Decreasing Morbidity and Mortality

South Africa has a complex – and heavy – disease burden and wide-ranging actions are needed to make an impact on the key health indicators, that is, various mortality figures, prevalence rates for major diseases and the length of disease-free life.

The 10 Point Plan prioritises the following:

• Safeguarding child, youth and adolescent health.
• Decreasing the incidence of HIV,AIDS, STIs and TB.
• Controlling malaria.
• Improving women´s health status.
• Promoting mental health.
• Controlling chronic diseases and managing disability.
• Alleviating poverty and promoting food security.
• Tackling violence against women and children.
• Improving emergency medical services.

In terms of the Strategic Framework, specific targets and objectives have been set in each of these areas and progress is reported below against each of these. However, there are additional strategies – not specifically mentioned in the Strategic Framework – that also have an impact on mortality and disease patterns. These, too, are described below and include:

• Preventing work-related illness, disability and death
• Ensuring access to medicines.
• Assuring the safety, quality and efficacy of medicines.

Safeguarding Child, Youth and Adolescent Health

Five-year goals for child health

• Reduce infant mortality from 45/1000 live births.
• Reduce under-five mortality from 59/1000 live births.

The challenge in reducing infant and under-five mortality is greater in some provinces, as reflected in Figure 3.

The disease pattern among children under five years in our country is similar to that of other developing countries. Diarrhoeal disease, respiratory infections, malnutrition and, increasingly, HIV and AIDS are major contributors to the disease burden carried by our children. Measles, once a major factor, has had minimal impact in recent years. The relatively low incidence of various vaccinepreventable diseases is due to a fairly robust immunisation programme.

In accordance with this disease pattern, our strategy centres on sustaining and building the immunisation programme, improving nutrition and managing the common diseases as effectively as possible.

Figure 3: Infant and under five mortality rates per province (1998)

Immunisation

Five year goals for immunisation

• Polio Eradication by 2005.
• Elimination of indigenous measles by 2002.
• Attaining 90% full-immunisation of one-year-olds by 2003.

Key objectives for 2001/2

• Reaching 80% target for AFP stool monitoring in all provinces.
• Strengthening routine immunisation by effective programme management.
• Initiating adverse event monitoring.

Polio

Polio eradication is a focused global effort to consign this disease to history by the year 2005. The initiative is led by the World Health Organisation.

Although the last case caused by the wild polio virus occurred in South Africa in 1989, this is not enough to consider our country to be polio-free. There are set criteria that must be sustained by every country worldwide for three years in order achieve the global eradication of polio. The criteria established by the World Health Organisation are:

• Effective surveillance of acute flaccid paralysis – that is, cases with polio-like symptoms – and testing of detected cases to ensure these are not polio.
• Coverage of at least 80% of children in each health district with oral polio vaccine.

South Africa has organised several successful mass immunisation campaigns for polio and our coverage through routine clinic-based immunisation has just recently exceeded 80%. (See Figure 4).

However, we are experiencing some difficulty in meeting the requirements in terms of detecting and checking acute flaccid paralysis (AFP). We are currently one of only three countries in Southern Africa that have not reached the targets for AFP surveillance. We must meet these within 2002 and sustain this level of surveillance and testing for three years in order to be certified polio free by the deadline of 2005.

Figure 4: Immunisation coverage in South Africa 2000 and 2001

Table 2: AFP surveillance in South Africa 1997 – 2001 AFP detection

The targets are measured in terms of the number of cases detected and the adequacy of stool sample testing. As can be seen from Table 2, we have been detecting the expected number of cases, but until recently were nowhere near meeting the standards on stool testing. This improved significantly in 2001, putting us in striking distance of the target.

However, the performance of provinces in relation to the targets is quite variable. The national Department is supporting provinces in an attempt to meet targets in every health district.

In 2001, three specialist structures were set up to boost our efforts: The National Certification Committee, the Lab Containment Committee and the Polio Expert Committee that classifies all AFP cases. These committees also support Swaziland and Lesotho on request.

Measles

When it comes to eliminating indigenous measles, 2001 showed a sustained ability to keep outbreaks of this illness at a low level. (See Table 3)

Elimination of measles requires that all suspected cases be reported and at least 80% be investigated epidemiologically and by means of laboratory tests. It also requires that at least 90% of children under 15 should have had one measles vaccination.

While we achieve the immunisation target on mass campaigns, our routine immunisation is still falling a bit short. (See Figure 4) Furthermore, there are numerous “silent areas” that are not contributing reports.

Measles cases have fallen sharply since the mid-90s when the Department introduced the first mass immunisation campaigns.

Table 3: Reported measles cases in South Africa 1998 - 2001

Neonatal tetanus

The Expanded Programme on Immunisation also strives to eliminate Neonatal Tetanus. Some of the criteria have already been met – for instance, the proportion of women assisted by trained birth attendants. Although the incidence of neonatal tetanus appears low (See Figure 5), this may be distorted by incomplete hospital data.

Routine immunisation

Routine immunisation refers to the clinic-based vaccination of babies and pre-school children against:

• Tuberculosis
• Polio
• Measles
• Hib
• Diphtheria
• pertussis (whooping cough) and tetanus
• Hepatitis B.

A child is considered fully immunised when he or she has received all the required doses of all the above vaccines. Collection of data has been fragmented but it was rationalised as part of the District Health Information System in the latter part of 2001 and early 2002. There are still some shortcomings, in terms of uniform definitions and the inclusion of Gauteng and private sector data. The information in Figure 4 should be viewed with this in mind:

Campaigns are conducted to raise public awareness of the benefits of immunisation and ensure that parents can make informed choices. In 2001 awareness initiatives commenced with a media breakfast, continued with a workshop for health workers and culminated in an Awareness Week in August. The national office supported public education activities in four provinces with low immunisation coverage.

The Department acknowledges that the prompt and transparent investigation of any suspected adverse reactions to vaccines will promote public confidence. The development of a formal monitoring system commenced during the year.

Managing childhood illnesses

Medium-term goal

• Implement Integrated Management of Childhood Illnesses (IMCI) fully by end of 2003.

Key objectives for 2001/2

• Improve case management skills of health workers.
• Strengthen health systems in relation to drugs, supplies and equipment.
• Monitor achievements in relation to above.

Figure 5: Reported cases of Neo-Natal Tetanus in South Africa 1995 – 2001

IMCI is an approach that was developed by the WHO and Unicef in 1995. It is recommended for use where infant mortality exceeds 30/1000 live births and it has three main elements:

• Improving the clinical skills of health workers.
• Strengthening the health system.
• Promoting behaviour at household and community level that will improve child health.

The clinical component teaches health workers to look beyond the presenting problem and systematically assess every child for the main symptoms of childhood illness – coughs or difficult breathing, diarrhoea, fever and ear problems – and to check for: malnutrition, anaemia, tuberculosis and HIV.

South Africa embarked on IMCI pilot projects in 1996, just a year after the WHO adopted the approach. In July 1999, the Health Minmec adopted it as a national strategy.

In May 2001, IMCI practice at 82 randomly selected primary health care facilities in four provinces was assessed. The results suggest that the clinical component of IMCI improves quality of care for sick children. This should be enhanced when the Household and Community Component of the approach begins to kick-in during 2002. In terms of the extent of implementation, Table 4 shows uneven achievements across provinces. In some instances, provinces with low per capita health spending have embraced the approach most enthusiastically. However, this is not consistently the case and populous provinces with the highest infant and under-five mortality rates are not among the front-runners on IMCI.

Table 4: Status of IMCI Implementation in Provinces

The Department has an IMCI research committee that supports research initiatives in provinces, focusing on new or improved methods for preventing or managing childhood illness. With technical and financial support from Unicef, two such projects were undertaken in 2001.

Training is a key means of expanding the programme and training materials are continually being developed, reviewed and adapted. An important addition has been material to assist health workers to identify and manage children infected and affected by HIV and AIDS.

Nutrition

Five-year goals

• Reduce wasting among children from 2,6% to 1% and stunting from 23% to 15% by the end of 2004.
• Reduce prevalence of underweightfor- age among under-sixes from 9% to 5% by end of 2004.

Key objectives for 2001/2

• To strengthen the Baby Friendly Initiative.
• See also section on Alleviating poverty and promoting food security.

Nutrition interventions in relation to child health focus on the promotion of breastfeeding, early detection of malnutrition, provision if nutritional supplements for children and fortifying staple foods. Most of these matters are addressed under the related strategic goal of Alleviating poverty and promoting food security.

