The year 2001/2 was a challenging period for the public health sector. On the one hand, we witnessed increased recognition for some of the health principles we hold most precious. This was reflected in the Minister of Health's successful defence of our legislation designed to afford access to cheaper medicines; by the World Trade Organisation's Doha statement on patent rights and medicines; and by the rapid establishment by the United Nations of the Global Fund to Fight HIV/AIDS, TB and Malaria.
But these welcome developments produced new challenges for our public health system. By opening up opportunities, they placed additional responsibilities on heavily loaded public health authorities. In addition, they fuelled unprecedented demands from pressure groups for improved treatment, particularly for people living with HIV and AIDS. These demands went to the heart of the capacity of our health care system, and to the fundamental issues of equity and reconstruction.
In this fluid and sometimes turbulent environment, we were fortunate to have stability at senior level in the Department of Health, with low turnover here and managers who had been at the helm for some time. Programmes that represented pioneering work three or four years ago, had reached a stage of maturity and stability. This consolidation ensured sustained progress in significant areas of work even as heated debates on access to particular forms of care flared in the public arena.
The year under review opened with success for the Minister of Health in the protracted legal battle initiated by international pharmaceutical industry with the aim of overturning the Medicines and Related Substances Control Amendment Act, No 90 of 1997. On the brink of the hearing in the Pretoria High Court, the pharmaceutical multinationals had second thoughts and offered a withdrawal.
This paved the way for two important processes:
The drafting of regulations and initiation of other preparatory work to bring the Act to life after three years of legal paralysis.
Reshaping the relationship between the Department and the major pharmaceutical companies, based on the notion that co-operation in certain areas would benefit both parties and – more importantly – the South African public.
The draft regulations were produced through intensive debate and hard work within three months of the end to the court case. They were published for comment in June. The comments we received confirmed what we had realised during the drafting, namely, that amendments to the principal Medicines and Related Substances Control Act of 1965 would be necessary to produce a coherent body of law and to comply fully with Constitutional provisions. These amendments were drafted in the last few months of the financial year and were ready for publication for comment as the year closed.
Significant areas addressed by this package of law are provisions that:
Make it possible for government and private sector organisations to purchase drugs on the international market, targeting the cheapest global price for the identical product.
Enable the Minister to set up a Pricing Committee that will advise on policy related to the pricing and procurement of medicines.
Encourage the use of generic drugs wherever possible as substitutes for brand-name drugs that are no longer patent-protected. This has always been legal and widely used by the State – but it is seldom practised in the private sector, to the detriment of the consumer.
As international markets become more accessible, the responsibility of ensuring the safety and quality of medicines bought for use in South Africa will increase and the role of the Medicines Control Council will expand. We have been preparing for this and for the technical support that the Pricing Committee will require in order to fulfil its potential.
In terms of constructive interaction with major pharmaceutical players, the Department and the Pharmaceutical Manufacturers´ Association have established a seven-a-side structure that meets from time to time to exchange information and to define potential areas of co-operation. The tone of our meetings is positive and the relationship is based on a frank recognition that our interests are not identical, but there are substantial areas of common concern.
The Departments of Health and Trade and Industry have been exploring possibilities for expanded local manufacture of medicines. In the last year, technical teams visited several countries – including Brazil, India and Cuba – to observe various models of state involvement in medicine production. We remain convinced that this is a priority area for development.
We have also witnessed some movement by the multinationals in granting voluntary licences for the manufacture of their patented products.
The World Trade Organisation´s Doha statement truly vindicated the position that this Government has asserted, namely, that it is possible – even within the limitations of existing international instruments – to pursue humane policies on access to medicines while upholding our commitments as a nation.
We adhere to this principle as strongly as ever – although the bold statements of 2000 have given way to the grind of producing systems that will deliver the promises. The painstaking work that we have done this last year to enable us to truly exploit our framework for cheaper drug purchasing is, in fact, testimony to our continued commitment.
Implementation of the national Strategic Framework on HIV, AIDS and STIs is moving forward steadily. Inevitably, progress is overshadowed by the magnitude of the epidemic and the scale of human suffering that follows in its path. Shortcomings are unavoidable in a situation of such extensive need – and the spotlight tends to dwell on these.
