Chapter 10

Infectious and Communicable Disease Control

Infectious and Communicable Diseases include Tuberculosis (TB), hepatitis, measles, polio, diphtheria pertitis, malaria, and other diseases such as cholera and leprosy. The control of Communicable diseases which are largely preventable is a vital function of the Department of Health. The Department is committed to effective control of this set of diseases by a number of strategies including improving access to Primary Health Care, improving preventive strategies, accelerating vaccination programmes and improved clinical management.

South Africa is facing one of the worst TB epidemics in the world and TB is one of South Africa most important public health problems. In 1995 there were over 90000 new cases of TB and an estimated 3,000 deaths. The incidence of TB is currently estimated at over 224/100,000. The interaction between HIV and TB has enabled the HIV epidemic to contribute to a further increase in TB incidence. Other factors contributing to the increased incidence of TB is the development of multidrug resistant TB which is difficult and expensive to treat. An effective control strategy is required to prevent South Africa's TB epidemic from spiralling out of control.

Department of Health has taken the unprecedented step of declaring TB a top national health priority. This action is aimed at motivating key role players and decision makers to invest adequate resources in TB management and help mobilize role players and communities to improve TB control activities. TB cure rates will be an indicator for the success. Other planned activities for TB intervention will include cooperation and agreement with neighbouring countries on joint control strategies, ensuring adequate skills at provincial and district levels and integrating services at clinic level. A Tuberculosis Operational Centre has been established to monitor the progress of the TB Control Programme and to provide technical support for the provinces.

With regard to the Expanded Programme on Immunization (EPI), a national review has been conducted. Hepatitis B has been included in the EPI schedule. The Haemophillus influenza type B vaccine and an active Acute Flaccid Paralysis (AFP) surveillance system will soon be implemented. It indicates that the last reported polio case was in 1989. As a follow up to a comprehensive review a comprehensive cold chain system is to be implemented. Following a successful sub-national polio campaign and a mass national polio and measles campaigns in 1996. A mass national measles campaign is also scheduled for 1997.

South Africa is experiencing one of the worst Malaria epidemics in decades. Exacerbating the Malaria problem is the spread of parasite resistance to malaria drugs of choice and changes in mosquito vector species. The current vector does not always rest inside on the wall services after taking blood from the human host which makes the insecticides sprayed on the walls less effective. Malaria control strategies should be reviewed and intensified. Since malaria is a regional problem collaboration among Southern African countries is being initiated to enable a regional approach in the control of Malaria.

10.1 CDCS SHOULD BE ACCESSIBLE AND INTEGRATED INTO COMPREHENSIVE PRIMARY HEALTH CARE SERVICES

The prevention, diagnosis and treatment of CD are essential components of comprehensive primary health care. TB is the most common opportunistic infection in people infected with HIV and kills more people than any other infectious disease. Given the high incidence of TB in South Africa, it -is important that TB should be managed in a primary care setting.

Immunisation is one of the essential elements of primary health care services. Services should be available to all children and mothers on a daily basis at all clinics, community health centres and out patient departments of hospitals.

Malaria cannot yet be totally integrated into primary health care. Passive diagnosis and treatment can be fully integrated but active detection, diagnosis and treatment still play a vital role in malaria control. Vector control through spraying of structures with insecticides is still a specialised service being managed at regional level.

Strengthening CD services through appropriate management structures will help to strengthen primary care services.

10.1.1 Implementation Strategies

(i) Health Facility Level

TB and malaria diagnosis and treatment services should be available in all primary health care facilities. Collaboration between many service providers including Departments of Health, nongovernmental organisations and the private sector will make TB diagnostic and treatment services more accessible. TB Coordinators at district, provincial and national levels will facilitate this collaboration. EPI services should be available at every primary health care facility and should be supported by mobile services.

(ii) District Level

Every district should have a coordinator responsible for TB and one for EPI who may also be responsible for other communicable diseases. This coordinator will ensure that the CDC strategy is properly implemented and will provide technical support and supervision to health care providers. The coordinator should also participate in the district health management team to ensure that CDCS services are fully integrated with other health services.

(iii) Provincial Level

Integration at provincial level should be achieved by coordination and communication with other programmes. Given the magnitude of the TB epidemic, the EPI programme and the malaria epidemic and the need to coordinate activities within and outside the Department of Health, a full time Coordinator should be appointed for each programme in every province. A coordinator should also be appointed to manage the response to outbreaks of diseases such as haemorrhagic fevers e.g. Ebola and Congo Fever, Cholera and Plague. These coordinators should also liaise with the national managers of these diseases.

(iv) National Level

Integration at national level should be achieved by coordination and communication with other key role players. The functions of the National TB, EPI and Vector-borne Diseases (mainly Malaria) and Other diseases (such as Cholera and Leprosy, as well as outbreak response) Control Programmes should include strategic and operational planning, policy formulation, advocacy to ensure understanding and commitment to effective disease control, production of health education materials, development of standardised training materials, monitoring and evaluation. A strong team is required at national level to provide adequate technical support to the provinces.

(v) Establishment of a Peripheral Microscopy Network

In order to diagnose smear-positive (infectious) TB cases, microscopy services must be accessible to primary health care services. International recommendations suggest that there should be approximately one microscopy centre per 100,000 population. Microscopy services should be provided in the context of laboratory services for primary health care. Sputum smear results should be available quickly enough to be convenient for health workers and patients (preferably on the same day the sputum sample is taken). This service can be incorporated into the already well established microscopy services in the provinces where malaria is prevalent.

10.2 CDCS SHOULD BE EFFICIENT, COST-EFFECTIVE AND OF GOOD QUALM

The DOTS strategy has proven to be a cost-effective way to control the spread of TB, even in poor socioeconomic conditions and high levels of HIV infection. The quality, quantities and costs of the medicines used in the TB and Malaria programmes, as well as the vaccines used in the EPI programme, should be assured by a national tendering and contract system.

10.2.1 Implementation Strategies

(i) Demonstration and Training Districts

In order to implement the full TB Directly Observed Treatment Strategy (DOTS) strategy, demonstration and training districts should be established. Once these sites achieve success as demonstrated by high smear conversion rates and high cure rates, they will act as templates for other districts. The demonstration and training districts will expand to cover the entire country by 1999. In this way, South Africa will be able to achieve the goal of curing 85% of new smear-positive TB cases by the year 2000.

The national EPI in collaboration within the WHO and UNICEF have trained personnel on provincial and district levels.

(ii) Uniform drug management approaches nationally using standard treatment guidelines for the Essential Drug list are important since the proliferation and use of different management schemes would contribute to an increase in Multi-drug resistant tuberculosis.

(iii) Early identification and treatment of opportunistic infections for TB/HIV will contribute to effective management of both TB and HIV/AIDS,

10.3 HEALTH CARE STAFF SHOULD BE ADEQUATELY TRAINED ON CDC STRATEGIES

The capacity of primary health care workers to implement the CDC strategies should be strengthened by training all health staff (both those in training and those in service).

10.3.1 Implementation Strategies

(i) Pre-service training

TB, Immunisable Diseases, Vector-borne Diseases such as Malaria and Rabies, as well as some of the Other diseases, should be incorporated into the training curricula of medical students, nurses, laboratory technicians and allied health professionals.

(ii) In-service training

Initial training is required to orientate working health professionals to new strategies. Subsequently, ongoing refresher training is required. At least one staff member in every primary health care facility should be familiar with one of the above-mentioned strategies.

10.4 COMMUNITIES SHOULD BE INVOLVED IN CDC ACTIVITIES

For the TB programme the essential element of the DOTS strategy is Directly Observed Treatment (DOT). DOT supports TB patients by observing them swallow their TB drugs to ensure that they complete treatment and are cured. TB treatment should be made as accessible and convenient for TB patients as possible. TB patients can receive DOT at clinics, at the workplace or in their communities. Every TB patient should choose a treatment supporter to provide DOT, in consultation with a health worker. Rigorous DOTS should be instituted in hospitals during the initial treatment period for TB. Communities are already involved with malaria control where their houses are sprayed annually for vector mosquito control. Closer involvement should be developed in future in areas where mosquito-proof bed nets and other personal precautionary measures can be introduced.

10.4.1 Implementation Strategies

(i) Employers

Many of those who develop CD e.g. TB are working. As far as possible, after the acute phase such people should receive treatment under supervision at their place of employment. Treating TB sympathetically means that others who suspect they have the disease are encouraged to come forward and be treated early in their disease.

(ii) Community-based

Any responsible community member can provide the DOT for TB. District Coordinators should encourage increased involvement of communities through health education, and liaison between health services and community-based organisations.

10.5 EDUCATION OF INDIVIDUALS ON CD SHOULD BE ADEQUATE

Individuals should know the symptoms of the most important diseases such as TB, childhood diseases and malaria. They should know which diseases can be prevented and that all of them can be cured if diagnosed in time. There should be no discrimination against people suffering from TB.

10.5.1 Implementation Strategies

(i) World TB Day

Every year on March 24, the world focuses its attention on TB. March 24 was the day in 1882 when Dr Robert Koch announced his discovery of the bacillus that causes TB. World TB Day should be used as an opportunity to inform the general public about DOTS and to reduce the stigma attached to TB.

(ii) Health promotion materials

Media releases, posters, pamphlets, comic books and videos on CD prevention and control should be produced and distributed.