Breastfeeding

The Baby Friendly Hospital Initiative is a major vehicle for the promotion of breastfeeding. The Department aims to have 72 health facilities declared Baby Friendly by Unicef by March 2007. By December 2001, a total of 39 had been recognised.

The promotion of breastfeeding has become more complex with high HIV prevalence rates, as this is one of the routes through which HIV-positive mothers may infect their babies. It is against this background that South Africa needs to consider giving effect to the International Code on the Marketing of Breast Milk Substitutes.

• Work began during 2001 on draft regulations prescribing a South African code of ethics.
• A group of 30 health workers were trained locally on the international code during 2001 and two attended an international training workshop in Malaysia.

Genetic disorders and birth defects

Although not specifically mentioned in the Strategic Framework, preventing and managing genetic conditions and birth defects impacts on infant and under-five mortality rates, and also on patterns of childhood morbidity. Monitoring of perinatal deaths at sentinel sites revealed that congenital conditions are among the top three causes of death in some localities.

Key objectives for 2001/2

• Produce policy guidelines on preventing and managing birth defects and genetic disorders.
• Train provincial health workers in this field.
• Organise an international conference.
• Strengthen information systems.

A targeted approach, coupled with a systematic effort to collect information on the extent and nature of birth defects in our country, underpins the Department´s approach. Currently, the Department prioritises the conditions of albinism, Downs syndrome, foetal alcohol syndrome and neural tube defects.

There is also a sustained effort to build knowledge of genetic conditions and birth defects among health care workers, particularly among nurses.

Developments in 2001/2 included:

• The awarding of a three-year tender for the surveillance of birth defects at designated sentinel sites. The Department of Public Health at the University of Cape Town will carry out this work. Our Birth Defects Surveillance System exchanges data with the International Clearinghouse for Birth Defects Surveillance Systems.

• The finalisation of national policy guidelines on the management and prevention of genetic disorders and their launch by the Minister of Health in August.

• Training of an initial group of 70 health care workers on the priority conditions took place over two months in mid- 2001.

• Development of a curriculum for a one-year genetics diploma course for professional nurses. This was submitted to the Nursing Council for approval.

• The organisation of the first International Conference on Birth Defects and Disabilities in the Developing World. Partners in this included WHO, Unicef and the Centres for Disease Control and Prevention in the United States. Representatives from 19 countries on six continents participated in discussions that revealed the following needs:
  • Locally relevant studies to determine the extent of birth defects.
  • Generic training material suitable for country-specific adaptation.
  • Community leadership and involvement of other sectors.

Youth and adolescent health

Youth and adolescence are characterised by rather different health conditions than those that affect younger children. Consequently the goals are differentiated.

Five-year goals

• Reduce teenage pregnancy from 35% of young women under 19 years.
• Reduce adolescent mortality.
• Reduce tobacco smoking among adolescents (23% of teenagers between 13 and 18 years smoke) as well as substance abuse.
• Finalise and implement guidelines for youth and adolescent health.

Key objectives for 2001/2

• Promote youth-friendly health services.
• Prevent teenage pregnancy, STIs and HIV-infection through appropriate services and campaigns.

The Policy Guidelines on Youth and Adolescent Health were finalised during the period under review and launched by the Minister of Health.

The development of youth friendly health facilities is viewed as a critical factor in improving access to appropriate reproductive health services for young people and impacting on teenage pregnancy, STIs and HIV infection. The training of health workers to run such facilities was piloted in the Northern Cape this year and will be expanded over the next two years.

To strengthen this approach, the Department and the Henry J Kaiser Foundation concluded an agreement in July 2001 to provide substantial funding to loveLife over a three-year period to conduct a multi-faceted programme to influence teenage sexual behaviour. Youth friendly clinics will form part of this project.

So will awareness campaigns, that will complement those described under the HIV, AIDS and STI programme.

The report on the South African survey that forms part of the Global Youth Tobacco Survey was launched in the Eastern Cape on World No Tobacco Day. Radio programmes, posters and pamphlets have been used to provide information intended to counter tobacco use.

Alleviating Poverty and promoting Food Security

Five year objectives

• Intensify implementation of the Integrated Nutrition Programme (INP).
• Promote community-based growth monitoring.
• Strengthen nutrition interventions to rehabilitate malnourished children.
• Work with other sectors to tackle the causes of poverty and poor nutrition.
• Introduce food fortification.

Key objectives for 2001/2

• Introduce fortification of two staple foods.
• Promote growth monitoring for early detection of malnutrition.
• Strengthen implementation of Primary School Nutrition Programme.
• Improve management of conditional grants.

Food fortification

A food survey undertaken in 1999 showed that children in our country not only get too little food to meet their energy requirements, but they also lack important micronutrients, particularly Vitamin A and iron. This situation informed the decision to fortify mealie meal and wheat flour with a range of micronutrients. The fortification programme moved into the final preparatory phase during this year. The micronutrients that will be introduced into the manufacture of these staple foods include: Vitamin A, riboflavin, niacin, vitamin B6, folic acid, iron and zinc.

The levels of additives have been carefully researched, taking into account international experience and local consumer responses. Research on attitudes to fortification among rural communities was commissioned during closing months of the year to inform the communication strategy. Draft regulations were completed and ready for refinement by the Legal Unit as the year closed.

Growth monitoring

Systematic monitoring of the growth of children enables health workers and caregivers to detect malnutrition at an early stage and prevent permanent damage. The tool used in primary health care clinics is the Road to Health Chart, which tracks both the height and weight of the child against the normal range for his or her age.

• During 2001, the Road to Health Chart was extensively changed and updated. Guidelines for health workers were produced. And one million copies of the set were distributed to provincial health authorities.

• Training material on growth monitoring was produced. Training commenced and will continue in the in the coming year.

Table 5: Allocation and expenditure of INP conditional grant for 2001/2

Table 6: Allocation and expenditure of poverty relief funds

Integrated Nutrition Programme

The Department´s Integrated Nutrition Programme acknowledges extreme inequities in our society and targets the most disadvantaged groups through a variety of channels. It includes school feeding programmes, community nutrition projects and income generation projects.

Slightly more than R590-million is administered by the Department for the INP and poverty relief projects. Allocation to the provinces is based on a combination of poverty and health indicators. The distribution of these conditional grants and the expenditure per province is reflected in Tables 5 and 6.

With three exceptions, provinces showed substantial under-spending on the Poverty Relief Allocation. Reasons relate to the fact that the grant is intended for small scale incomegenerating activities and there is limited human resource capacity in health departments to facilitate this work. Mechanisms for the distribution of these funds also play a part.

To improve the situation, workshops were held with provincial personnel on financial and programme management. The Department also communicated with provincial treasuries to expedite the release of funds.

The Primary School Nutrition Programme

The extent and costs of the Primary School Nutrition Programme (PSNP), which accounts for 85% of the conditional grant for the INP, are summarised in Tables 7 and 8.

The school feeding programme was evaluated during 2000. The research indicated that the programme was having a positive impact on the children – in terms of improved school attendance and better learner attentiveness during lessons. It also contributed to food security of the households from which the children were drawn.

Table 7: Information on the PSNP in 2001/2

Table 8: Number of schools and learners reached by the PSNP

However, there were a number of operational problems, including:

• Inconsistency in provision of feeding and a low ratio of school days covered, in some instances.
• Inadequate food quality and controls for food safety.
• High supplier profit margins in some provinces and weak contract management.
• Under-expenditure due to a lack of human resources for administrative support.
• Failure to maximise potential partnerships — within the health sector and with other sectors – that would enhance the programme.

During 2001, Cabinet endorsed the following steps to improve the school feeding programme:

• Standardising feeding days to 156 school days.
• Standardising menu options.
• Implementing a strategy to identify and reach areas where poverty is most extreme.
• Including Reception Grade learners in the programme.
• Adopting a standard monitoring system.
• Increasing participation of women´s groups in running the programme.

Improving women´s health status

Five-year objectives

• Reduce maternal mortality from 150/100 000 live births to 100/100 000 live births (including deaths due to AIDS).
• Reduce mortality due to unsafe abortions.
• Expand awareness of and screening programmes for cervical and breast cancer.

Key objectives for 2001/2

• Improve pregnancy outcomes.
• Strengthen programme to monitor maternal deaths.

