach

All health facilities, as far as possible, will render MCWH services on a one-stop, "supermarket" basis. Existing health facilities should review the allocation of available space and, where possible, relocate MCWH services closer to one another. The optimal integration of MCWH services must be ensured in the design of all future health facilities.

(b) Minimum package of MCWH services

The minimum package of MCWH services that is to be provided at the various levels of care will be developed further, and implemented in accordance with the functions attributed to each level of care.

(c) Training

Relevant training should be undertaken to facilitate the integration of MCWH services.

(d) Co-ordination with other services

MCWH services should be coordinated with other health services, including the following:

• Environmental health and sanitation
• Nutrition
• Disability.

(e) Intersectoral collaboration

This should be encouraged, as the health status of women and children will benefit from interventions in other sectors.

(f) Non-governmental organisations

Collaboration with NGOs is of great importance, since much of the work done in the area of MCWH is undertaken by such organisations.

8.3 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 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD

8.3.1 Implementation strategies

(a) Formulation of health sector goals and objectives

In consultation with the provinces, and drawing on the reports of the Ministerial Committees appointed in 1994, the Department of Health will compile health sector goals to be achieved by the year 2000. These goals will be based on those of the RDP, the World Summit for Children and the Convention on the Rights of the Child.

Where such goals do not exist, e.g. in the field of youth and adolescent health, targets and objectives will be developed through participatory consultation with relevant groups.

Specific and achievable MCWH objectives should be set at the provincial and district levels, using national goals and objectives as a framework.

A participatory process will be adopted at the community level to enable communities to set their own objectives.

(b) Moral and ethical basis

There should be a moral and ethical basis for the provision of MCWH and other services, in accordance with the Convention on the Rights of the Child.

Health planners, managers and other health workers should be committed to the attainment of RDP/health sector goals, as well as those elaborated in the Convention on the Rights of the Child. Planners should allocate adequate resources to programmes that impact on the health of children and women.

Furthermore, it is essential that health workers develop a caring ethos and improve their attitude towards their patients and the community at large. The Department of Health will work closely with training institutions, health professional organisations, nongovernmental organisations and the private sector to address this issue effectively.

(c) Annual plans

Annual health plans will be drawn up by the provinces and districts. These should include distinct targets to be achieved.

(d) Monitoring and evaluation

The impact and efficiency of MCWH will be assessed through the monitoring of various performance indicators. The performance of the provinces will be monitored at the national level, while district performance will be monitored at provincial level. Achievements at the community and local levels should be monitored effectively at district level.

The health information system should be utilised at all levels to provide the required information. In addition, the health sector will utilise household surveys and other relevant surveys and studies to assess progress made with achieving MCWH objectives.

8.4 INDIVIDUALS, HOUSEHOLDS AND COMMUNITIES SHOULD HAVE ADEQUATE KNOWLEDGE AND SKILLS WHICH PROMOTE POSITIVE BEHAVIOUR RELATED TO MATERNAL, CHILD AND REPRODUCTIVE HEALTH

There is great potential for targeting individuals, households and communities with relevant health information. This will increase their knowledge base and facilitate its application to help prevent or solve common health and health-related problems affecting mothers and children. The capacity for effective communication, planning, implementation, monitoring and evaluation at various levels is, however, lacking, especially at the district and community levels.

The majority of health workers have poor communication skills and are unable to develop health messages based on formative audience research. Much of the health educational material produced is inadequately pretested, and little or no evaluation of its impact on behavioural change is undertaken.

8.4.1 Implementation strategies

Whereas information is a tool for raising awareness of health and health-related issues, the translation of information requires skill and adequate resources, organisation and management at all levels, especially at the community level.

(a) Needs assessment

Assessment of the needs and existing capacity of the health sector to provide effective communication on women and children will be undertaken by the Department of Health's Directorate- Health Promotion and Communication.

(b) Communication strategy

Based on this assessment, a communication strategy for the health sector will be developed, the emphasis being on the promotion of MCWH. It is envisaged that this strategy will, inter alia, address health workers' training to improve their communication skills and ability to undertake formative research; develop and pretest health information materials, and monitor and evaluate their impact on behaviour change; use the media (including traditional media) to promote the health of women and children; and form alliances with relevant stakeholders.

(c) Communication plans

Communication plans will be developed at the national, provincial, district and community levels, based on the communication strategy to be developed in terms of (b) above.