10.6 THE CDC PROGRAMMES SHOULD ENSURE ACCOUNTABILITY THROUGH THE USE OF RECORDING AND REPORTING SYSTEM, BY ESTABLISHING A FINANCIAL MANAGEMENT SYSTEM, AND THROUGH REGULAR EVALUATION AND REVIEW

The TB recording and reporting system uses cohort analysis to measure treatment outcomes. This system allows the measurement of key programme indicators including the cure rate of new smear-positive TB patients. The goal of the TB Control Programme is to cure 85% of new smear-positive TB patients by the year 2000. Linking financial expenditures to cure rates will give a measure of cost-effectiveness. Measuring and reporting cost-effectiveness will allow the Department of Health to be accountable for TB control activities.

Recording and reporting on the Vaccine Preventable Diseases, Vector-borne disease and Other diseases to analyse their cost-effectiveness should also be established and continued.

Information and surveillance data of communicable diseases will be used for further planning, and management of communicable Diseases.

10.6.1 Implementation Strategies

(i) Implementation of the recording and reporting system

The TB register and accompanying documentation should be made available to all health care facilities which diagnose and treat TB. Health workers in these facilities, District Coordinators and Provincial Coordinators should be trained to complete the forms and to use the information for management purposes.

Report systems on the Vaccine Preventable, Vector-borne and Other diseases should also be continued and established where not yet available. An active Acute Flaccid Paralysis surveillance system was implemented to notify and de- notify cases.

(ii) Supervision

The TB register and quarterly reports should be reviewed by District Coordinators during monthly supervisory visits to health facilities to ensure the accuracy of the information which is reported. Similarly, the reports of the other diseases mentioned above should also be reviewed by District Coordinators, their reports by Provincial Coordinators and the reports of Provincial Coordinators should be reviewed by the National Manager on a quarterly basis.

(iii) Financial management system

A system compatible with the State financial management system should be implemented to account for TB, EPI, Vector-borne Diseases and Other Diseases expenditures.

(iv) Evaluation and review

Regular evaluation and review of the TB, EPI, Vector-borne Diseases and Other Diseases Control Programmes should be done to ensure that the programme is on the right track to achieve its goals.

10.7 COMMUNICABLE DISEASE CONTROL SERVICES SHOULD ENSURE EFFECTIVE INFECTION CONTROL INCLUDING CONTROL AND MANAGEMENT OF EPIDEMICS

Epidemic control and management is an important activity of the department. The Department of Health with relevant partners will ensure effective infection control to protect health and laboratory workers as well as individuals at risk of various infections diseases. Epidemics will be carefully monitored, managed and contained to protect communities from morbidity and mortality associated with communicable and infectious disease.

10.7.1 Implementation Strategy

A epidemic management system will be developed across the country. In each province and region a coordinator who liases with the national department will be appointed to manage the response to outbreaks of diseases such as haemorrhagic fevers, Cholera, and Plague. The epidemic management system will cover a broad range of stakeholders as well as neighbouring countries to ensure effectiveness in epidemic management.

Infection control will be strengthened and continuously monitored in health and health related facilities. Measures will be instituted to ensure that safety guidelines for infection control are adhered to in health and medical environments as well as in social environments such as schools, kindergartens and shelters.

Chapter 11

Environmental Health

The Department of Health, in collaboration with other relevant sectors, is responsible for the improvement of South Africa's environmental health status. It therefore endeavours to limit the health risks which arise from the physical and social environment,

The broad aim of environmental health services is to address environmental health priorities as defined by, inter alia, the RDP, the World Health Organisation's Global Strategy for Environment and Health, the UNCED 92 Agenda 21 Strategy and the relevant Year 2000 Health Goals and Objectives set out in Chapter 21 of this document.

The Basic Subsistence Facilities Report published by the Department of Health in January 1995 illustrated the water and sanitation situation as follows:

(a) Drinking water

• Rural population: 52% have no access to potable drinking-water
• -Marginal urban population: 2,7% have no access to potable drinking water

(b) Latrine facilities

• Rural population: 54% have no facilities
• Marginal urban population: 34% have no facilities

(c) Domestic refuse removal/disposal

• Rural population: 61,5% have no access to a refuse removal system
• Marginal urban population: 70,6% have no access to a system

Because of rural inequalities in socioeconomic development as well as rapid industrialisation and urbanisation, South Africa experiences a wide range of environmental health impacts.

11.1 EVERY SOUTH AFRICAN HAS THE RIGHT TO A LIVING AND WORKING ENVIRONMENT WHICH IS NOT DETRIMENTAL TO HIS/HER HEALTH AND WELL-BEING

11.1.1 Implementation strategies

The health sector will collaborate with other sectors to implement the following strategies:

(a) Human resource development for environmental health

This will be undertaken through the support of formal and informal training programmes which are sensitive to the country's needs. All environmental health practitioners should be technically competent to deal with the management of health risks in the physical and social human environments in order to promote a sustainable and healthy environment.

(b) Intersectoral collaboration

In view of the multidimensional and multidisciplinary nature of the interactive process between the environment and health, the Integrated Environment Health Management Strategy should interface with all sectors which play a role in environmental health risk reduction.

Existing mechanisms for intersectoral collaboration such as the Interdepartmental Liaison Committee of the Departments of Health and Water Affairs and Forestry, and the National Sanitation Task Team (NSTT) will be utilised to promote intersectoral action.

(c) Distribution of environmental health services

Based on community needs and related risk assessments as they impinge upon the quality of physical and social environments, environmental health service interventions including the promotion of clean water, adequate sanitation provision and food safety will be aimed at addressing needs and reducing the associated risk on a prioritised basis.

(d) Environmental health: a "shared responsibility"

The environmental health sector will be responsible for the provision of accessible services and support communities in managing environmental health risks. Ultimately, however, each individual must take responsibility for the maintenance of a healthy environment.

(e) Environmental health legislation

A community development rather then a law enforced approach will be followed in creating environmental conditions conducive to good health. Environmental health legislation will comply with the requirements contained in the Interim Constitution's Bill of Rights and will be based on integrated, appropriate and uniformly applicable legislation.

11.2 ALL PERSONS SHOULD HAVE ACCESS TO KNOWLEDGE ON ENVIRONMENTAL HEALTH MATTERS AND THE SERVICES AVAILABLE TO THEM

11.2.1 Implementation strategies

1. Community empowerment is central to the principles of the RDP. The primary health care approach to the delivery of community-based services involves the active participation of these communities. This will be done through the dissemination of strategic and appropriate environmental health and hygiene information, education and communication (IEC) to develop the communities' capacity for participation.
2. Environmental health information will be included in health promotion and marketing activities at all levels. In support of EEC, environmental health information centres should be established.
3. Environmental health practitioners, in collaboration with other stakeholders, will ensure that communities are able to plan and implement effective environmental health strategies through an integrated IEC Programme aimed at improving social mobilisation.

11.3 ENVIRONMENTAL HEALTH SERVICES SHOULD BE ACCESSIBLE, ACCEPTABLE, AFFORDABLE AND EQUITABLE. THEY MUST BE IMPLEMENTED WITH THE ACTIVE PARTICIPATION OF THE COMMUNITIES

11.3.1 Implementation strategies

1. A comprehensive environmental health service, sensitive to and inclusive of the communities' needs, will be rendered.
2. Environmental health services should be representative of the diverse cultural composition of the South African population and be distributed according to the communities' real needs.

11.4 ENVIRONMENTAL HEALTH SERVICES SHOULD CONTRIBUTE POSITIVELY TOWARDS SUSTAINABLE PHYSICAL AND SOCIO- ECONOMIC DEVELOPMENT

The health sector has an important role to play in promoting interaction between health, the environment and overall development.

11.4.1 Implementation strategies

(a) Ensuring health impact assessment

An integrated health and environmental approach should be included in the environmental impact assessment of all major development projects.

(b) Integrating health policy with overall developmental policies affecting the environment

The health sector should participate in developing policy co-ordinating mechanisms at all levels of government and within the private sector and NGO's to ensure the sustainability of a healthy environment.

(c) Establishment of a WHO regional centre for environmental health in South Africa

This should ensure liaison in the spheres of health, environment and development with member states within the AFRO region of the WHO.

(d) Supporting / promoting international conventions/ programmes aimed at ensuring sustainable development

The Department of Health should contribute to implementing the Agenda 21 principles within the health sector, as it relates to programmes such as Healthy Cities, the Montreal Protocol, etc.

11.5 THE ESTABLISHMENT OF EFFECTIVE ENVIRONMENTAL HEALTH SURVEILLANCE IS ESSENTIAL TO DETERMINE WHETHER OR NOT THE SERVICES ARE FUNCTIONAL AND EFFECTIVE AND HAVE A POSITIVE HEALTH IMPACT

11.5.1 Implementation strategies

1. Training will be undertaken to improve capacity for planning, implementation, monitoring and evaluation of environmental health issues at the provincial, district and community levels.
2. Indicators for monitoring and evaluating the impact of environmental health services will be improved.
3. The National Environmental Health Services Surveillance Programme (NEHSSP) will ensure linkages and networking with all stakeholders concerned with environmental health information.

Mental Health and Substance Abuse

Mental illness is a major cause of morbidity as well as some mortality, particularly amongst citizens at risk in South Africa. The latter refers specifically to communities which have been ravaged by State neglect and abuse for decades. Generally, mental health promotion and the provision of services have been neglected in the past. Common manifestations are interpersonal violence, gender and age-specific forms of violence, trauma, neurosis of living under continual stress, post-traumatic stress reactions and disorders, substance abuse, suicide, and adjustment-related reactions and disturbances in children and the elderly.