Maternal mortality

The reasons for the high rate of maternal mortality – 150/100 000 live births – are varied and complex. Annual reports on confidential enquiries in maternal deaths have revealed preventable problems emanating from the patient, from the community, from the health system and from the practice of individual health workers.

AIDS has a major impact on maternal deaths and it has been necessary to adjust our targets to take account of this. The aim is to reduce maternal deaths to 75/100 000 live births (excluding AIDS related deaths) or 100/100 000 live births if AIDS related deaths are included.

Strengthening surveillance is critical to pinpointing the problems and this has improved since the system was set in place three years ago.

Table 9: Number of maternal deaths reported annually by provinces

Indirect causes of maternal deaths increased from 37,5% in 1999 to 38,6% in 2000. Data for 2001 had not been fully analysed at the time of publication. The increase in indirect causes is largely due to non-pregnancy related sepsis, probably due mostly to AIDS.

Guidelines for maternity care and for managing common causes of maternal deaths have been developed and copies have been distributed to provinces together with a standard Maternity Case Record. Training workshops on the guidelines and use of the case record were conducted in five provinces, namely: Limpopo, North West, Free State, Northern Cape and Mpumalanga. The impact of this will be evaluated in 2002.

Concerns relate to:

• The failure of provinces to establish advanced midwifery training, which has been identified as a critical strategy to improve the quality of care of pregnant women and their babies.
• The fact that the “Hands On” community education programme on pregnancy and childbirth has stagnated. A master trainer was trained for each province in 2000/1 but none of these has taken the programme further by training additional trainers.

Contraception

Access to reproductive health services is a right recognised in the Bill of Rights. It is also an important factor in improving the health status of women. By reducing unwanted pregnancies, the risks associated with childbirth and termination are correspondingly limited.

During the year, the Department launched national policy guidelines on contraception. Before the formal launch, workshops to familiarise key health workers with the guidelines were held in eight provinces (the exception was KwaZulu-Natal). A popular version of the policy guidelines has been developed to inform communities of the public health sector´s approach to contraception.

Termination of pregnancy

The value of legal termination of pregnancy as a public health measure is ultimately measured in the decrease in maternal deaths and severe infection incurred during termination, usually because of unsafe circumstances in which the termination occurs.

The incidence of severe morbidity associated with termination has decreased from 16,7% to 9,5% of terminations since the Act commenced.

Easy access to termination is clearly a significant factor, and the figures in early 2002 suggest progress in the past two years.

The total number of terminations performed since the passing of the Choice on Termination of Pregnancy Act in 1996 is 216 718. The number of terminations increased between 2000 and 2001, from 47 194 to 57 304.

Strategic planning workshops on termination of pregnancy were held in eight provinces and at national level during the year. The service is still not operating optimally, largely as a result of human resource constraints. There is a high turnover of service providers and, inevitably, some resistance to providing the service on the part of managers and health professionals.

Cervical and breast cancer

According to the Cancer Register, breast cancer has overtaken cancer of the cervix as the most common cancer among South African women. Early detection is an important strategy in both kinds of cancer.

The national Department conducted workshops in all provinces to familiarise providers with the national guidelines on screening for cervical cancer. The public sector guidelines provide for three free Pap smears, approximately 10 years apart, for women from the age of 30 years. This is estimated to reduce the cumulative incidence of cervical cancer by 64%.

Breast Cancer Awareness Month in October has become a major event in the health calendar, with private, public and NGO sector participation. Media coverage generated by the Department on breast cancer during this period totalled about R1,49-million in publicity value in 2001.

Educational materials were also reproduced and distributed to various provinces for clinic- and communitybased activities on breast cancer.

Table 10: Health system capacity to perform Termination of Pregnancy

Tackling violence against women and children

Five-year objectives

• Raising awareness of basic human rights.
• Training health personnel to provide support to survivors of violence.
• Developing protocols for the management of survivors of violence and abuse.

Key objectives for 2000/1

• Awareness raising activities.
• Guidelines on management of survivors of sexual assault.

The Department participated in programmes of public events during the Sixteen Days of Activism on No Violence against Women and National Women´s Month in August.

Work has commenced on national policy guidelines for the management of survivors of sexual offences. A standard package of interventions is already defined in the primary health care service package.

Violence prevention programmes in schools continued to expand during 2001/2, along with programmes to prevent child abuse that focus on parent-child bonding.

The life skills programme in schools, which forms part of the HIV and AIDS Strategy, contains material on gender and is designed to encourage relationships of equality and mutual respect.

Decreasing incidence and impact of HIV, AIDS and STIs

In this specific area, the 10-Point Plan has been overtaken by the HIV, AIDS and STI Strategic Plan for 2000 to 2005, which sets objectives in four main performance areas:

• Prevention of new infections
• Treatment, care and support of those infected and affected.
• Legal and human rights
• Research, monitoring and surveillance.

Balance between the various elements – particularly between prevention interventions, treatment of STIs and opportunistic infections and broader forms of care and support – is critical to the success of the strategy.

Partnership

It is also important to recall that a broad partnership – across government departments, and combining the efforts of government and civil society – is the basis of achieving the objectives of the HIV and AIDS Programme. In this context, the exercise of leadership and establishment of coordinating mechanisms are key success factors.

The South African National AIDS Council (SANAC) has been central to the expansion of a cross-sectoral HIV and AIDS programme. Since the launch of SANAC under the leadership of Deputy President Zuma in January 2000:

• Key constituencies have been effectively mobilised, including women, youth, traditional leaders, faith-based organisations, sporting bodies and the transport sector.
• AIDS Councils have been established in all provinces.
• AIDS Councils have been set up for 29 out of a possible 53 metro and district council areas.

Members of SANAC were appointed for a period of two years and the time has come to reconstitute the structure. This will be informed by a review of the terms of reference and composition of SANAC undertaken by its founding members.

The Department funded about 120 non-governmental organisations during 2001/2 to the extent of about R30-million.

Trends in HIV prevalence

The gravity of HIV and AIDS as a public health problem was once more reflected in the results of the annual HIV prevalence survey undertaken at public sector antenatal clinics. The survey yielded a prevalence rate of 24,8% in this section of the population. The Department has generated a model to use the results of the survey to estimate the total number of people infected in the South African population. In 2001, the figure was estimated at 4,74-million.

Figure 6: National HIV prevalence trends among Ante-Natal Clinic users

Figure 7: Conditional grants to Provincial Health Departments for HIV and AIDS work

Table 11: allocation of conditional grants to provinces for various activities

The most important trend in the survey was the fact that the prevalence rate of 24,8% was an insignificant change from 2000. As shown in Figure X, it sustained a picture of "levelling off" in the proportion of people infected with HIV. Further details of the survey are contained in the box on page XX.

Achievements

Broad programme achievements in the fight against HIV and AIDS in 2001/2 included:

• Successfully presenting to Treasury the case for substantially increased funding in order to enhance Government's response to HIV, AIDS and TB. The success was reflected in major annual increases for various interventions in the medium term expenditure framework. (See Table 11 and Figure 7). This increased funding will impact particularly on treatment, care and support.

• Bringing on stream elements of the Strategic Plan that previously existed mainly on paper – for instance, prevention of mother-tochild transmission, home- and community-based care, and a more extensive network of voluntary counselling and testing services.

• Contributing to recognition within international forums of the importance of the link between poverty and major public health problems in developing countries; and of the need for donor assistance to respect national health priorities and strategies. This approach is to be recognised in the Global Fund to Fight HIV, AIDS, Tuberculosis and Malaria. Through the Ministry of Health – and in co-operation with our SADC partners — South Africa participated vigorously in the processes that gave birth to the Fund and shaped its character.

Prevention initiatives

It is internationally acknowledged that prevention efforts need to be the first line of defence against the HIV and AIDS epidemics. The national strategy places a strong emphasis on preventive measures and on the building of a range of partnerships to expand the terrain that is reached.

Five-year goals in Strategic Plan

• Promote safe and healthy sexual behaviour.
• Improve management and control of STIs.
• Reduce mother-to-child transmission of HIV.
• Address issues relating to blood transfusions and HIV.
• Provide appropriate post-exposure services.

Key objectives for 2001/2

• Establish research sites on prevention of mother-to-child transmission.
• Improve condom management and condom access through 24-hour sites.
• Strengthen public awareness.
• Expand effective treatment of STIs.