(d) Household level involvement

At the household level, the individual and other household members, i.e. mothers, fathers and siblings, as well as other caregivers, should be involved actively in the promotion of child health. Roles in the household should include:

1. early recognition of common health problems, including diarrhoea and acute respiratory infections;
2. maintenance of appropriate personal hygiene;
3. supporting and participating in health promotion activities, including immunisation and breast-feeding;
4. ensuring adequate child-feeding practices; and
5. disseminating health education messages to other members of the household.

8.5 MCWH SERVICES SHOULD BE EFFICIENT, COST-EFFECTIVE AND OF A GOOD QUALITY

8.5.1 Implementation strategies

(a) Norms and standards

Norms and standards will be established. Standardised case management protocols for various priority health problems will be developed, including the following:

1. common conditions affecting children, including acute respiratory infections, diarrhoea, measles, malaria and severe malnutrition;
2. antenatal, intranatal and neonatal care, as outlined in the Perinatal Education Programme (PEP);
3. advanced midwifery training in accordance with the Decentralised Education Programme for Advanced Midwives (DEPAM);
4. all aspects of adolescent health; and
5. all other aspects of reproductive health, through the proposed Reproductive Health Education Programme.

(b) Training of health workers

Health workers will be trained to improve their skills in the provision of quality, integrated MCWH services. Health managers will be trained in micro-planning, focusing on improving the coverage and effectiveness of MCWH services.

(c) Tools

A set of tools will be developed to improve planning, implementation, supervision, monitoring and evaluation.

(d) Cost-effectiveness studies

Cost-effectiveness studies will be conducted at the provincial level. Provincial and district managers will be trained in the appropriate methodology for the analysis of cost, resource use and effectiveness.

8.6 WOMEN AND MEN WELL BE PROVIDED WITH SERVICES WHICH ENABLE THEM TO ACHIEVE OPTIMAL REPRODUCTIVE AND SEXUAL HEALTH

8.6.1 Implementation strategies

1. Information on sexuality and reproduction will be provided.
2. Services for the diagnosis, management and counselling of HIV/AIDS and STD patients will be made available at all health centres.
3. Confidentiality will be enforced in accordance with individual preferences.
4. PAP smears and breast examinations will be conducted at scheduled intervals and provision will be made for appropriate management, when required.
5. Family planning services, which will be made available to women and men, will provide information and consultation on a wide range of methods of family planning. Clients can then decide for themselves which are the most appropriate methods.
6. Human genetic counselling will be provided at all levels, commencing at the community level.
7. Peer group education on sexuality and life skills will be encouraged.
8. Greater emphasis will be placed on the presentation and management of climacteric and menopausal symptoms, with a view to improving the quality of life.

HIV/AIDS and Sexually Transmitted Diseases

The HIV epidemic is well established in South Africa. Approximately 1,8 million people are already infected, and more than 700 new infections occur every day.

Statistics from the national annual antenatal clinic surveys indicate that the epidemic has increased tenfold in the last five years. At present, the doubling rate of infection is estimated to be between 13 and 15 months. The results of the annual survey conducted in October-November 1995 show that 10,4% of women attending antenatal clinics of the public health services were infected. The prevalence of HIV in each province was found to be as follows: KwaZulu-Natal 18,2%; Mpumalanga 16,2%; Gauteng 12,0%, Free State 11,0%; North-West 8,3%; Eastern Cape 6,0%; Northern Cape 5,3%; Northern Province 4,9%; and Western Cape 1,7%. It is evident that the virus is spreading more rapidly among young people aged between 15 and 30 years, women and mobile persons.

It is clear that HIV/AIDS is one of the key health issues affecting our population, and that the State's commitment to developing a comprehensive and coordinated national AIDS programme is essential. In terms of this commitment a National AIDS Control Programme was formed. It is based on the National AIDS Plan for South Africa, which was developed through a consultative process by the National AIDS Convention of South Africa (NACOSA). The Plan identified various mechanisms for the control of HIV including behavioural. strategies; early detection and treatment of classical sexually transmitted diseases (STI)s); maintenance of safe blood supplies; and popularisation and extensive distribution of barrier methods. These have been adopted and are being implemented in terms of the National AIDS Control Programme.

Overall, the Programme aims to reduce the transmission of STI's and HIV infection, and provide appropriate care, treatment and support for those infected. The Programme endeavours to coordinate the efforts of all role-players to ensure the optimal use of resources.