Mental health services, like all other services, have been fragmented and are ill-equipped to intervene effectively. Available services are neither appropriate nor accessible to the majority of the population, especially those in rural areas. Successfully improving and promoting the psychosocial well-being of all communities is an essential ingredient in the implementation of the RDP. South Africa has the advantage of a strong NGO presence and other social formations, like concerned and committed business communities, church groups and organised children, youth and women's associations. With the proper co-ordination and support, they could play a major role in the promotion of mental health.

12.1 A COMPREHENSIVE AND COMMUNITY-BASED MENTAL HEALTH AND RELATED SERVICE (INCLUDING SUBSTANCE ABUSE PREVENTION AND MANAGEMENT) SHOULD BE PLANNED AND CO-ORDINATED AT THE NATIONAL, PROVINCIAL, DISTRICT AND COMMUNITY LEVELS, AND INTEGRATED WITH OTHER HEALTH SERVICES

In the past, mental health care was largely custodial and based on medical therapy. The focus was limited to occupational therapy and in- and outpatient psychotherapy and counselling. The latter forms of therapy tend to be skewed in favour of the urban, wealthier population in terms of access, quality and personnel.

Mental health services are run as a vertical programme and lack a comprehensive approach as the primary health care philosophy suggests. There is poor intersectoral liaison and co-ordination of services, leading to duplication and fragmentation.

12.1.1 Implementation strategies

(a) National level

At the national level, the Mental Health and Substance Abuse Directorate will be responsible for planning mental health and substance abuse services through a process of consultation with other role-players and consumers. This will ensure the effective co-ordination and integration of the services as well as their monitoring and evaluation. The Directorate will facilitate the development of functions at various levels of care, focusing on the role of communities. The approach should be multi-professional, with the emphasis on preventive and promotive services.

Among other national level functions will be the following:

1. evaluating the prevalence of mental health problems and promoting strategies to address problems identified;
2. coordinating the restructuring of mental health services, including the development of norms and standard and integration of mental health services into PHC;
3. promoting intersectoral co-ordination and the multidisciplinary team approach;
4. developing norms and standards for the education and training of mental health human resources;
5. monitoring research on mental health on a national basis and promoting research in priority areas;
6. monitoring and evaluating mental health services nationally and ensuring equity;
7. exploring the nature and extent of collaboration with traditional healers;
8. reviewing and evaluating legislation relating to mental health and substance abuse to safeguard the human rights of all service users;
9. developing and promoting specific programmes addressing substance abuse, child abuse, women abuse and the management of victims of violence, in collaboration with other sectors;
10. planning, providing and monitoring forensic psychiatric services;
11. planning and promoting specific services for the mentally handicapped in collaboration with the relevant stakeholders and users of the services; and
12. planning, developing and promoting specific services for psychogeriatrics to ensure quality of life, in collaboration with other role-players.

(b) Provincial level

The planning, co-ordination, effective supervision, monitoring and evaluation of mental health services will be undertaken at the provincial level. The provincial health authorities should provide a sustainable budget for provincial and district mental health and substance abuse services.

The provincial health authorities will also have other functions, including the following:

1. Facilitating intersectoral co-ordination in order to bring together workers from other sectors for example religious, educational, women's, industrial, police, agricultural, youth and sport groups and NGOs;
2. ensuring the comprehensive integration of mental health and substance abuse services with other health services, to avoid verticalisation of the service; and
3. ensuring that mental disability and psychogeriatric services are also included in the health services provided.

(c) District level

At district level, the health authorities will ensure the comprehensive integration of mental health services with other services. Planning of mental health services should be undertaken, with the active participation of various stakeholders, especially the communities.

The following activities will be undertaken at the district level:

1. Providing mental health and substance abuse prevention, promotion and rehabilitative services, giving special attention to the planning, implementation and co-ordination of community-based rehabilitation;
2. planning and implementing inpatient and day-patient care for the mentally ill and substance abusers, establishing a 24 hour consultation service for mentally ill patients and victims of substance abuse;
3. providing training for health facility staff,
4. undertaking mental health education programmes in communities;
5. establishing and maintaining mental health committees and maintaining collaboration with other sectors, private practitioners, traditional healers and NGOs; (vi) providing emergency and crisis interventions and counselling;
6. collecting data, and initiating and contracting out research in accordance with local needs, with the support of relevant institutions; and
7. developing appropriate indicators for monitoring and evaluation.

It is important that data collection, analysis and resultant action be performed at each level and appropriate feedback given, especially to the communities.

(d) Community level

At the community level, non-governmental and other grassroots organisations should be involved in mental health services. Communities should be actively involved in the planning and implementation of community-based mental health care services, as well as substance abuse prevention, management and rehabilitation.

Among the activities to be promoted will be the following:

1. the formation of community mental health forums to evaluate causative factors and problems within the communities may facilitate the elimination of the stigma attached to mental illness and reduce substance abuse;
2. development of special programmes addressing aspects of violence within communities, with an emphasis on children and women;
3. provision of health education and information on mental health and substance abuse - especially to the youth - and the establishment of community centres for crisis intervention; and
4. development of special programmes aimed at educating and providing information and support to the mentally disabled and psychogeriatrics, thereby improving their quality of life in the community.

12.2 ESSENTIAL NATIONAL HEALTH RESEARCH SHOULD INCLUDE AN ANALYSIS OF MENTAL HEALTH AND SUBSTANCE ABUSE TO IDENTIFY THE MAGNITUDE OF THE PROBLEM

Mental health services and substance abuse have been accorded inadequate attention by researchers. There is little doubt that the burden of mental ill health in South Africa is costly in terms of health care expenditure and loss of productive years of life. It is, therefore, essential for research to be directed at both prevention and rehabilitation.

12.2.1 Implementation strategies

1. Additional funds should be allocated for research on mental illness, substance abuse and violence, especially at the household level, with emphasis on age and gender differentials.
2. Young research interns should be encouraged to conduct research projects on mental health, substance abuse and violence to ensure sustained interest.

12.3 HUMAN RESOURCE DEVELOPMENT FOR MENTAL HEALTH SERVICES SHOULD ENSURE THAT PERSONNEL AT VARIOUS LEVELS ARE ADEQUATELY TRAINED TO PROVIDE COMPREHENSIVE AND INTEGRATED MENTAL HEALTH CARE BASED ON PRIMARY HEALTH CARE PRINCIPLES

12.3.1 Implementation strategies

Among the strategies to be adopted are the following:

1. district health teams should be trained to improve their capacity for planning, implementing, supervising, monitoring and evaluating mental health programmes at the district and community levels.
2. all mental health staff should undergo special training to deal with post-traumatic stress and the impact of violence. Their communication and counselling skills should also be upgraded.
3. Staff at the lower referral levels, i.e. clinics and community health centres, should be trained to do basic screening and counselling and to identify and refer patients for further assessment and management.
4. Drugs required for the management of psychiatric problems must be available at all levels of health care provision as appropriate.

Oral Health

Oral health services in the public and private sectors are delivered by dental practitioners, oral hygienists, dental therapists, technicians and assistants. Like most of the health services in South Africa, a major deterrent to the availability of oral health services has been the inability of poor communities to pay for oral health services. This is made worse by the fact that most oral health providers work in the private sector.

Oral diseases, especially dental caries and periodontal diseases, are among the most common diseases affecting South African society. More than 90% of adults in South Africa suffer from dental caries, and 93,5% from periodontal diseases. It is worth noting that oral diseases are increasing among major sections of the population, especially the disadvantaged and urbanised groups.

13.1 THE PRIMARY HEALTH CARE APPROACH SHOULD BE ADOPTED IN THE DEVELOPMENT OF ORAL HEALTH SERVICES IN SOUTH AFRICA

13.1.1 Implementation strategies

(a) Prioritisation of service delivery

1. Preventive measures and other oral services should be provided to mothers, children, pregnant women, the physically and mentally disabled and the elderly as a matter of priority.
2. Services at all dental clinics should be aimed at providing all the above groups with at least a minimum package of services.
3. The provision and expansion of oral health services will be accelerated so that an equitable distribution of services is reached in the shortest possible time.

(b) Focus on prevention

1. Innovative strategies should be employed to provide a cost-effective oral health service, with the emphasis on prevention. It may prove cost-effective to purchase certain services from the private sector to increase the coverage of services.
2. The oral disease profile suggests that most treatments could be undertaken by oral hygienists or dental therapists. It should be possible to fill a vacant dentist's post in the public service with two dental therapists, or one therapist and an hygienist. This will improve staffing levels at clinics.

(c) Integration of oral health care

1. Oral health services should be integrated with other health services at all levels of care. (ii) A basic package of oral health services should be provided at all primary health care facilities.
2. Plans for oral health facilities should be included in the design of all primary health care institutions.

(d) Training of oral health personnel

The training of oral health personnel must be reviewed to prepare professionals for different environments and to work among different sections of the population. The deployment and utilisation of oral health personnel should meet all South African's needs, and be in keeping with the new focus of oral health service delivery.

13.2 THE INCIDENCE OF COMMON ORAL DISEASES SHOULD BE REDUCED BY THE PROMOTION OF HEALTH, PREVENTION OF ORAL DISEASES AND PROVISION OF BASIC CURATIVE AND REHABILITATIVE ORAL HEALTH SERVICES

13.2.1 Implementation strategies

(a) Minimum package of oral health care

A defined minimum package of oral health care should be provided to the priority groups listed above. This package should consist of an annual examination, bitewing radiographs, cleaning of teeth, simple 1-3 surface fillings, fissure sealants and emergency relief of pain and infection control.