Figure 8: National Syphilis Prevalence among Ante-Natal Clinic users

Promoting safe sexual behaviour through information and education

Information, education and communication initiatives cut across the prevention, treatment and support, and human rights features of the HIV and AIDS Strategy. When it comes to prevention, communication lays the foundation for more intensive educational interventions, such as the life skills approach.

During August 2001, tenders were awarded for a period of two years for mass media campaigns; the production and distribution of small media and media advocacy. The first two tenders were awarded to a consortium headed by Johnnic Communications and the advocacy tender to a consortium headed by Meropa Communications. Both consortia are a mix of private sector and non-governmental organisations.

Mass media campaigns in the field of prevention were approved for 2001 to 2003 and focus on the following:

• Promotion of safe and healthy behaviour among the youth. Messaging will be differentiated, encouraging a younger audience to delay sexual activity and those in later teens to practise safer sex.
• Enhancing TB detection and treatment.
• Promoting effective treatment of STIs.

Apart from ongoing campaigns, the Department also observes key international and national days related to HIV and AIDS and tuberculosis.

Mass media campaigns utilise television, radio and print advertising. They also employ “below the line” media, where the message is embedded in an existing event (for instance, a concert or sports event) or existing programming (in a soap opera, for instance, or television continuity announcements), and mass events.

A particularly valuable partnership was concluded with the SABC and the contribution of free air time as a result of this has hugely boosted the volume of advertising.

The AIDS Helpline, run by Lifeline under contract to the Department, continues to provide individualised information and counselling. It fields an average of 25 000 calls a month and operates in a variety of languages.

Table 12: Condoms distributed

The schools-based Life Skills and HIV and AIDS Education Programme aims to provide young people with information and to enable them to use this information in making choices regarding relationships and sex. It operates in primary and secondary schools and is managed mainly by the Department of Education. This programme is now a part of the formal school curriculum.

The Department of Health supported the development of this programme in 2001 by producing various materials: a training video for life skills master trainers; posters and pamphlets in various languages for learners, teachers, lay counsellors and parents.

The Life Skills Programme spontaneously produced a group of peer educators among learners. This development was encouraged and, to ensure quality, the Department produced standards of practice and criteria for participation in peer education.

Barrier methods and STI s

The promotion of safer sex is taken a step further by the Department through its procurement and distribution of large quantities of high quality condoms. The volume has increased annually and the option of female condoms has been available for the past three years. To expand distribution beyond public health facilities and increase after-hours availability, non-governmental and community based organisations are encouraged to participate and link into the computer-based Logistics Management Information System. No stock-outs have been reported at the 190 "primary" distribution sites since the logistics system was implemented in early 2001.

The effective management of STIs, using the syndromic approach, plays a central role in reducing the risk of HIV transmission. This programme is driven through the development and distribution of resource materials for health workers and through training of health workers in syndromic management of STIs.

• At least 80% of public sector clinics have health workers trained in syndromic management.
• The quality of treatment has been independently assessed and found to be more effective than that in the private sector.

Despite this positive situation, indications are that many people prefer to seek STI treatment in the private sector. This suggests that issues of confidentiality, stigma and health worker attitudes at government clinics may play a part.

During 2001 the following measures were taken to tackle this question:

• A partnership was concluded with the Kaiser Family Foundation to cosponsor youth friendly health services, with loveLife as the implementing agency.
• STI services are being profiled more highly within the mass communication strategy, with messages that highlight quality of care, no charge and confidentiality.

Syphilis prevalence rates among pregnant women attending public health facilities have been measured countrywide for five years. There is a sustained and rapid decline in the prevalence of syphilis – from 11,2% in 1997 to 2,8% in 2001. (See Figure 8)

However, there is evidence that suggests that the national decline in syphilis does not apply to all STIs and further investigation of this is needed. Work commenced in the year under review on expanding STI surveillance to create a comprehensive, countrywide system over the next two years.

Mother-to-child transmission

An important facet in the area of prevention is the operational research programme on prevention of mother-tochild transmission of HIV (PMTCT). This involves the administration of the drug Nevirapine to mother and baby, within a comprehensive package of treatment, at selected sites in all provinces.

The programme was set up:

• To test the extent to which results obtained in PMTCT clinical trials could be replicated in “real life” service delivery.
• To establish the resources required and other operational demands of a PMTCT service.
• To investigate the medium-term outcome in terms of overall health of mother and baby.
• To conduct research on drug resistance in relation to this limited use of Nevirapine.

Implementation began in May 2001 in some provinces, with others coming on stream in the subsequent four months. The research project was designed to run for a two-year period. About 250 individual health facilities were clustered as 18 research sites, with two per province. The size and complexity of the sites varied considerably.

The service at each site included:

• General information on the programme.
• Voluntary counselling and testing for HIV.
• Nutritional supplements for HIVpositive women during pregnancy.
• Single dose Nevirapine for mother and child at the time of birth.
• Management of labour of HIVpositive mothers in accordance with protocols.
• Counselling in relation to safe infant feeding practices.
• Free breast milk substitute for six months for mothers choosing this option.
• Cotrimoxazole for babies of HIVpositive mothers for six months after birth.
• Periodic follow-up of mother and baby to ensure wellbeing.
• Testing of baby at one year to establish HIV-status.

The risk of an HIV-positive mother transmitting the virus to her child is at its highest during the course of birth. But transmission can also occur later on through breast milk. The Department took the view from the outset that infant feeding practices would be a critical factor in sustaining the benefits of Nevirapine in reducing mother-tochild transmission. While formula feeding could overcome the HIV-risk, it might not be an acceptable substitute and it might open the door to other infections and malnutrition in situations where clean water was unavailable or where over-dilution of the powder was likely.

These were critical considerations that dictated fairly long research timeframes and positioned the follow-up process centrally.

Within the broader programme there are two specific studies:

• The “resistance study”, which will process blood samples from 1 140 women and 248 infants to ascertain the levels of drug resistance that occur in response to a single dose of Nevirapine and the duration of any resistant forms of the virus.

• The “cohort study” that will investigate the infant feeding practices of HIV-positive and HIVnegative women; and describe and measure the impact of the PMTCT programme on the babies of HIVpositive mothers. The sample will comprise 1 200 mother-baby pairs.

In the first year of the PMTCT programme, about 101 200 women received ante-natal care at the research sites. Details on uptake of the service are reflected in Table 13.

Approximately 62% opted for counselling and HIV-testing and more than a quarter of those tested were HIV-positive. By the end of the first year 7 300 babies had received Nevirapine.

Just as there were variable levels in the volume of patients and rate of testing uptake, there were also considerable provincial variations in infant feeding preferences. In Limpopo and Eastern Cape there was a marked preference for exclusive breastfeeding; in KwaZulu- Natal formula feed and exclusive breastfeeding were almost balanced; while in all other provinces there was a very strong preference for formula.

While the impact of the programme in terms of preventing HIV-infection will only become clear in the next reporting period, the programme has already yielded valuable information on the operational demands of the service.

Some of the lessons learned are that:

• A strong voluntary counselling and testing service is key to good uptake of the PMTCT intervention.
• Equally important is community involvement as this reduces stigma and creates a climate for women to exercise their choices.
• The quality of the PMTCT programme will be constrained or boosted by the quality of the primary health service on which is built.
• The programme requires dedicated human resources and physical space; if it is simply “squeezed” in it will not succeed.
• The resources of service users access to transport, clean water and electricity – impact on the programme.

By the end of 2001/2, some facilities outside the original 18 sites were offering the programme in compliance with the national protocol. Furthermore, a Constitutional Court hearing was pending to determine whether Nevirapine should be available at institutions where there was no comprehensive PMTCT programme if individual medical officers deemed it medically advisable to prescribe it on a case-by-case basis.

Blood safety

In terms of ensuring safe blood supplies, the creation of a single national Blood Service (see page 69) enhances the prospect of good quality control. The Service completed the first national blood surveillance report in the period under review. This surveillance was based on reporting and investigation of adverse reactions among recipients of blood products and it indicated that the blood used throughout South Africa is overwhelmingly safe and meets international norms.

Table 13: Uptake of PMTCT at research sites

Treatment, care and support programmes

The emphasis of Government is currently to improve quality of life for those living with HIV and AIDS through support for positive living; through effective, prompt treatment of opportunistic infections – especially tuberculosis; and through care for those living with HIV and AIDS, and their families.