It is recognised that HIV/AIDS cannot be prevented without addressing the socioeconomic factors which underlie its spread. The cause and impact of AIDS extends beyond the health sector, requiring the commitment of and intervention by a sectors - the State, private sector, nongovernmental organisations (NGOs) and community-based organisations (CBOs).

The implementation of the National AIDS Control Programme focuses on five central objectives:

1. To prevent the spread of the epidemic through the promotion of safer sexual behaviour, adequate provision of condoms and control of STDs;
2. to protect and promote the rights of people living with HIV or AIDS by ensuring that discrimination against such people is outlawed;
3. to use the mass media to popularise key prevention concepts and develop life skills education for youth in and out of school;
4. to reduce the personal and social impact of HIV/AIDS through the provision of counselling, care and social support, including social welfare services for persons with HIV/AIDS, their families and the community; and
5. to mobilise and unify local, provincial, national and international resources to prevent and reduce the impact of HIV/AIDS.

The following principles will therefore be adopted for the control of HIV/AIDS in South Africa:

9.1 CIVIL SOCIETY AND THE GOVERNMENT SECTOR WELL BE INVOLVED MUTUALLY IN CONTAINING THE SPREAD AND IMPACT OF HIV/AIDS

The HIV/AIDS epidemic is rooted in society's fabric. This multifaceted epidemic, with its medical, social, psychological and economic dimensions, requires the involvement of all sectors of society. The Government has a particular role to play in implementing control strategies for IRV infection and STDs. To improve the effectiveness and ensure the credibility of such strategies, it is important that Government benefits from the collective experience of civil society.

9.1.1 Implementation strategies

(a) Ensuring government commitment

The Government is committed to achieving the National AIDS Control Programme's objectives and will, within the confines of the limited resources available, ensure that an appropriate level of funding is provided for its implementation.

The Government's role is to lead and guide the process. It cannot implement the National AIDS Control Programme on its own, hence the need for coordinating and linking the strategies and activities of a wide range of role-players. In this regard, the initiatives and efforts of NACOSA, the National Association of People Living with HIV/AIDS (NAPWA), NGOs, CBOs and the private sector are recognised and affirmed.

To consolidate the roles of the various Government departments, a multi-sectoral, interdepartmental approach will be adopted. In this regard, an interdepartmental task team will be convened to develop a multisectoral approach to the problem.

(b) Establishing mechanisms to involve all members of civil society and other stakeholders

Mechanisms for the co-ordination and active participation of all stakeholders should be created to facilitate the participation of civil society in HIV/AIDS control.

(i) National AIDS Convention of South Africa

NACOSA was formed after a national conference entitled "South Africa United Against AIDS" held on 23-24 October 1992. The Conference was held to develop a national strategy for HIV/AIDS control, develop strategic plans and co-ordinate the implementation of planned activities.

The National AIDS Control Programme will maintain a strong, mutually collaborative relationship with NACOSA, which will be pursued with the NACOSA Steering Committee at the national level and provincial NACOSA committees. This should ensure that NACOSA continues to provide guidance to the Programme. It also makes allowance for participation in the Programme by all sectors of South African society.

(ii) National HIV/AIDS and STD Advisory Group

A national HIV/AIDS and STD Advisory Group will be established to -

• review and comment on the Programme's policies, plans and activities;
• assist and advise the Programme with regard to securing resources for programme activities;
• establish technical subcommittees on specific issues as and when required;
• encourage linkages between the Programme and other role-players in AIDS/STD control; and
• serve as a resource for ad hoc advice on HIV/AIDS and STD- related activities, both within and outside Government.

The HIV/AIDS and STD Advisory Group intends to be as broadly representative as possible. In appointing members, cognisance will be taken of the need to ensure the representativeness of all stakeholders affected by the epidemic.

The Advisory Group will meet once every six months - or more frequently, if necessary - and its members will be appointed by the Director-General for Health. Meetings of the Advisory Group will be funded by the National AIDS Control Programme, which will also provide a secretariat.

The Programme Director and two other Programme staff members, appointed by the Director, will be ex officio members of the Advisory Group.

Nominations to serve on the Advisory Group will be open to the public. Requests for nominations will be advertised through a multi-media strategy. This will include the use of radio, national and local newspapers, the NACOSA and the HIV/AIDS-STD Directorate.