(b) Systemic water fluoridation

1. Systemic water fluoridation should be implemented immediately, at least in the major metropolitan areas of South Africa, the remaining areas being phased in systematically.
2. Alternative methods of fluoridation, such as the use of fluoride toothpaste and fluoride mouth-rinses, should be introduced in schools and among priority groups.
3. Legislation to enable the fluoridation of milk and salt should be pursued.
4. Dietary supplements (fluorides and vitamins) should be included as part of the Integrated Nutrition Programme.

(c) Reduction of the consumption of refined sugar

A nutrition programme should be introduced to -

1. remove or reduce the levels of sugar in infant and baby foods including medicines, fruit juices and vitamin preparations;
2. reduce the levels of added sugars in common foods and encourage the manufacture and consumption of sugar-free foods, snacks and drinks;
3. ensure the availability of accurate information on sugars and their levels on food labels; and
4. emphasise that sugars are nutritionally poor and decrease the nutrient quality of foods.

Occupational Health

Occupational injuries and diseases have an important role to play in health, particularly in developing and middle-income countries. By affecting the health of the working population, occupational injuries and diseases have profound effects on productivity and the economic and social well-being of workers, their families and dependants.

In recognition of the above and the past neglect of occupational health in South Africa, the development of occupational health services is a key priority area of the RDP and Department of Health.

South Africa, has more than 8,2 million workers who spend at least eight hours per day in formal employment in tens of thousands of factories and mines, on farms and other places of work. The health of many of these workers has been affected by:

• chemical agents, resulting in, e.g. skin problems, lung disease and systemic poisoning;
• physical agents, resulting in, e.g. noise-induced deafness;
• biological agents, resulting in, e.g. tuberculosis and Legionnaire's disease;
• ergonomic hazards, resulting in, e.g. back pain; and
• psychological hazards resulting in stress and stress-related diseases.

Occupational health programmes must focus on providing services, conducting research and disseminating information to improve workers' health status. This involves collaboration between disciplines such as occupational hygiene, biochemistry, immunology, toxicology, epidemiology, pathology and occupational medicine. The prime responsibility of occupational health services is to identify, control and prevent adverse health effects caused by the working environment.

Responsibility for occupational health is that of a wide range of authorities and is governed by at least twenty-four pieces of legislation. These authorities include the Departments of Labour, Health, Mineral and Energy Affairs and Agriculture, as well as provincial and local authorities.

Their efforts are currently fragmented and insufficiently coordinated.

It is evident that health authorities have some responsibility for early detection, management and rehabilitation of individuals suffering from occupational injuries or/and diseases. In the past, however, no special effort was made by the public sector to provide occupational health services, except in the case of mainly White miners (which has been transferred to the employer in terms of the Occupational Diseases in Mines and Works Amendment Act, 1993) and the establishment of the National Centre for Occupational Health in Johannesburg.

14.1 EFFECTIVE INTERDEPARTMENTAL CO-ORDINATION AND ORGANISATION OF THE VARIOUS COMPONENTS OF OCCUPATIONAL HEALTH AND SAFETY IS REQUIRED

14.1.1 Implementation strategy

A new legislative framework making provision for improved co-ordination of the various components of occupational health and safety (OH&S) is required. The creation of a coordinating body along the lines of a health and safety agency with national and provincial components should result from this framework. Such bodies are common around the world, and there is need for one in South Africa. It will provide a forum for policy-making and standard-setting that is legitimate, credible and authoritative. It will also provide a setting within which a coherent policy framework for OH&S practices in South Africa can be developed. Contributions could be made by organised labour, business and State departments and OH&S specialists.

Occupational health and safety is a multidisciplinary activity and falls within the domain of a number of Government departments, business and labour. The Department of Health supports the Cabinet memorandum which initiated the investigation to establish a health and safety agency at the national and provincial levels.

14.2 THE DEVELOPMENT OF OCCUPATIONAL HEALTH SERVICES AND ASSOCIATED HUMAN RESOURCES IS REQUIRED AT THE NATIONAL, PROVINCIAL, REGIONAL AND DISTRICT LEVELS

14.2.1 Implementation strategy

Employers are primarily responsible for providing occupational health services in the workplace. Only a limited number of occupational health services are available at present. These have generally been developed to serve large workplaces, or smaller workplaces where the internal environment is especially hazardous.

Recent legislation governing the provision of occupational health services includes the Occupational Health and Safety Act (Act No. 85 of 1993), the Lead Regulations of 22 March 1991 and the Hazardous Chemical Substances Regulations of 1995. The specific requirement that all workplaces provide occupational health services should now be investigated.

The provincial health departments have a role to play in the provision of occupational health services to small and medium-sized enterprises, and the public and informal sectors. The ideal model for the provision of services to small and medium enterprises is through the district health system. It is proposed that an occupational health capacity be created in all districts where there is substantial industrial or other productive or commercial activity. Occupational health services at the district level must be integrated with the horizontal model of comprehensive health care delivery, and not run as a vertical programme. The district health service must -

1. develop occupational health education strategies;
2. develop occupational hygiene;
3. develop medical diagnostic (primary level) capacity through the use of occupational health doctors, occupational hygienists, occupational health nurses, environmental health officers and other allied professionals; and
4. liaise with the preventive enforcement agencies in the Departments of Labour and Mineral and Energy Affairs.

At the regional level, a secondary diagnostic and rehabilitative capacity for occupational health must be created at regional hospitals. These facilities will serve as referral centres for both private (workplace) and public (district) primary level occupational health services.

An occupational health facility should be created in each province. It should preferably be staffed with occupational medicine and occupational hygiene specialists, and have access to tertiary level investigations and laboratory services.

In the provincial administrations, sub-directorates for occupational health should be created. This will drive (or serve as vertical support for) the implementation of an occupational health strategy and liaise with other Government departments, the private sector, business, labour and interested parties.

At the national level, the Chief Directorate: Occupational Health has the responsibility to promote occupational health, manage the national institute for occupational health (National Centre for Occupational Health) and satisfy the statutory requirements of the Occupational Diseases, in Mines and Works Amendment Act, 1993. It has an important role to play in the development of occupational health services in the provinces and in the provision of specialised services, particularly those which cannot be cost-effectively delivered elsewhere.

The National Centre for Occupational Health has a unique mix of disciplines and provides specialised laboratory and other services, research, education, training, information dissemination and international liaison. It also houses the AJ Orenstein Library and the CIS-ILO National OH&S Information Centre.

14.3 NORMS AND STANDARDS FOR A HEALTHY AND SAFE WORKING ENVIRONMENT MUST BE DEVELOPED IN COLLABORATION WITH OTHER DEPARTMENTS

14.3.1 Implementation strategy

Occupational health and safety standards, guidelines and codes of practice are essential. They detail the measures required to protect workers from the effects of inadequately controlled equipment and ventilation and unsafe work practices.

A review of the current situation in South Africa with regard to OH&S legislation and standards is required. This will determine further steps required for South Africa to ratify and comply in full with the various International Labour Organisation OH&S Conventions and Recommendations.

14.4 BENEFIT EXAMINATIONS FOR THE IDENTIFICATION OF COMPENSABLE DISEASE IN FORMER MINE WORKERS SHOULD BE EXTENDED TO UNDER-SERVED AREAS

The statutory obligations of the Department of Health in terms of the Occupational Diseases in Mines and Works Amendment Act, 1993 include benefit (compensation) examinations of former mine workers.

Access to benefit examinations is poor in historically under-served areas (notably the Eastern Cape, Northern Province and KwaZulu-Natal). Consequently, a backlog exists and many thousands of former mine workers may suffer from unidentified compensable diseases.

To rectify this, practitioners in key locations should be identified and trained to conduct these examinations, at least until the backlog has been eliminated.

14.5 THE HARMONIOUS DEVELOPMENT OF OCCUPATIONAL HEALTH AND SAFETY IS REQUIRED ACROSS SOUTHERN AFRICA

14.5.1 Implementation strategy

During the development of the European Community (EC), the Treaty of Rome (1956) committed the EC to work for "a harmonious development of economic activity". This involves removing barriers to trade which can arise, for example, when laws such as trade regulations, worker protection or environmental standards differ nationally. The Treaty of Rome also called for better working conditions, including the prevention of occupational accidents and diseases and improvements in occupational hygiene.

As in Europe, the formation of a Southern African Economic Area will be critical for the development and wealth (and hence the health) of the Southern African community.

Initiatives by the Southern African Development Community (SADC) to form an economic area without barriers to trade are in progress. The move towards common standards, including those for occupational health and safety, will be especially important.

South Africa has special obligations to its Southern African neighbours because migrant labour has been recruited from almost all states south of an east-west line drawn to the north of Angola and Malawi. By far the most industrialised nation in the region, South Africa should play a leading role in the development and harmonisation of OH&S across the Southern African community. The Department of Health will have to play its part in this process, especially through its Chief Directorate: Occupational Health. The establishment of structures to implement the recommendation of the 1994 Conference on Occupational Health in Southern Africa would serve as a start to the development and harmonisation of OH&S standards across Southern Africa.