Five-year goals in the Strategic Plan

• Improve access to voluntary HIV testing and counselling.
• Provide treatment, care and support in health facilities.
• Provide adequate treatment, care and support services in communities.
• Develop and expand care for children and orphans.

Key priorities for 2001/2

• Capacity building for health workers.
• Improved implementation of guidelines on opportunistic infections.
• Treatment literacy campaign.
• Activate plan for home-based care.
• Expand effective treatment for STIs.
• Expand sites for integrated TB/HIV management.
• Produce guidelines on use of antiretroviral drugs for managing AIDS.

Table 14: Location of VCT services

Voluntary counselling and testing

Identifying people living with HIV at an early stage is an important factor in an effective, positive programme of support, treatment and care. The expansion of facilities for voluntary HIV counselling and testing is therefore a constant feature within the programme.

The Department introduced the rapid HIV-test at the end of 2000. In the period since then – mostly covering the year in review – 691 VCT sites have become operational and 2 666 additional counsellors have been trained, bringing the total number of counsellors trained since 2000 to 4 466.

The Health Systems Trust has been commissioned to assess the quality of services at the VCT sites and results are expected in July 2002.

Guidelines and training

If VCT is the point of entry to treatment and care, the foundation of an effective service is a body of health workers who understand the epidemic and the medical conditions associated with it and have the skills to respond.

Having produced a range of guidelines for treatment and care in 2000 – and distributed about 50 000 copies of each – the Department instituted a programme of training on selected aspects of these. In the last three months of 2001, approximately 1 000 health workers were trained and the process continued in 2002. The need for this training arises from the fact that most health professionals in public health facilities were trained when there was limited information on HIV, AIDS and opportunistic infections in training curricula.

Guidelines were produced in 2001 on the use of anti-retroviral drugs (ARVs) in the long-term management of AIDS. Although ARVs are not available in the public health sector for this purpose, the aim was to assist practitioners in the private sector and to ensure appropriate use.

Guidelines for sound nutrition for people living with HIV were also produced and distributed to health workers and nongovernmental organisations.

Participation of people living with HIV and AIDS

One of the guiding principles of the Strategic Plan for HIV, AIDS and STIs is the involvement of people living with HIV and AIDS (PWAs). The Department has a PWA Support Programme. Through this programme several drug literacy workshops were held in 2001 to provide information about treatment available in the public sector and promote compliance with drug regimes.

The Department funds the posts of PWAs in six national government departments to assist them shape their response to the epidemic.

The National Association of People Living with HIV and AIDS (NAPWA) is also part of the consortia responsible for the communication programmes. Three mass communication campaigns related to treatment, care and support were approved by the Health Minmec at the end of 2001 and will run through the next financial year. They are:

• Health worker excellence in the field of HIV, AIDS, TB and STI care. This is intended to affirm health workers in these fields of work and counteract stigma.

• Positive living. This takes special account of the information needs PWAs and their families and seeks to encourage a more positive public attitude to PWAs by placing them at the forefront of the campaign.

• Circles of support: This will focus specially on the needs of children affected by the epidemic and will use interactive media to link those able to offer help with those in need.

Treatment

When it comes to management of opportunistic infections, tuberculosis demands priority. TB is both an epidemic in its own right and one that feeds off and feeds into the HIV and AIDS epidemic. It is dealt with in detail on page 42, and mentioned here only to the extent that joint management of these infections has been shown to benefit those infected.

There have been pilot projects for the joint management of HIV,AIDS and TB in four provinces for two years. A standard package of interventions is offered at all the pilot sites and it has elements of prevention, treatment and support. Another specific focus for improving opportunistic infections is the Diflucan Partnership Programme. In terms of this, the costly drug fluconazole (trade name Diflucan) is provided free of charge by Pfizer Inc for two years for the treatment of cryptococcal meningitis and oral thrush at public health facilities.

The programme effectively came on stream with the start of this financial year and more than 25 000 patients benefited in the first year. The programme also features training of health workers in the management of these conditions – and more generally in diagnosing and treating opportunistic infections. The non-governmental organisation IAPAC has undertaken this training and 6 491 health workers participated during 2001/2.

Community-based care

During 2001/2, progress was made in implementing the plan for home-based and community-based care that was developed the previous year. This is a joint initiative of the Departments of Health and Social Development.

Home- and community-based care has been endorsed as a strategic option for two reasons:

• The public health system does not have the resources to manage the full load of AIDS patients and beds should therefore be reserved for those who would benefit most from hospital-type treatment.

• There are potential psychosocial benefits for patients who are terminally or chronically ill being cared for in a familiar environment, surrounded by family and friends.

The main challenge in establishing home-based care is to ensure that this is managed correctly and does not constitute an abrogation of the responsibilities of the public health care system. The programme requires considerable resources and support – but still of a lower order than hospital care.

During 2001/2:

• The relevant Departments conducted a rapid appraisal of existing homebased care projects to establish their number and capacity. This report provides the basis for decision-making on where new projects need to be established and existing ones strengthened.

• Implementation of the new model started in six provinces: Eastern Cape, Northern Cape, North West, Northern Province, Mpumalanga and Free State. Provincial and local coordinating structures have been set up. Supplies for home-based care are being provided.

Some basic dimensions of existing homebased care, revealed by the rapid appraisal, were that:

• There are at least 466 projects.
• A minimum of 61 663 individuals benefited from the home-based care services of these projects between March 2000 and July 2001.
• At least 370 000 people benefited from the total range of services associated with these projects during the same period. Such services included counselling, child care support, PWA support groups, food parcels.
• A total of 16 288 care-workers were associated with the projects identified, some as volunteers and others in employment.
• Government was the most frequently mentioned funder of these projects (29%), followed by business (17%) and NGOs (10%).

An electronic-format Directory of Services for Children Infected and Affected by HIV and AIDS was produced.

Research and surveillance

Five-year goals in Strategic Plan

• Ensure AIDS vaccine development.
• Investigate treatment and care options.
• Conduct policy research.
• Conduct regular surveillance.

Key objectives for 2001/2

• Commission research to inform policy development.
• Support vaccine research.
• Strengthen surveillance systems.

Vaccine development

The South African Government is actively engaged in the search for an AIDS vaccine through its participation in the South African AIDS Vaccine Initiative (SAAVI). Funding to SAAVI is channelled through the Departments of Health and Arts, Culture, Science and Technology. SAAVI was established in 1999 and is a partnership between the public and private sectors and between research bodies in South Africa and the United States.

Its brief was to develop and test an effective and affordable vaccine relevant to South African conditions within 10 years.

SAAVI continues to work on candidate subtype C HIV vaccines. The SAAVI immunology laboratories were fully accredited and are ready for phase one clinical trials.

It is, however, important to realise that – significant as this progress may be – an AIDS vaccine is not around the corner and there can be no relaxation of programmes to prevent infection through lifestyle choices.

During the past year, SAAVI researcher Dr Caroline Williamson received the World Technology Forum award for biotechnology.

Surveillance

For the 12th consecutive year the Department undertook an HIV seroprevalence survey among women attending public sector ante-natal clinics. The main findings of the survey were summarised at the start of the section on HIV and AIDS. Further details of prevalence trends across provinces and age groups appear on page 31.

In 2001 private maternity services were also surveyed for the first time. Because the method differed slightly from that used and fine-tuned in the public sector, the results were still being processed at the end of the year under review and had not been released.

• As mentioned in the prevention section, surveillance of STI incidence is undertaken in three provinces and will be expanded in 2002.
• There is a research component in the communication programme that will track changing attitudes and behaviours at sentinel sites.

The commissioning of policy-related research has been mentioned in the sections on prevention and treatment.

Human and legal rights

Five-year goals in Strategic Plan

• Create a supportive and caring environment.
• Develop an appropriate legal and policy environment.

Key objectives for 2001/2

• Facilitate promulgation of HIVtesting policy.
• Information and advocacy campaigns.

This is not primarily an area of implementation for the Health Department. However, through intersectoral work and funding of NGOs, the Department works across a broad front to build acceptance and counter discrimination.

Information and training workshops for employers, health NGOs and trade unionists focused on legal rights and making Government policy transparent. Various workshops of this kind were held during the year.

The messaging in all awareness campaigns has been designed to counter prejudice and negative perceptions of people infected and affected by HIV and AIDS.

A number of practical strategies for more effective enforcement of the rights of people living with HIV and AIDS were proposed at the Health Summit in November (Page 90).