Membership tenure of the Advisory Group will be three years. (iii) Committee on NGO funding

To facilitate the contribution of NGOs and CBOs to HIV/AIDS prevention and control, a committee will be formed to co-ordinate support for NGO/CBO activities. This committee will -

• develop an NGO funding policy for the Programme;
• process NGO applications for Government funding of HIV/AIDS/STD- related activities, and rank them in order of priority; and
• review the progress made by NGOs/CBOs.

(iv) Involvement of the private sector

The private sector should be actively concerned with the support of HIV/AIDS prevention and control measures. The resources available to this sector should be mobilised accordingly, in support of activities within the overall framework of the National AIDS Plan developed by NACOSA.

(v) Working relationships with international agencies

A commitment to working with international agencies has been given. Technical and other support will be obtained as needed from the international community including UN Agencies such as the WHO, UNICEF, UNDP and UNAIDS.

(vi) Co-ordination of research on HIV/AIDS and STDs

It is as important to co-ordinate research on HIV/AIDS-STDs as it is to ensure the use of data generated. A committee will be established to -

• develop a research policy for the Programme in accordance with the Essential National Health Research (ENHR) policy of the Department of Health;
• review applications for research funding and rank them in order of priority within the research funding guidelines of the Department; and
• make recommendations to the Ethical Committee of the Department of Health.

(c) Developing key strategies

Within the framework of the NACOSA AIDS Plan and current understanding of the epidemic, the following key strategies have been identified:

(i) Life-skills programme targeted to the youth

There is general consensus in South Africa about the need for HIV/AIDS- STD education for youth in and out of school.

Studies have shown that appropriate sexuality and AIDS education may delay the onset of sexual activity, and promote the use of safer sex practices among students who are sexually active. It is envisaged that HIV/AIDS-STD education will be a component of a broader education programme, which will include other aspects of health and family-life education such as nutrition, substance abuse and environmental awareness.

Life-skills are required by young people to respond appropriately to the challenges and hurdles they face. Such skills will enable young people to develop self-esteem and self-confidence.

While such education will endeavour to be sensitive to the moral and cultural ethos of different communities, it will, nevertheless, ensure that factual information is provided to the youth.

The National Youth Development Forum and the South African National Students' Congress will be supported in their efforts to provide life-skills training to their constituents.

(ii) Use of mass communication media to popularise key prevention concepts in AIDS

HIV infection and AIDS in the South African context are largely influenced by a number of socioeconomic factors, making disadvantaged communities more susceptible to infection. Economically depressed communities are further disadvantaged by lack of access to AIDS and condom information, and to the supportive infrastructure required to stabilise and reverse infection trends.

The socioeconomic implications of the disease are likely to undermine dramatically the achievements of the reconstruction and development process. The current media strategy, therefore, focuses on the prevention of infection and overcoming discrimination against HIV-infected individuals. This emphasis will be reviewed as the epidemic progresses, and shifts in strategy become necessary.

Communication techniques will be applied to popularise key prevention concepts in AIDS, including the following:

(iii) Appropriate treatment and management of patients seeking treatment for STDs

There is a close relationship between classical STDs and HIV. Appropriate treatment and management of classical STDs will, therefore, impact on HIV transmission. Historically, classical STDs have been a neglected area of health care provision. The emphasis in future will be on improving the quality of STD services in both the public and private sectors. This will ensure that such care is available to all health care users, promoting the use of the syndromic approach to STD management.

(iv) Improved access to barrier methods

The use of barrier methods has proved to be one of the most effective ways of ensuring a high level of protection against the spread of STI)s and HIV infection. An important task of the National AIDS Control Programme, therefore, is to ensure that a range of barrier methods is made freely available to everyone, and that health care workers are trained to assist people in their correct use. In particular, there is a commitment to promoting the use of female barrier methods.

(v) Promotion of appropriate care and support

A commitment has been made to ensure that all persons infected with HIV or suffering from AIDS enjoy access to a continuum of appropriate care and support. Such treatment should include access to counselling services and drugs for treatable opportunistic infections.

Now is an opportune time to develop national, cost-effective plans for the medical management of people living with HIV or AIDS before the epidemic grows. The provision of care is largely the responsibility of the Department of Health at all levels. The relevant Directorate will facilitate and support this matter through the development of guidelines.