Academic Health Service Complexes

Academic Health Service Complexes (AHSCs) are essential national resources. They play an important role in educating and training health care workers; caring for the ill; creating new knowledge; developing and assessing new technologies and protocols; evaluating new drugs and drug usage; and assisting in the monitoring and improvement of health care quality.

It is generally recognised that a major shift is required from the position where academic medicine was based predominantly at the tertiary level. Academic medicine must have a role to play in providing a wide range of services from basic primary health care to more sophisticated services.

Each AHSC will consist of one or more faculties or departments of health sciences at one or more universities, technikons or other tertiary educational institutions, together with a number of health service facilities at different levels with which those faculties or departments are associated.

Expressed differently, it will comprise several health facilities and a consortium of educational institutions all working together to educate and train a wide range of health professionals, and conduct research.

The following principles have been adopted, to enhance the role of AHSCs in health development in South Africa:

15.1 THE ACTIVITIES OF DIFFERENT AHSCs WILL BE CO-ORDINATED WITH THOSE OF OTHER STAKEHOLDERS. SERVICES IN PROVINCIAL AND DISTRICT FACILITIES THAT ARE PART OF AN AHSC WELL BE LINKED WITH SIMILAR FACILITIES, FOR THE BENEFIT OF ALL COMMUNITIES

There has hitherto been little or no co-ordination of the education, training and research activities of AHSC. Furthermore, the support provided by these complexes to their historic "catchment" areas has been varied and uncoordinated, resulting in some areas having had no support.

15.1.1 Implementation strategies

(a) Establishment of a national council for AHSCs

A national council for AHSCs will be established to facilitate the co-ordination of these complexes' activities, including -

1. the elaboration of their role in the referral system;
2. obtaining agreement on areas of responsibility for the complexes,
3. advising on norms and standards for the complexes;
4. reviewing and making recommendations on the numbers and types of health professionals to be trained; and
5. facilitating the re-orientation of the complexes' educational, training and research functions to be more responsive to the needs of the communities.

The National Council for AHSCs should also form subcommittees to facilitate its work. For example, the Council should form a National Committee on Student Selection (NCSS), which would consult widely with all relevant stakeholders, including the universities, on issues such as -

1. the establishment of a national student entry form-,
2. criteria for admission;
3. standard application fees;
4. review of why certain universities do not receive applications from all sections of the community; and
5. academic support programmes.

This committee will have to ensure that the output of AHSCs progressively represents the demographic profile of the country.

(b) Linkages with other facilities

There are currently eight potential AHSCs located in five of the provinces.

There is a need for AHSCs to agree on their areas of responsibility and support for health services at the provincial and district levels. It is expected that these areas of responsibility will be flexible and extend across provincial boundaries. In setting up these "catchment" areas, there must be consultation between the health services-rendering authorities and AHSCs concerned.

Other strategies to be promoted are:

1. Development of undergraduate medical teaching according to the principle of "schools without walls", making use of a variety of secondary and primary health care services in the provinces and districts; and
2. integration of the service component of an AHSC into the plans of the health services-rendering authorities.

(c) Structured link with the Department of Education

A formal link will be established between the Departments of Health and Education, to ensure regular communication and discuss policy issues affecting the education and training of health professionals. This should ensure that the two departments' policy decisions and budget allocations are well coordinated.

15.2 AHSCs WILL BE ACCOUNTABLE TO BOTH THE NATIONAL DEPARTMENT AND PROVINCIAL HEALTH AUTHORITIES

15.2.1 Implementation strategies

(a) Budgeting and communication

In order to facilitate national planning and equity of access, the budgets of academic central hospitals and possibly the budgets of a very few highly specialised services in other hospitals, will be allocated by the Department of Health in consultation with all provinces.

The budgets of other health facilities that form part of the AHSC will be determined by the relevant province or district authority. There is a need for sound channels of communication to be established between the AHSC's, the National and Provincial Health Authorities.

(b) Guidelines for collaboration

Guidelines for joint agreements with the various health services-rendering authorities will be developed to facilitate services provision, research and training. These guidelines will also facilitate collaboration between the different AHSCs.

15.3 AHSCs SHOULD MAXIMISE THE BENEFITS FROM AVAILABLE RESOURCES AND ADOPT COST-EFFECTIVE APPROACHES

15.3.1 Implementation strategies

(a) Rationalising highly specialised services

Highly specialised services rendered by AHSCs should be coordinated at the national level, with steps being taken to achieve internal and external rationalisation of services within a region. The number of highly specialised services provided must be based on need.

(b) Improving the referral system

The AHSCs and various authorities should review existing referral patterns to ensure that common and minor ailments are treated at lower levels of the system. Tertiary hospitals should not be overburdened with these cases. Excess beds in some of these hospitals should be transferred to secondary and community hospitals, where the cost of patient care is considerably less.

(c) Improved hospital management

Hospital management responsibilities will increase greatly. Existing staff will be trained to improve their management skills, and posts appropriately filled. This will ensure the efficient management of hospitals by adopting cost-saving measures, generating additional funds by cost recovery and monitoring costs and efficiency. Administration and management in all health facilities will be decentralised to improve management and financial processes.

(d) Resource allocation

An equitable system of allocating resources to AHSCs will be introduced and efforts made to redress past inequities in funding, Funding of training, education and research will be through direct allocation from the national budget. Funding related to service provision will be through the provincial budgets, with the exception of national services.

15.4 THE CURRICULA OF AHSCs WILL BE REVISED TO PLACE GREATER EMPHASIS ON THE NEEDS OF THE COMMUNITIES, IN ACCORDANCE WITH PRIMARY HEALTH CARE PRINCIPLES

15.4.1 Implementation strategies

(a) Upgrading curricula

Under the guidance of the proposed National Council for AHSCs, the curricula for health cadre training, including doctors and nurses, should be revised and upgraded to include primary health care approaches. In so doing, lessons learnt by other countries which have made progress in this area should be considered.

(b) Post-graduate education

A subcommittee of the National Council for AHSCs should be established to evaluate the types and numbers of post-graduate students required, the appropriateness of their training and the extent of continuing education required.

(c) Re-orientation of teaching staff

To facilitate the adjustment of AHSC's education, training and research functions - making them more supportive of primary health care-based interventions - AHSC's teaching staff will have to be re-orientated towards primary health care principles and concepts.

National Health Laboratory Services

The main problems facing the national health laboratories in South Africa include the fragmentation, duplication and geographic inequity of service provision and the lack of service co-ordination.

Evidence of inadequate facilities, equipment and professional staffing is most apparent in the former homelands and independent states. This is in contrast to the concentration of services in metropolitan and urban areas.

The streamlining of health laboratory services country-wide can only be brought about in close collaboration with other health services. This is in view of the essentially supportive nature of laboratory services and because they are an essential component of health service delivery.

The single largest provider of pathology services to the public sector is the South African Institute for Medical Research (SAIMR), an independent, non-profit-making organisation, whose major trustees include the Department of Health and the Chamber of Mines of South Africa. The SAIMR has a network of over 80 laboratories providing an estimated 60% of nonacademic public sector laboratory services in South Africa.

The South African Medical Service of the South African National Defence Force runs its own pathology laboratories to a large extent. The Department of Health, however, administers and provides separate laboratory services for occupational and environmental health services in Johannesburg, and laboratory aspects of malaria control in Gauteng.

The provision of academic laboratory services is undertaken by the academic departments of the various pathology disciplines.

The Ministerial Committee on Laboratory Services has defined National Health Laboratory Services (NHLS) as comprehensive laboratory services which are nationally controlled or coordinated. They are responsible for providing the spectrum of laboratory services listed below.

• diagnostic laboratory (pathology) services-,
• environmental health laboratory services, e.g. water, food, milk, poisons;
• occupational health laboratory services,
• forensic laboratory services; and
• other laboratory-based activities, e.g. those relevant to the control of malaria and other communicable diseases, pest and other vector control, genetic services, pharmacology and virology services.

16.1 NATIONAL HEALTH LABORATORY SERVICES SHOULD BE CONSOLIDATED AND CO-ORDINATED

16.1.1 Implementation strategies

(a) The tiered system currently in operation should be rationalised, the lowest level developed and services introduced and strengthened in previously under-served areas, using the following approach:

(i) Lowest level
A PHC-orientated service, with a very limited repertoire of tests (e.g. within community health centres).

(ii) Intermediate level
Peripheral laboratories (largely hospital-based) at district/ subregional/regional level with extended, but still limited, test repertoires.

(iii) Provincial level
More automated, specialised and "centralised" services, interacting with academic departments for some referred tests and consultations.

(iv) National level
Highly specialised/"non-reproducible" services, e.g. the activities of the National Institute for Virology (NIV).

(b) A national reference centre, or centre of specific expertise should be recognised. Where possible, the most appropriate provincial centre (NHLS or academic) must be identified and strengthened by allocating more resources at the national level, rather than establishing separate (duplicate) national reference laboratories.

(c) A directory of esoteric, rare or expensive investigations should be compiled to facilitate the co-ordination of such services and avoid duplication. Such a directory should be updated on an annual basis.

16.2 QUALM CONTROL AND LABORATORY ACCREDITATION SHOULD BE ASSURED BY ALL LABORATORIES

16.2.1 Implementation strategies

1. Minimum standards for quality control should be set and adhered to by all laboratories.
2. Laboratories must maintain internal quality control on an on-going basis.
3. In view of the need for the appropriate training of competent laboratory personnel, all training institutions should improve their quality of training.
4. An external quality control system should be established, to monitor the performance of laboratories independently. This system will ensure constant quality monitoring of the test repertoires of individual laboratories.
5. A laboratory audit should be undertaken, and linked to accreditation. This should be part of a process through which a laboratory's fitness to practice can be judged.