Reducing tuberculosis and TB deaths

The targets for tuberculosis control specified in the Strategic Framework have been expanded in the Medium Term Development Plan for the National TB

Table 15: Reported cases of TB 1998 – 2001

Figure 9: Incidence of all types of TB per 100 000 people by province

In terms of sheer numbers, the provincial picture looks like this:
Table 16: Number of cases of all types of TB by province

Table 17: Provincial performance against five-year objectives

Control Programme. This plan flowed from a strategy adopted in Amsterdam in November 2000 by the 22 nations with the highest TB burden. It was launched by the Minister of Health in January 2002 and covers 2002 - 2005. It objectives are:

• To decrease TB-related mortality and illness and reduce transmission of the disease.   To reduce human suffering and the social and economic burden of this disease.
• To establish optimal co-ordination with the HIV and AIDS Programme.
• To prevent the development of drug resistance.

Five-year treatment objectives

• Attain a cure rate of 80 - 85% among smear positive cases.
• Reduce treatment interruption to less than 10%.
• Detect 70% of new smear positive cases.
• Expand DOTS coverage to all districts.

Key objectives for 2001/2

• Develop a medium-term plan for TB control.
• Undertake an audit of multi-drug resistant TB.
• Review TB hospitals run by nongovernment organisations.
• Strengthen integrated management of HIV and TB.

The challenge in relation to TB cannot be overstated. South Africa ranks near the bottom of the international league table in terms of the extent of the TB problem - it is ninth last - and still this epidemic is growing. (See Table 15) The increased figures are partly due to improved reporting. But the spread of TB is also fuelled by the HIV epidemic, as compromised immunity makes people much more susceptible to TB infection.

Since TB can be cured even in HIVpositive individuals, the Department has not reduced its treatment targets to make allowance for HIV.

Of the 129 000 pulmonary TB cases reported in 2001, 101 000 were infectious.

The incidence of TB over time and the burden in various provinces are reflected in Figure 9 and Table 16. Against this background, some progress has been recorded towards the programme's stated objectives:

• The national cure rate improved from 56,6% in 1997 to 62,9% in 2000. Figures for 2001 patients were not available at the close of the financial year due to the length of the course of treatment.
• Interruption rates dropped slightly from 18,6% to 15,8% between 1997 and 2000.
• DOTS coverage existed in two-thirds of districts in 2001.

However, the mortality rate of new smear positive PTB patients increased from 6,3% in 1997 to 8,3% in 2000. Only in the Western Cape, has this death rate remained stable at between 3,5% and 3,8% over the past four years.

Considerable variation among provinces is evident. Each province will during 2002/3 develop its own medium term plan. In support of this process, during February and March 2002 a team from the national Department and an expert from the Royal Dutch TB Association visited the provinces.

TB and HIV programme integration

This has been dealt with on page 40.

Multi-drug resistant TB

Multi-drug resistant (MDR) TB is a result of incomplete or inappropriate treatment of TB. It is a serious public health problem because:

• It is extremely difficult to treat, with cure rates from 30% to 50%.
• It is very costly to treat - 10 to 20 times more expensive than regular TB treatment.
• Mortality rates are high - ranging from 30% to 50% within two years. Available research by the Medical Research Council, based on work in three provinces, indicated that MDR TB occurs in about 1% of new TB cases and 4% of previously treated cases.

A nationwide surveillance project on MDR TB got underway during 2001/2 and results are expected in 2002. This will not only give a total picture of the size of the problem, but may suggest circumstances linked to shortcomings in treatment that give rise to this condition.

A rational, step-wise approach to MDR can achieve better control - but good information is the key to this.

Hospital review

Specialised hospitals for TB are run in the provinces by SANTA and Lifecare. A review of these institutions was undertaken to assess their contribution within the new community-based strategy for TB management. Although the situation differed from province to province, overall it was found that the hospital services were not well aligned with the Department´s strategic direction and, in many cases, did not represent good value for money.

The review gave rise to disquiet about the operation of the SANTA head office. A forensic audit was commissioned and the report resulted in a halt to government funding of the head office. The audit report was handed over to an appropriate law enforcement agency for further investigation and possible action. The Health Minmec took the view that provinces should, over a few years, resume direct care for TB patients and terminate the contracts with SANTA and Lifecare.

CONTROLLING MALARIA

Five-year objectives:

• Improved disease management.
• Appropriate and effective measures to control the anopheline mosquito that transmits malaria.
• Stronger co-operation with neighbouring states.

Key objectives for 2001/2

• Launch malaria component of Lubombo Spatial Development Project.
• Evaluate effectiveness of insecticides used in vector control.
• Revise treatment guidelines in light of parasite response to present drugs.

There was action on all three counts in 2001/2. This included:

• Changing the insecticide used for spraying inside houses in malaria endemic areas. DDT was reintroduced as a consequence of a specific relaxation on the ban on its use.
• Revising the drug policy for malaria treatment.
• Strengthening international collaboration, especially with Mozambique and Swaziland.
• Building operational capacity in the area of malaria control.

Significant reductions were achieved as a consequence of these measures, both in the number of cases and in the case fatality rate.

Five malaria programme managers from South Africa completed a three-month course in Ethiopia that covered malaria operations, epidemiology and project management. This training has benefited the malaria control programme as knowledge has been transferred from managers to programme personnel.

The Minister of Health launched the malaria control component of the Lubombo Spatial Development Initiative in November 2001 in KwaZulu-Natal. This is a collaborative venture, involving South Africa, Swaziland and Mozambique, with the goal of eradicating malaria in the areas along their common border and thereby contributing to the economic development of the area.

The Department also launched its strategic plan in terms of the global Roll Back Malaria initiative on SADC Malaria Day, 9 November, using the occasion to raise awareness of malarial disease.  

PROMOTING MENTAL HEALTH AND REDUCING SUBSTANCE ABUSE

The Department's vision in this area is to promote the mental well-being of all South Africans through appropriate mental health interventions within the primary health care approach.

Five-year objectives

• Setting in place a new Mental Health Care Act.
• Integrating mental health services into primary health care.
• Introducing strategies - especially preventive strategies - to reduce substance abuse.
• Introducing violence prevention programmes in educational settings.
• Implementing guidelines on treatment of rape survivors in all districts.
• Treating chronic mental illnesses and disorders through community based psycho-social rehabilitation, wherever possible.
• Implementing strategies to prevent suicide, especially among youth.

Key objectives for 2001/2

• Submit Mental Health Care Bill to Parliament.
• Participate in WHO global focus on mental health.
• Strengthen systems for community care and prevention programmes.

The year in review coincided with a WHO focus on mental health that emphasised the rights of people with mental health problems. The international slogan, “Stop exclusion – Dare to care,” was taken up in a national campaign that peaked on World Health Day in April. Several events were held on that day and bells were rung at noon across the country to symbolise our commitment to reach out to people with mental disabilities and disorders.

The annual WHO World Health Report surveyed mental health services globally and highlighted the need to provide comprehensive services for people with mental disabilities as these disabilities represent a substantial, and ever increasing, “disease” burden. The main recommendations in the 2001 World Health Report reinforce the policy direction already adopted by the Department in terms of integrating mental health care, increasing community based care and involving communities, families and consumers more in making policy and designing care.

The World Health Report was launched in South Africa by the WHO head of mental health, Dr Benedetto Saraceno, at the national Health Summit in November.

Mental Health Legislation

The year saw the passing of the Mental Health Care Bill in the National Assembly. The Bill won unprecedented support from all political parties and is a breakthrough in terms of recognising and guaranteeing rights for people with mental disabilities and regulating mental health services.

Deinstitutionalisation

An independent evaluation of two pilot projects on deinstituionalisation – in the Eastern Cape and KwaZulu-Natal – showed that releasing people from institutions to community care is indeed the most cost-effective and humane strategy to assist many people with chronic mental disabilities.

However, the research reinforced the position that effective programmes are needed in the community to continue to care for those who are discharged from institutions and to assist them settle into community life. The Department continued to fund non-governmental organisations to encourage the expansion of community care. It is also working with provinces to shift funds within mental health budgets towards community oriented services. The new mental health legislation, with its provisions for the review of patients in institutions, promotes earlier discharge.

Building primary care capacity A comprehensive training manual for health workers at primary care level was developed to facilitate the policy of integrating mental health care into general services and decentralising to the primary level. An initial group of 27 people – three per province – was trained in the use of this manual.