There is, however, reason to hope that the South African epidemic can be curbed. The last three annual HIV prevalence surveys done at ante-natal clinics suggest that the rate has stabilised at just under 25% of women of child-bearing age. While this implies a huge number of infected people, the experience of some other countries tells us that this epidemic´s natural “saturation point” is much higher than 25%. It seems that the combined prevention efforts of many dedicated South Africans, in civil society and the State sector, are having an impact.
An important advance for the Department in the year under review was the production of the policy paper setting out the need for an Enhanced Response to HIV, AIDS, other STIs and Tuberculosis. This detailed both the strategies to be employed and the resources required. It was submitted to Treasury and resulted in:
A substantial allocation being made for the first time to provinces, as part of their equitable share, for use to offset the impact of treating AIDSrelated conditions at provincial health facilities. This was in response to our presentation of evidence that existing services were straining under the impact of increased numbers of very ill patients. Various resources – including personnel, drugs and hospital beds – were stretched to the limit in many instances.
Specific allocations, to be stepped-up quite steeply year by year, for priority HIV and AIDS programmes – such as, Voluntary Counselling and Testing, the Prevention of Mother-to-Child Transmission, Home- and Communitybased Care and Step Down Beds.
Figures for these additional mediumterm allocations to provinces are reflected in Figure 1. While the conditional grants are earmarked for particular health projects, the allocation to the equitable share is channelled to health at the discretion of the provincial treasuries. The figures reflect a pro-active approach by Government to the epidemic, investing progressively more resources to deal with the treatment and care aspects – but recognising that expansion cannot exceed the carrying power of health system infrastructure. The strategy must be to reinforce health facilities and support services at the same time as expanding HIV and AIDS programmes. There is little point in overwhelming limited infrastructure with funding it cannot absorb and use productively.
The national Department achieved 99% spending on the HIV and AIDS funding directly under its control during this year. This result reflects a strengthening of capacity to manage funds efficiently and an understanding of the dynamics of the programmes for which the funds are needed.
Conditional grants were disbursed to the provinces as required by law. Most provinces utilised funds as intended– but there were isolated instances of underspending.
The contested research programme on preventing mother-to-child transmission of HIV (PMTCT) very clearly illustrated how the quality of a specialised programme of this nature depends on the strength of the facility where it is inserted. Existing personnel shortages, shortcomings in the management of resources, the lack of basic resources such as transport or physical space, all place fundamental constraints on the response to HIV and AIDS – as, indeed, on all other services at that facility.
The Health Systems Trust (HST), in its independent assessment of the PMTCT research sites, underscored this factor. The HST´s interim report on the programme also positioned the question of infant feeding practices as the central issue to be explored in PMTCT. This was one of the factors that the Department felt needed resolving before embarking on full-scale roll-out of the PMTCT programme.
Essentially, the HST was at one with the Department in recognising the significance of the operational issues we sought to investigate through the PMTCT programme. Where it differed with us was on the pace of rollout – also a central issue in the court action brought by the Treatment Action Campaign and others. Details of the PMTCT programme and the court case are contained in section 2 of this report (on pages 36 and 88 respectively).
Despite the finite number of PMTCT sites offering Nevirapine within a comprehensive service package, more than 100 000 pregnant women passed through the antenatal clinics offering this service during the first year of operation. It is probably the biggest programme of its kind in Africa – but it clearly was not sufficient to meet the expectations of those most affected.
Health departments in provinces that are reasonably well resourced and have a high HIV prevalence came under increasing pressure to expand the number of services offering PMTCT and, to some extent, did so. The experience of PMTCT has enriched our understanding of the complexities of attaining equity in health care.
The persistent inequities in health spending between provinces remain a cause for concern. Figure 2 indicates how conditional grants from the national allocation have reinforced the disparities rather than reducing them.
The year 2001/2 produced the empirical weapon for us to begin to restructure conditional grants rationally and fairly in more determined pursuit of equity. The key has been to establish the quantity of tertiary care that is provided in each province – and how this measures up against the conditional grant funding that is allocated to each province for tertiary care. The dramatic lack of alignment between tertiary care funding and tertiary services delivered has provided the basis for a substantial reallocation of funds, beginning in 2002/3.