16.3 PROVISION OF LABORATORY SERVICES SHOULD BE CO-ORDINATED AT THE NATIONAL LEVEL BY A DIRECTORATE OF THE DEPARTMENT OF HEALTH. IN THE LONGER TERM, THE POSSIBILITY OF ESTABLISHING A STATUTORY, PARASTATAL CO-ORDINATING LABORATORY SERVICE SHOULD BE CONSIDERED

16.3.1 Implementation strategies

1. A directorate exists within the Department of Health to co-ordinate country-wide laboratory services and consider service delivery options.
2. The advantages and disadvantages of having a parastatal body co-ordinate laboratory services and other recommendations made to the Minister of Health, are being assessed.
3. Appropriate legislation will be introduced if a statutory body is required. The Minister of Health will appoint most of the body's members.

16.4 THE ACTIVITIES OF ACADEMIC AND NON-ACADEMIC LABORATORIES SHOULD BE CO-ORDINATED

16.4.1 Implementation strategies

1. Academic pathology departments should support provincial and other laboratory services. However, academic laboratories should have limited responsibility for routine service provision outside their academic complexes and satellite training sites.
2. An appropriately constituted provincial committee should be established to monitor and co-ordinate collaboration between academic and non-academic laboratory services.

16.5 PROVINCES WITHOUT MEDICAL FACULTIES SHOULD BENEFIT FROM INTER-PROVINCIAL "CATCHMENT AREAS"

16.5.1 Implementation strategy

The academic "catchment areas" adopted for clinical services should also be adopted by the academic laboratory services.

16.6 PRIVATE SECTOR LABORATORY SERVICES SHOULD SUPPORT PUBLIC SECTOR LABORATORIES

16.6.1 Implementation strategies

1. Areas for possible collaboration between public and private sector laboratories should be identified, with a view to improving services, cost-effectiveness, etc. (Possible areas include the transportation of specimens, services in remote areas, communications and assistance with excess service loads.)
2. Private pathology laboratories should confine themselves to providing services to the private sector, but they should also be available to tender via the NHLS.
3. The private sector's willingness to provide laboratory-based data for surveillance purposes (e.g. on communicable diseases) should be followed up by the public sector.
4. Existing co-operation between the public and private sectors in accreditation standards development should be extended to include a national external quality assurance system.
5. Possibilities for collaboration regarding the training of laboratory professionals should be explored.

16.7 INFORMATION GATHERING BY THE HEALTH LABORATORY SERVICES SHOULD BE IMPROVED

16.7.1 Implementation strategy

Laboratory services should be linked to the National Health Information System and information gathered by health laboratories should be processed and disseminated appropriately.

The Role of Hospitals

Most public hospitals have been neglected for years. Major problems of inequity and inefficiency are apparent, quality of care varies widely and breakdowns in referrals to and from hospitals occur. Buildings and equipment have not been properly maintained, resources are poorly distributed, industrial relations and personnel management are often poor and highly trained staff are continually being lost to the private sector.

It is essential to find solutions to these problems. Hospitals have always been, and will remain central to the health care system. Adequate health care services cannot be provided without them.

The PHC system cannot function efficiently without the support of the hospitals to which they refer patients. Therefore, substantial improvements to the PHC system are intimately connected with the functional efficiency of hospitals.

In the 1996-97 budget, expenditure on hospitals is estimated to account for 77% of total public sector health expenditure. Most additional resources for primary health care will have to be mobilised from existing allocations to the hospital sector. The prospects for such reallocation are, however, dependent on achieving substantial efficiency gains.

17.1 THE ROLE OF HOSPITALS WELL BE REDEFINED TO BE CONSISTENT WITH THE PRIMARY HEALTH CARE APPROACH

Inadequate access to hospital care because of geographical and financial barriers is aggravated by fundamental problems in the referral system's structure and functioning.

Referral problems have resulted in the under-development of PHC services and district and regional hospitals. Central hospitals have become overdeveloped and patients tend to be institutionalised. This, in turn, has led to inappropriate treatment of patients at higher level hospitals, while lower level hospitals and PHC services are underutilised.

The system lacks cohesion and gross inequity is apparent.

17.1.1 Implementation strategies

1. An appropriate hierarchy of hospital service provision will be clarified and the roles of the various hospitals in the referral chain (district, regional and central) clearly defined in terms of the level of care provided in each facility.
2. Appropriate referral mechanisms will be established to facilitate appropriate interaction between community, clinic and hospital-based care.
3. Appropriate clinical referral guidelines will be developed to improve the equity, efficiency and quality of care.
4. There will be clear differentiation between the primary, secondary and tertiary levels of care within the hospital system.
5. Financial incentives and disincentives, such as the use of by-pass fees, will be used to facilitate the above.
6. Existing hospital-based staff will be reorientated towards the PHC approach, and training will be upgraded to render hospital staff more community-orientated.

17.2 PLANS WILL BE DEVELOPED TO RATIONALISE HOSPITAL SERVICES, FACILITIES, STAFFING AND CAPITAL INVESTMENT

There is gross inequity in the distribution of hospital beds, and the physical state of the buildings in which they are housed varies widely. Many buildings are also poorly designed, contributing to inefficient patient care and high recurrent costs. Despite relatively higher levels of funding, many academic hospitals are also in need of extensive refurbishment or replacement. Redressing inequities and the past lack of investment in infrastructure and maintenance will require major capital investment in the hospital sector. It will also require the development of comprehensive capital investment plans.

There is also considerable variation, within and between hospitals, in the workloads of nurses, doctors and support staff. To improve both equity of provision and efficient utilisation of personnel, an extensive parallel process of rationalisation and redistribution of staff is required. The skills mix of staff establishments should also be improved.

Rationalisation of staff resources is the key to any real efficiency gains in the hospital system.

Realistic strategies must be developed to reallocate financial, human and physical resources from urban to rural centres, and from expensive to more cost-effective levels of care.

Hospitals attached to health science faculties consume a large proportion of the health budget. International experience suggests that academic functions increase unit costs by 30% to 40%. However, South African teaching hospitals have more generous staffing levels than regional hospitals and their unit costs are substantially more than 40% higher than those of other hospitals. The challenge with these hospitals is to maximise academic development and support of good clinical practice. This will attract and retain skilled personnel in teaching and research posts, and limit any excessive costs pertaining to academic activities.

Previous budgetary allowances to cover extra costs for academic involvement were based on historical expenditure data, and have included provision for the costs of Level III and highly specialised services. This has to be reviewed in view of the proposed shift towards greater utilisation at Level II and Level I facilities for teaching and training purposes.

17.2.1 Implementation strategies

1. In line with the recommendations of the National Health Facilities Audit, national and provincial priorities are being developed for upgrading or replacing existing facilities.
2. A comprehensive capital investment plan will be developed at the provincial level.
3. Guidelines for the licensing of facilities, equipment and certain procedures will be formulated.
4. National affordability guidelines for the staffing of all types of hospitals will be formulated and developed.
5. National policy on the location, size and financing of Level III services will be developed.
6. Level II care, which is offered mainly in regional hospitals accessible to potential patients, will be strengthened substantially. The quality and efficiency of Level I care, which is provided by district hospitals, will also be improved.
7. The concept of Academic Health Centres will be developed to place less emphasis on Level III care, ensure more academic staff availability at other levels and greater involvement by academics in teaching and research throughout regions.
8. Rational hospital reimbursement mechanisms for contributions to clinical training and research will be agreed upon and implemented.
9. Areas of underprovision, overprovision and inefficiency in referral patterns will be identified by comparing baseline data on resource allocation with national affordability guidelines.
10. Comprehensive plans for the rationalisation of hospital services will be developed to address the appropriateness and affordability of -
1. levels of service provision;
2. teaching and research activities,
3. facilities planning; and
4. staff allocation.

17.3 DECENTRALISED HOSPITAL MANAGEMENT WILL BE INTRODUCED TO PROMOTE EFFICIENCY AND COST-EFFECTIVENESS

Most public hospitals are severely undermanaged, mainly due to -

• limited responsibility and authority accorded to hospital managers;
• ineffective and inappropriate structures and systems of management;
• limitations in the number and skills of managers;
• insufficient operational authority or incentives for managers to manage budgets efficiently; and
• the existing organisational culture within hospitals.

Hospital management must be strengthened fundamentally. Only then can health resources spent on hospitals be reduced significantly, without seriously compromising the quality and accessibility of hospital care.

17.3.1 General implementation strategies

1. In order to overcome the problems outlined above, there will have to be substantial decentralisation of hospital management. This will allow managers of institutions to take responsibility for the provision of efficient and cost-effective services to the public. Hospital managers will also be involved in making longer term strategic decisions affecting the running of hospitals.
2. The provincial health departments will delegate significant decision-making powers to hospital managers, giving them greater control and flexibility to manage daily operations. These delegations will include the authority to make decisions relating to personnel, procurement and financial management. The extent to which a province delegates powers will depend on the capacity of hospital management to take on additional responsibilities.