Improving care in psychiatric institutions

The Department convened a three-day meeting for senior managers of all state psychiatric institutions for training and sharing ideas on improving hospital services. This has become an annual event and it has contributed to more efficient management of hospitals as well as to greater regard for patients’ rights.

Our institutions play a part in the criminal justice process to the extent that they perform psychiatric observation of individuals who have been charged and treat those found unfit to stand trial. Annual meetings between forensic mental health specialists and representatives of relevant government departments (Justice, Correctional Services, South African Police Services and the Directorate for Public Prosecutions) have helped improve this service.

Preventing violence

The Department continued to support Non-natural Mortality Surveillance, which is providing valuable information for the planning of appropriate strategies by various departments.

The Health Department took responsibility during the year for interacting with other departments to ensure violence prevention was prioritised and that policy and plans were based on the best available information.

In response to the identified problem of suicide among school-going youth, a prevention programme was initiated.

The Free State was designated as the pilot province, where the intervention plan is being tested and a manual developed so that the intervention can be replicated.

REDUCING SUBSTANCE ABUSE

Further epidemiological research on foetal alcohol syndrome was supported by the Department, this time in De Aar and Upington in the Northern Cape.

Until this the Western Cape was the area with the highest documented levels of foetal alcohol syndrom in the world, but the dubious distinction has shifted to the Northern Cape.

The prevalence rate in De Aar was found to be 98/1000 children and in Upington 80/1000. This has massive implications for the Departments of Health, Education and Social Development as many of these children require special education and will need social grants.

The national Department is assisting the province with prevention strategies.

The negative effects of “home brew” drinks prompted the Department to commission the CSIR to conduct tests on various alcohol sample in Galeshewe, Northern Cape (following a similar study in Mamelodi, Gauteng). Although these alcoholic drinks are greatly abused – largely because of their low cost – the samples did not contain major toxic additives. Nonetheless, there is a need for creative approaches to reducing abuse of “home brews”.

In collaboration with WHO and the South African Alliance for the Prevention of Substance Abuse, nine nongovernmental organisations are receiving support to develop new community based interventions for preventing substance abuse, including approaches relevant to young people.

MANAGING CHRONIC DISEASES AND DISABILITY

Five-year objectives

• Implement national guidelines for control of hypertension, diabetes and obesity.
• Control asthma in children and adults.
• Strengthen and expand the National Cancer Control Programme.
• Increase the rate of cataract surgery.
• Ensure access to assistive devices.

Key objectives for 2001/2

• Implement statutory ban on smoking in public places.
• Expand health promotion in schools.
• Develop information material on cancer, asthma and disability.
• Develop guidelines on managing asthma.
• Decrease backlogs in assistive devices by 30%.
• Evaluate wheelchair repair centres.
• Promote access to health care for people with disabilities.
• Raise awareness of abuse of older people with a view to preventing it.

Lifestyle is a critical causal factor in relation to a range of chronic diseases and conditions and therefore health promotion is a key approach in this area.

Some chronic conditions have a major impact on the mortality rate – for instance, high blood pressure is linked to heart disease, stroke and kidney disease all of which are often fatal. Of equal importance, however, is the impact that chronic diseases have on quality of life.

The focus therefore falls equally on prevention, early detection and good management.

Healthy lifestyles and environments

Measures were taken to ensure that the Tobacco Products Control Amendment Act was effectively implemented. The provisions prohibiting smoking in all enclosed public places – except clearly designated smoking rooms – came into effect at the beginning of 2001. These restrictions are designed to protect nonsmokers, including children, from the harmful effects of tobacco smoke.

Health promotion personnel and environmental health officers were trained to assist with implementation of the Act, by means of advice to thepublic and monitoring. The Department also set up a hotline for tobacco related queries. This line handled more than 12 000 calls in just over a year.

There has been a substantial drop in the national average consumption of cigarettes since 1990. This appears to be related to a sharp rise in the price of cigarettes due to excise tax. Health warnings on all cigarette packs also became mandatory in the mid-90s.

The Department also actively supported international tobacco control initiatives, as described on page 93.

Schools-based health promotion programmes attempt to create health awareness at an early age and to empower young people to exercise personal lifestyle decisions in the light of sound information. By March 2002, nationwide 7% of schools had adopted the Health Promoting Schools model.

Chronic conditions

The Department has established a unit for therapeutic education that will identify and address barriers that prevent patients from complying with programmes of treatment. Presently the emphasis in the unit is on researching the barriers to compliance among patients with chronic, noncommunicable diseases. The results of this research will be used to train health professionals to deal more effectively with their patients.

TABLE 19: SURGICAL OPERATIONS FOR CATARACTS AND CATARACT SURGERY RATE (CSR)TABLE 19: SURGICAL OPERATIONS FOR CATARACTS AND CATARACT SURGERY RATE (CSR)

*Operations per 100 000 population

Guidelines for a range of conditions were developed and/or printed during the year. They relate to:

• Osteoporosis.
• Stroke and transient ischaemic attacks.
• Long-term domiciliary oxygen therapy.
• Home-based care.
• Managing asthma in adults at primary care level.
• Preventing blindness

Disabilities

On the policy front two important developments were:

• The public launch of the National Rehabilitation Policy by the Minister of Health in Umtata in August 2001.
• The adoption of a policy on assistive devices by the Provincial Health Restructuring Committee (national and provincial heads of health) in February 2002.
• Communication and health promotion
• Communication and health education in relation to people with disabilities represent a major challenge and the national Department has made some progress in this area.
• For the last few years a six-week sign

Communication and health promotion

Communication and health education in relation to people with disabilities represent a major challenge and the national Department has made some progress in this area.

For the last few years a six-week sign language course for health workers has been organised in conjunction with the Wits University Centre for Deaf Studies. This equips trainees with the basic skills to communicate with deaf clients. The total number of health workers trained to date is 93.

Audiotapes on the prevention of HIV and AIDS were produced and launched in September 2001 to raise awareness among blind and visually impaired people. To date 20 000 tapes have been recorded. Playing cards with educational HIV themes were also prepared in large print format for use by visually impaired people.

Audiotapes and videotapes on preventing chronic diseases of lifestyle were distributed to the provinces.

Cataract surgery

The project to reduce blindness by means of cataract surgery, which is part of the WHO Vision 2020 – Right to Sight programme, regained ground in 2001. In total 3 202 more surgical operations were done than in the previous year.

A group of 11 Tunisian surgeons, who are accredited by the Bureau for Prevention of Blindness and operate regularly in South Africa in terms of a country-tocountry agreement, performed 260 cataract operations in six weeks in 2001.

Since the programme began in 2000, they have performed 494 cataract operations in rural areas, making a major contribution to health in our country.

A public-private initiative involving free services of members of the Ophthalmological Society of South Africa is becoming an established feature of the cataract surgery programme.

Assistive devices

The Department boosted provincial efforts to provide assistive devices by purchasing 309 wheelchairs and 65 hearings aids, mainly for clients from rural areas.

In November 2001 a Taiwanese organisation, Buddha’s Light International Association, handed over 152 wheelchairs to the Minister of Health.

This brought the total number donated by this organisation to the Department to 652 since 1999.

Maintenance of wheelchairs is almost as great a problem as their initial purchase and, with the help of a donation from the Flemish provincial government, repair centres were established in most parts of the country in the year prior to this reporting period. An audit of the centres this year indicated that there are problems of sustainability but most will survive the challenges that confront small enterprises. People with disabilities are involved in the running of these centres.

In terms of accessibility of health facilities, the Department has developed criteria for facilities to assess how they rate. In the Free State, 79 facilities out of 300 have met “silver” and “bronze” gradings for meeting accessibility requirements. None has yet been awarded “gold” class recognition.

Older persons

Each year the Department holds an event to recognise older people and to raise awareness of their special health needs.

There is a very real problem of abuse of older people and, in an attempt to counter this, the Department has launched a national initiative known as the Dignity Project. This facilitates interaction between young people and the older generation, in the belief that abuse is less likely when there is emotional engagement between generations.

ORAL HEALTH

Key objectives for 2001/2

• Ensure major water providers comply with provisions on fluoridation.
• Complete National Children’s Oral Health Survey.

In terms of the regulations on water fluoridation, water providers were scheduled to apply for registration with government. Most of the large providers, covering the metropolitan areas, did so.