The following will, therefore, be undertaken in close collaboration with the relevant Chief Directorates of the DOH:

• management protocols for men, women and children;
• strategies to improve tuberculosis control;
• guidelines for the delivery of care at the appropriate level, along a continuum from home to hospital to hospice, with appropriate discharge and referral patterns;
• procurement of drugs for treatable opportunistic infections; and
• training of health care workers to provide appropriate care.

A commitment to ensuring that counselling services complying with the minimum standards developed by the NACOSA are available to all communities, has been made.

(d) Internal and external channels of communication

The National AIDS Control Programme will ensure that communication is facilitated between the Programme and the various role-players, including role-players in the Department of Health, the private sector, civil society, NGOs and CBOs.

This will include making sure the general public is kept informed of the Programme's activities, achievements and problems encountered. To facilitate this, a clearing house will be established and kept current, to ensure that new material is disseminated widely.

9.2 PEOPLE LIVING WITH HIV OR AIDS WELL BE INVOLVED IN ALL PREVENTION, CONTROL AND CARE STRATEGIES. THERE WELL BE NO DISCRIMINATION AGAINST PEOPLE LIVING WITH HIV OR AIDS, AND THEIR LEGAL RIGHTS WILL BE PROTECTED

9.2.1 Implementation strategies

(a) Involvement of people living with HIV or AIDS

People living with HIV or AIDS will be involved in all decision-making forums of the national HIV/AIDS and STD control programme. This should include their involvement in prevention, education and care-giving activities.

(b) Non-discrimination and legal rights: testing

No HIV testing shall be undertaken before informed consent has been obtained. Test results shall be confidential and only disclosed with the person's consent. It has been recommended that HIV testing should only be conducted within the guidelines set down in law and by the South African Medical and Dental Council (SAMDC).

Testing for the purposes of anonymous, linked or unlinked sero-prevalence studies should adhere to the parameters set out in the WHO guidelines.

HIV testing should be conducted in accordance with the Department of Health's testing policy guidelines.

(c) Legal reform

The National AIDS Control Programme commits itself to a broad programme of legal reform. This will ensure the creation of a non-discriminatory environment which supports the Programme's public health interventions. This includes legislative interventions to outlaw discriminatory practices. (d) Non-discrimination and equity

The Programme commits itself to ensuring justice and equity for all persons living with HIV or AIDS.

(e) Addressing the vulnerability of women

The National AIDS Control Programme recognises the vulnerability of women to the epidemic and it is, therefore, committed to ensuring that all its projects are gender-sensitive. It is also committed to introducing multi-disciplinary, special gender programmes throughout the country.

9.3 THE EMPHASIS WILL BE ON ADEQUATE CAPACITY-BUILDING AT ALL LEVELS, TO ACCELERATE HIV/AIDS PREVENTION AND CONTROL MEASURES

9.3.1 Implementation strategies

(a) Developing human resources

The Government is committed to the development of human resources in the public service, NGOs and CBOs to ensure a greater capacity for dealing with the epidemic's varying challenges.

In particular, adequate training will be provided to improve counselling services throughout the country.

(b) Ensuring safe blood supplies

Since 1985, all blood donated through recognised blood transfusion service centres has been tested for HIV. It is necessary to ensure the safe supply of blood, despite the rise in HIV. To this end, it is essential that blood and blood products are not pooled until all testing precautions have been taken. Blood donors should not be paid and transfusions should only be given in essential cases.

(c) Capacity for effective communication and health promotion

In order to achieve the desired behavioural change for the prevention and control of HIV/AIDS, pre-tested messages and the ability to target priority groups will have to be developed. Formative research will be conducted to enrich this process and ensure that education, counselling and supportive care activities are sensitive to culture, language and social circumstances.

(d) Capacity for monitoring and evaluation

The National AIDS Control Programme is committed to the ongoing monitoring and evaluation of priority interventions. The capacity for monitoring and evaluation will be strengthened at all levels.

(e) Universal precautions

Protocols will be developed to reduce the risk of occupational exposure to HIV by staff in different settings.

(f) HIV/AIDS surveillance

Existing mechanisms of HIV surveillance will be strengthened and expanded to include the monitoring of STI)s, indicators of AIDS and indicators to ensure that the impact of policy and behavioural changes are measured.

(g) Co-ordination of activities

The National AIDS Control Programme commits itself to coordinating and facilitating AIDS programmes, research and other AIDS-related activities in the country.