17.3.2 Management structures, systems and capacity

1. A system of general management will be introduced to unify and integrate management, and facilitate decentralisation within a hospital.
2. Management structures within hospitals will be based on cost centres and functional units. Each will have a single focus and significant managerial authority with regard to their budgets, staff and other resources. Details will vary to accommodate the hospitals' particular needs and circumstances.
3. There will be a shift from the culture of "rules and regulations" to one of accomplishing tasks, meeting needs and reaching targets. This will be accompanied by a strong emphasis on continually reorienting hospitals to patients' and other clients' needs. The quality of services, guided by the principle of total quality management, will also have to be improved.
4. Existing systems will be revised and new ones developed to support decentralised management and promote efficiency and flexibility. This includes systems for financial and human resource management.
5. Management development and training for senior and mid-level managers will be strengthened. Such training and development will be immediately relevant to the work environment, and closely linked to the decentralisation process and the introduction of new methods and systems in hospitals.

17.3.3 Staffing and personnel management

1. In time, authority for almost all line personnel management functions will be delegated to the institutional level, subject to certain checks and balances. Hospital managers will decide on most appointments, performance appraisals and promotions, and will be responsible for disciplinary and grievance procedures. They will also be able - within guidelines - to determine staff establishments and manage labour relations and human resource planning and training.
2. Central, national level bargaining on basic pay, increases and other basic conditions of service will continue. However, managers will have flexibility, within national guidelines, to determine competency grading, starting levels and performance-related rewards or bonuses.
3. Capacity to manage personnel and labour relations will be developed in all larger hospitals and groups of smaller hospitals which do not warrant full in-house capacity.
4. Labour relations management will be consistent with the Labour Relations Act's framework. Strategies will be aimed at ensuring justice in the workplace, the creation of workplace forums, opportunities for worker input to management decisions, and fair systems for grievances, dismissal, appeals and mediation or arbitration.

17.3.4 Procurement, public works and transport

1. The authority of hospital managers and hospital tender committees will be increased to enable them to purchase goods more efficiently and responsively. Spending bands will be widened, and modem systems and managerial skills developed to increase hospital procurement capacity. If hospitals have the capacity and are in a position to comply with the requisite financial regulations they will, in time, be able to decide whether to procure on their own, through government, or through other agencies.
2. It is also envisaged that for minor works and maintenance, hospitals should be able to decide whether to make use of their own staff, the Department of Public Works or outside contractors. Large hospitals, or groups of smaller ones will develop the technical capacity to perform certain maintenance tasks themselves, and manage those services they contract out. Implementation of this concept will depend on agreement reached with the relevant Government departments.
3. Hospital managements will have a greater role to play in the planning and design of major capital projects.

17.3.5 Financial management

1. Each provincial health department will appoint a financial manager at a rank immediately below that of the Head of Department. Appointment of financial managers in large regional and district hospitals may also be considered.
2. The departmental accounting officer will, in time, formally delegate the responsibility and accountability for financial performance to managers of large hospitals, and regional managers for smaller hospital groups. These delegations will include the power to shift funds between line items in the budget and retain and spend a portion of revenue generated. This will occur within a clearly defined framework of formal performance agreements.
3. Such agreements will be reviewed and renegotiated annually. They will specify the expected range of outputs and standards to be achieved by the hospital, and link these to the budget and thus to financial performance objectives.
4. Managers will be held fully accountable for the achievement of their defined objectives. All variances from budgets will have to be accounted for, and performance agreements will specify how accountability will be enforced.
5. Departmental accounting officers will be able to delegate this level of authority to hospital managers, provided the following elements of a "safety net" are in existence:
1. A "performance agreement" between the hospital and province;
2. an accurate and reliable system for reporting on hospital performance;
3. adequate technical skills for financial management at hospital level; and
4. appropriate and respected sanctions for non-compliance with the performance agreement.
6. A cost centre-based accounting system will be developed. This will account for all costs incurred on an accrual basis, allocate costs to the lowest appropriate level, ensure that the budget allocation can be accurately monitored, and assist in monitoring performance indicators and activities, so that costs can be linked to outputs. Key parameters of this system will be standardised nationally to encourage uniform standards and exchange of information. A national template will be developed, which can be modified by provinces or institutions to suit local requirements.
7. The Department of Health will liaise with other departments to negotiate a revised accounting framework for the implementation of decentralised financial management in hospitals. This may involve the shift of public hospitals to the "transfer payment" accounting framework. This would allow them full management control over their budgets, and make provision for detailed internal and external auditing. An alternative option is the establishment of trading accounts at the provincial level, with negotiation of exemptions from key rules, regulations and instructions. Other frameworks may also be suited to this vision of financial management, and final decisions will be made on the basis of consultation between the Departments of Health, State Expenditure and Finance.

17.3.6 Phasing in decentralised management

1. Each province will prepare a detailed implementation plan for a process of decentralising management. The provinces will receive support in the planning and implementation process from the national level.
2. Plans will include detailed proposals for securing the necessary outside assistance and other resources that hospitals will require to implement decentralisation successfully. Hospitals will not be expected to fund their decentralisation process from their existing budgets alone.
3. The decentralisation process will be tailored to address the specific conditions of each province and hospital. Decentralisation will be introduced progressively in three or more stages. For each stage, greater levels of managerial autonomy will be accompanied by increasingly stringent capacity and performance criteria. The pace at which individual hospitals proceed through the stages of decentralisation will depend on the speed at which they develop their various capacities.

17.4 HOSPITAL BOARDS WILL BE ESTABLISHED TO INCREASE LOCAL ACCOUNTABILITY AND POWER

Most members of existing hospital boards were appointed before any vision of an integrated health care system existed. These boards exercise very little power and do not represent the community served by that hospital. Some do assist the hospital by raising funds for particular projects and/or providing hospital managers with advice, but most fulfill a largely ceremonial role. Few, if any, have structured mechanisms for listening or accounting to the local community. Despite close interaction with patients and their relatives, most hospital management is relatively isolated from representative community structures.

There is a great need to bring hospital managers closer to the communities they serve. This will include greater accountability of managers to the local communities, and greater understanding and support of them by communities.

The provincial health departments will retain over" powers of governance over hospital management, setting health service objectives and targets, monitoring hospital performance, providing support and capacity for hospital management, and performing functions governed by economies of scale. Hospital managers will remain accountable to their province for the use of public funds. However, hospital boards will also exercise real power, both in their dealings with hospital managers and their interaction with MECs for Health.

17.4.1 Implementation strategies

1. Hospital Boards will be established as statutory bodies with three primary objectives:
1. To support hospital management in bearing the greater burden of responsibility attached to increased delegation of powers;
2. to ensure that hospital management meets its obligations in terms of its "performance agreement" with the province; and
3. to ensure that hospital management is responsive to community needs and views.
2. The Boards will have advisory, representative and oversight functions, and will be accorded appropriate powers to perform these.

17.5 A TARGETED, EFFICIENT AND EQUITABLE USER FEE SYSTEM WILL BE INTRODUCED AND FACILITIES WELL RETAIN PART OF THE REVENUE GENERATED TO ENCOURAGE EFFICIENT COLLECTION AND IMPROVED SERVICES

The existing user fee system in public hospitals is inequitable, inefficient and generates minimal revenues. It is inequitable, because it does not target the poor and often results in public subsidisation of better-off users of public hospitals. It is inefficient, because it fails to encourage use of the referral chain. The inability of hospitals to retain any of the revenue they generate also means that management and staff have no incentive either to attract paying patients or collect fees.

17.5.1 Implementation strategies

1. (a) The current hospital user fee schedule will be redesigned to improve equity, collection efficiency and revenue generation. Changes will include:
1. A bypass fee to be paid by all patients not referred by a PHC clinic, except in cases of emergency or where no clinic is available;
2. different levels of payment at district, regional and central hospitals to encourage the appropriate use of facilities,
3. modification to income categories to ensure exemptions for the poor and full cost recovery from those who can afford to pay; and
4. simple fee schedules and adjustments reflecting underlying costs and inflation.
2. (b) Application of the fee schedule in hospitals will be improved through incentives, the use of appropriate information technology and training of staff.
3. (c) Regulations will be changed to allow hospitals to retain and use a portion of revenue generated. Redistribution mechanisms will also be developed. This will be accompanied by the increased authority of hospital managers, allowing them to manage budgets and reward staff for efficiency.
4. (d) Efforts will be made to attract paying patients to public hospitals, and reverse the current shift of these patients to private hospitals. Specific measures will include:
1. Reversal of the policy of referring insured patients to private facilities;
2. Improving services in public hospitals as part of a targeted strategy to attract paying patients; and
3. Regulatory measures to control the expansion of the private sector.
5. (e) Arrangements with medical aid schemes, the Motor Vehicle Accident Fund and the Workmen's Compensation Commission will be improved to ensure higher levels of cost recovery by public hospitals.

17.6 POLICY AND REGULATIONS PERTAINING TO PRIVATE HOSPITALS WILL BE IMPLEMENTED TO ENCOURAGE COST CONTAINMENT IN THE PRIVATE SECTOR, AND ENSURE THAT PRIVATE HOSPITALS CONTRIBUTE OPTIMALLY TO THE NATIONAL HEALTH SYSTEM

Expanding the supply of private hospital beds has several negative effects on the national health care system. It leads to greater utilisation and increases in private sector costs and expenditures because of supplier induced demand. In addition, it undermines public hospital provision by enticing skilled staff away from public hospitals.