Others applied for exemption, as provided in the regulations, and the Director-General approved exemptions for a limited period.

Good progress was made with the Children’s Oral Health Survey – which is designed to determine the oral health status of our children — in all provinces except the Eastern Cape.

OCCUPATIONAL HEALTH

Key objectives for 2001/2

• Develop a risk assessment tool for workplaces.
• Develop a strategy for occupational health in SMMEs.
• Integrate the information systems for assessment and compensation of occupational lung diseases.
• Decentralise medical examinations for compensation.

Programme development for occupational health is managed in the Department. The National Centre for Occupational Health (NCOH) undertakes a range of research and assessment and compensation of mineworkers are the combined responsibility of the NCOH, the Medical Bureau for Occupational Diseases (MBOD) and the Compensation Commissioner for Occupational Diseases (CCOD).

Training of health workers in occupational health continued during the year with 46 nurses completing a diploma.

The occupational health risk assessment tool was completed and tested.

Following the completion of a study on the relationship between workplace stress and substance abuse among health workers, a pilot programme was developed and implemented in KwaZulu-Natal.

The NCOH

The NCOH published a wide range of studies during the year, on subjects including lung disease and asthma in the workplace, microbiological hazards in occupational settings, occupational allergies in specific industries, musculoskeletal disorders and trends in occupational diseases.

During 2001, the NCOH launched a new surveillance system focusing on upper limb musculoskeletal disorders. A major purpose of surveillance is to identify risk industries for targeted hazard control. It continued to manage the Surveillance of Work Related and Occupational

Respiratory Diseases in South Africa.

The NCOH also operates a pathology section. While its work is mainly in the area of certification of deceased mineworkers for compensation of their families, it also serves as a national referral centre for lung pathology and handled 519 consultations this year.

Compensating mineworkers

The CCOD pays compensation to mineworkers, former mineworkers or their families on the basis of medical reports received from the MBOD or post mortem reports from the NCOH (in the case of applications made by families in relation to deceased mineworkers) Amendments to the legal framework governing this process – the Occupational Diseases in Mines and Work Act of 1973 – were approved by Cabinet in March 2002.

The information systems of the three institutions were integrated during the year, resulting in improved efficiency. Procedures were also changed to secure the system against certain fraudulent practices.

Workshops were held with occupational health practitioners in seven provinces to improve the quality of medical examinations performed for purposes of certification. Examinations have been successfully decentralised with 40 public hospitals now performing them.

A total of 3 051 applicants were paid out by the CCOD in 2001/2, the total amount awarded being R85,1-million.

The MBOD received a total of 24 327 applications for certification in this period and certified more than 75% of applications within the year. A total of 6 061 of those certified were found to have compensatable diseases.

The NCOH performed 2 531 post mortems for certification purposes in 2001. An analysis of its 2000 post mortem results (involving about as many cases) showed the following disease rates:

IMPROVING EMERGENCY

MEDICAL SERVICES

Emergency services have the potential to reduce mortality and long-term damage to health in a country with high crime, accident and suicide rates.

Five-year objectives

• Improve emergency medical services, facilities, equipment and vehicles.
• Improve the training of EMS personnel nationwide.
• Improve emergency services inside hospitals.

Key objectives for 2001/2

• Formulate norms and standards for EMS.
• Develop models to cost EMS within the Integrated Health Planning Framework.
• Facilitate direct provincial management of EMS in eight provinces.

The development of norms and standards for emergency services got underway in early 2002. The project will enable each province to identify where to locate services for the best coverage and the size of the service needed for an effective response. The project will be completed in 2003.

Preparation of regulations on the registration of emergency services and minimum criteria for such services began, in anticipation of the enactment of a new National Health Act.

ENSURING MEDICINE SAFETY AND EFFICACY

The availability of safe and effective medicines is a critical dimension of saving lives and treating or managing illnesses. The Medicines Control Council (MCC) is the body established by statute to ensure the safety, quality and efficacy of medicines available on the South African market. All pharmaceutical products marketed here are required to be registered through the MCC. The Council is also responsible for monitoring activities related to the production and marketing of pharmaceuticals.

The MCC’s support structure is a section in the Department known as Medicines Regulatory Affairs, headed by the Registrar of Medicines. This provides backup to the council and its committees – who are not employees of the Department – through general administration; research and technical evaluation of medicines; and inspecting various premises where drugs are produced, used or marketed, with a view to law enforcement.

Key objectives for 2001/2

• Improve turn-around time on medicines registration.
• Strengthen safety surveillance systems.
• Build expertise and capacity in preparation for wider responsibility of MCC.

Registration of medicines

A total of 495 medicines were registered for human use in 2001. A handful of applications had been pending for as long as six years. But 149 of the applications completed in 2001 had been lodged in 2000 and a further 152 in 1999. In other words, about 60% of medicines registered were processed in under three years.

International standards

Members of the MCC, its committees and technical experts in the Department visited other regulatory authorities in Europe to build collaborative arrangements and exchange information on regulating clinical trials and pharmacovigilance programmes.

Since 1995 South Africa has been a member of the Commission on Narcotics Drugs (CND), which is the major United Nations policy-making structure in this field. Membership assists South Africa to align its policies and legislation with the requirements of the UN Convention on Narcotics and Psychotropic Substances, which we have signed. The MCC was represented at the annual meeting of the CND in Vienna in 2001.

In May 2001, the MCC co-hosted an international symposium on bioavailability and bio-equivalence, which are critical aspects of safety and effectivenes in the generic drugs field.

The symposium’s theme was Science and regulatory issues for the international pharmaceutical market – with reference to Sub-Saharan Africa. The proceedings informed the drafting of our domestic regulations on registration of generic medicines.

Safety programmes

The Department has prioritised expansion of drug safety programmes.

There is a National Adverse Events Monitoring Centre at the University of Cape Town, charged with gathering reports of serious adverse reactions to medicines. It was decided to establish two further centres, in order to achieve more effective coverage. The first new centre was set up at the Medical University of South Africa (Medunsa) in February 2002 and another is envisaged in KwaZulu-Natal. The Medunsa unit will include a safety surveillance programme on anti-retroviral drugs and will monitor all clinical trials to track serious adverse events during research.

The MCC established a new Pharmacovigilance Committee during the year, as well as an African Traditional Medicines Committee and a Complementary Medicines Committee.

INCREASING ACCESS TO MEDICINES

The National Drug Policy highlights the objective of universal access to essential medicines. In addition to the factors of safety and efficacy dealt with above, the Department has set objectives in relation to reducing the costs of medicines and improving the systems for making drugs available to the public health sector.

Key priorities for 2001/2

• Give effect to aspects of the National Drug Policy, particularly those arising from the Medicines Control Amendment Act.
• Develop and maintain an information system to support selection, procurement and rational use of drugs.
• Ensure a reliable, constant supply of drugs to all health facilities.

Reducing medicine costs

The Medicines and Related Substances Control Amendment Act (No 90 of 1997) was enacted largely as a measure to reduce the cost of medicines in both the private and public health sectors. The resolution of the court challenge to this legislation and the main provisions of the Act have been dealt with in the Director-General’s review.

Regulations to give effect to Medicines Control Amendment Act were drafted and published for comment in June 2001. In total, 55 organisation or individuals submitted comments and these were carefully evaluated in a series of 11 workshops and meetings to finalise the regulations.

By the end of the year, the redrafting was largely done but the publication of the regulations was postponed because of essential amendments that were required in the principal Medicines and Related Substances Control Act of 1965.

Strengthening delivery systems

In terms of the Nursing Act and the Medicines Control Act of 1965, the Director-General may grant permits for nurses to prescribe and dispense certain drugs. Changes were made to the criteria applicable to such permits to enable nurses working in occupational health clinics to prescribe and dispense specified schedule 1 to 4 medicines.

The national tendering system for medicines is central to the cost-effective procurement of essential medicines for the public health system. In support of this system and the various provincial distribution systems, a data warehouse on pharmaceuticals was developed, with donor assistance. Provinces, the public and suppliers can access data from this information system.

The Department believes that increasing public knowledge of medicines is an important factor in ensuring their appropriate use. A campaign was conducted during Pharmacy Week in collaboration with the Pharmaceutical Society of South Africa to inform the public about good pharmacy practice.

The new regulations under the Medicines Control Amendment Act will require that manufacturers provide user friendly patient information in addition to the package insert which targets the health professional.