Several of the reasons for this expansion will be addressed through policy and regulations. Lack of uniform criteria for granting private hospital licenses has created a vacuum in which private hospital operators have found ways of obtaining permission to erect new facilities. The legal definition of a private hospital is rather vague, allowing some operators to open facilities which are not strictly defined in law as private hospitals. Finally, the inspection and regulation of private facilities has been sub-optimal in recent years, allowing unscrupulous operators to open hospital facilities without even applying for a license. Some even extend existing facilities without any permission.

Some of the demand for private facilities is legitimately based on perceived and, in some cases, real declines in the standards of public hospital care. As noted above, these issues will be addressed directly. However, it will remain necessary, in some circumstances, to satisfy the demand for private facilities. One possible mechanism may be collaboration between the public and private sectors in the use of these facilities. This approach was widely used in the past - particularly in small towns where no private facilities were available - to the mutual benefit of both sectors. Medical and nursing staff continued to work in public hospitals, while still serving certain private patients.

In recent years, the trend towards opening private hospitals in small towns has had a devastating effect on public hospitals. Efforts will, therefore, have to be made to explore mutually beneficial solutions.

17.6.1 Implementation strategies

1. A national set of criteria and requirements for the granting of new private hospital licenses and extensions to current ones will be developed and implemented.
2. The legal definition of private hospital facilities, unattached operating theatres and associated facilities will be revised to eliminate current loopholes.
3. Inspection, implementation mechanisms and capacity will be considerably strengthened to ensure fall compliance with all applicable laws and regulations governing private health facilities.
4. Mechanisms for collaboration between the public and private sectors in the use of public hospital facilities will be investigated and discussed with all interested stakeholders. This will form part of a process of developing creative solutions with benefits for both sectors.

17.7 HOSPITALS PROVIDING UNIQUE OR HIGHLY SPECIALISED SERVICES WELL BE TREATED AS NATIONAL RESOURCES

South Africa has a number of facilities offering unique services. The majority of these are linked to the Academic Health Centres. These facilities will be treated as national resources. Not only are the services they provide useful to this country, but they can also serve as an important resource for the Southern African region.

17.7.1 Implementation strategies

1. Agreement will be sought on definitions of unique and highly specialised services, and on a formula for their funding.
2. Clear guidelines for admission to these facilities will be formulated. The underlying principle will be ensuring access according to need and non- discrimination, especially for the poorest patients and for those outside the immediate geographical location of the facilities.
3. Priority will be given to South African citizens in these facilities.
4. Similar facilities will only be opened or licenced on the basis of a clearly identified need, and within the context of available resources. Such decisions will be taken by the Minister of Health after consultation with the provincial MECs for Health. This way, due attention will be given to the equitable geographical spread of services.
5. A new policy on solid organ transplantation will be developed and implemented. This will include:
1. Amendments to the Human Tissue Act, 1983 (Act No. 65 of 1983);
2. Co-ordination of donor organ harvesting and recognition that donor organs are a national resource; and
3. review of existing facilities in both the public and private sectors, with a view to their rationalisation.

Health Promotion and Communication

The health status of the South African population must be viewed within a historical, social and economic framework. Poverty, and poor social and physical conditions, such as lack of adequate access to safe water and sanitation, and poor housing, have impacted negatively on health status.

Whilst a minority population enjoyed fairly high standards of health and health care, a large proportion of the population was seriously disadvantaged through grossly inequitable access to health services and health-related information.

In addition, health programmes have been vertical, disease-focused and based on theoretical frameworks that are not always sympathetic of community perspectives. The struggle for health and development as promoted by the progressive school and progressive practitioners did, however, lay a unique foundation for health promotion based on community consultation, participation and control. The transition to democracy, reconstruction and development and the principles elaborated by the RDP are in themselves important cornerstones for developing necessary health promotion initiatives. The challenge facing health promotion is to support this policy framework through focused initiatives that highlight the relationship between health and development, and build capacity for a health-literate nation.

Communication strategies for health promotion have been restrictive and have favoured target audiences that are literate, urban based and who have easy access to print and audio-visual media. The language of health promotional messages and the ethnocentric nature of a majority of messages suggested that communication strategies were inadequate and narrow in their focus as health promotion tools.

Areas of principal activity identified for an effective health promotion and communication strategy are the development of public policies and legislation, community action, skills development, promoting healthy physical and social environments, empowerment of communities and individuals to promote their own health and a focused reorientation of the health services and service delivery.

The aim of health promotion is to improve the health of all South Africans through creating a social, political, economic and physical environment which helps to make healthy choices easy.

The following objectives will be pursued:

• To contribute to the development and achievement of a healthy nation, national health goals and targets;
• to promote standards of excellence in health promotion practice, drawing on both international and local experience;
• to promote and develop health promotion activity in government and civil society; and
• to develop a skilled cadre of health promoters.

Health promotion will be developed in accordance with the principles which underpin the WHO movement "Health for all by the year 2000".

• Equity: everyone should have similar opportunities to health and, therefore, certain target groups will have to be prioritised, e.g. low income families, rural people and women.
• Empowerment and respect: health promotion activities should be designed to increase and enhance the control that communities and individuals have over their own health- in the process, traditional values and beliefs will be respected.
• Participation: communities and individuals will be involved as respected partners in the planning and implementation of health promotion programmes.
• Intersectoral activity: multidisciplinary, inter-agency collaboration will be undertaken wherever relevant and possible.
• Standards of practice: the highest standards of practice, incorporating the above principles and based upon researched needs and adequate evaluation, will be encouraged.

18.1 HEALTH PROMOTION AND COMMUNICATION WILL BE ESTABLISHED AS AN INTEGRAL PART OF THE NATIONAL HEALTH SYSTEM

18.1.1 Implementation strategies

(a) Structures

Structures will be established at the national, provincial and district levels to facilitate the planning, implementation, co-ordination, monitoring and evaluation of health promotion and communication activities.

(i) National level

A Health Promotion and Communication Directorate will be established at the national level. This directorate will be responsible for coordinating and supporting health promotion initiatives. Together with the provinces, it will also develop clear and transparent criteria for establishing national health promotion priorities, including training and capacity-building.

The Directorate will have the additional responsibility to ensure that all decisions, policies and laws emanating from other organs of state are health promoting. It will also ensure that opportunities for health promotion are maximised in all settings and in relation to all topics.

(ii) Provincial level

The health promotion team will be responsible for coordinating, facilitating and supporting health promotion activities at the provincial and district levels. This will include monitoring and evaluation and sharing of good practice within and between districts.

(iii) District level

An officer will be employed to initiate, support and co-ordinate health promotion activities at the district level. District health promotion activities will be based on a community development model, work closely with RDP initiatives and programmes, and involve local expertise (both statutory and non-statutory).

(b) Setting Priorities

Health priorities will be set in consultation with provincial departments of health, in order to respond to the needs of all South Africans in accordance with RDP goals. Among the priority groups are children, women, youth, the aged, the disabled and the poor. Priority health problems are violence, substance abuse, health problems related to lifestyle and HIV/AIDS.

18.2 THE SCOPE OF HEALTH PROMOTION ACTIVITY WILL BE IN ACCORDANCE WITH THE FIVE AREAS OUTLINED BY THE OTTAWA CHARTER

18.2.1 Implementation strategies

1. Promoting health public policy in all sectors of South African society, e.g. food labelling, taxation on the sale of tobacco and alcohol and fluoridation of water supplies.
2. Creating supportive environments, i.e. ensuring that the South African environment (social and physical) is healthy and that healthy behaviour is promoted, e.g. the creation of smoke free environments, safe workplaces and safe play areas for children.
3. Supporting community action by facilitating and encouraging communities to take action that will improve their health and resolve problems.
4. Developing personal skills in the formal and informal education sectors, including provision for basic health, personal and social education in schools.
5. Reorienting the health services to provide services which are relevant, appropriate and close to where people live. Users should also feel welcome and accepted.

18.3 PARTNERSHIPS WILL BE ESTABLISHED WITH ALL STAKEHOLDERS, ESPECIALLY WITH COMMUNITIES, IN ORDER TO ACHIEVE OPTIMUM HEALTH FOR THE NATION

18.3.1 Implementation strategy

All stakeholders will be mobilised to work in partnership towards achieving a nationwide impact on the major health problems.

The stakeholders will include all relevant Government departments, nongovernmental and community-based organisations, the business community; education sector, the media and other mass communication bodies, professional associations, trade unions, policy makers and the public.

18.4 ADEQUATE CAPACITY WILL BE BUILT INTO THE HEALTH SYSTEM, ENABLING IT TO PROVIDE SOUTH AFRICANS WITH INFORMATION ON HEALTH POLICY, NEW HEALTH INITIATIVES, THEIR HEALTH- RELATED RIGHTS AND OPPORTUNITIES FOR GAINING AND MAINTAINING GOOD HEALTH

18.4.1 Implementation Strategies

(a) Capacity-building and training

The training of all health personnel will be undertaken to improve their skills in health promotion and communication.

Undergraduate and postgraduate courses in health promotion will be established in suitable institutions, enabling skilled health promoters to work in all areas of the country. Provision should be made for both short and long courses.

(b) Research

Research capacity to support health promotion and communication will be developed. In this regard, the National Health Information System will be utilised to provide accurate and relevant baseline information. This will provide a basis for the planning and evaluation of health promotion activities.

(c) Communication

Effective communication underpins every health promotion activity. Communication will be participative, gender-sensitive and two-way. innovative and culturally acceptable methods of communication methods will be utilised. Special communication methods will be developed for the disabled (blind and hearing impaired), illiterate and rural communities. All messages will be based on sound research, and tested on target audiences prior to their use.