The proposal for the new “like for like” funding of highly specialised care through the new Tertiary Services Grant will make substantial additional funding available to the least resourced provinces. The allocation to the Eastern Cape will actually double in the first year, while the Northern Cape will get 44% more and KwaZulu-Natal a boost of R50-million.
These gains will generally be reinforced by the training allocation although the impact is slightly less dramatic when the training component is factored in. (Table 1)
Significant though the reallocation of funding for tertiary level care and training is, it will not on its own create equity.
Province |
2001/2 R ’000 |
to 2002/3 R ’000 |
% increase |
| EC | 118 238 | 194 016 | 64% |
| FS | 338 180 | 375 588 | 11% |
| GT | 2 098 131 | 2 130 949 | 2% |
| KZN | 581 913 | 641 178 | 10% |
| LP | 68 877 | 79 024 | 15% |
| MP | 61 965 | 68 802 | 11% |
| NC | 41 077 | 51 654 | 26% |
| NW | 58 577 | 66 303 | 13% |
| WC | 1 320 212 | 1 338 576 | 1% |
| Total | 4 687 170 | 4 946 090 | - |
Perhaps the most important feature of this reallocation is the knock-on effect it could have in terms of quality of care at secondary and primary level. Because of the lack of national funding, provinces without large academic hospitals have financed highly specialised services mainly out of the health votes of provincial legislatures - thus draining the funding available for more basic care.
Assuming that the provinces maintain their levels of funding, once the new Tertiary Services Grant kicks in, the provincial allocation should be freed for the critical task of strengthening the regional and district hospital system that provides for the needs of a large slice of service users.
It is arguable that the greatest gains in terms of quality of care - at this particular stage, as we move forward from the enormous investment already made to improve the public sector clinic system - could be achieved through investing in and revitalising regional and district hospitals.
The Department recognises that adequate funding only creates the minimum conditions for service improvement. In institutions with capable management, advantageous location for attracting professionals and adequate physical facilities, a financial injection may make a critical difference. But it certainly carries no guarantees.
The approach we have taken, therefore, is to supplement financial restructuring and broad quality initiatives, with an approach that offers intensive attention to selected hospitals and seeks to build quality on an incremental basis. The planning of this approach, known as the Hospital Revitalisation Programme, was completed in 2001/2. It also has a large capital works component and is set to move in the new financial year.
In terms of hospitals, therefore, the year under review has been a pivotal year with a range of research and planning initiatives converging and ready for activation. While some relief will be felt in year one, the full benefits of the Revitalisation Programme - even in the first group of hospitals selected - are unlikely to be experienced for a couple of years.
I would like to address the concerns that some people have about the impact that more equitable funding of tertiary services may have on large academic hospitals that have enjoyed the lion's share of funds in the past.
We are conscious of the significance of the academic complexes and their potential to influence our total health care environment through their role as centres of excellence in health care and research.
Indeed, we would like to see them restored as highly specialised referral centres offering care that utilises the most advanced knowledge and technology available. To do this we will need to organise efficiently, to eliminate duplication that is a remnant of our apartheid past and adopt an extremely rational approach to the location and number of highly specialised units available.
The research done on highly specialised care has provided us with basic information to begin this task of streamlining. The challenge for those who have a vested interest in this area is to exchange old loyalties for new possibilities and to put their considerable abilities towards shaping a new future. We undertake to provide the opportunities for this to occur through an extensive process of consultation in 2002/3.
In 2001/2 we initiated an approach to strengthening health districts through focusing on performance in terms of selected lead programmes - such as immunisation, and the management of STIs. We have commissioned a districtbased mapping of selected services - including those related to HIV and AIDS - and have designated index drugs which we will track in terms of supply and utilisation.
We remain committed to implementing a comprehensive package of care across clinics and health centres in all districts by 2004. However, we believe that a focused approach to quality of care in specific programmes will produce advances where a diffuse approach may fail.
A similar approach of consolidation and attention to quality prevails in the TB Control Programme. TB Demonstration and Training Districts (DTDs) are sites of best practice and serve as a reference point in expanding the community-based DOTS treatment method countrywide. A district can only hold Demonstration and Training status if it meets the established benchmarks. Concentrated support will be afforded to ensure more DTDs are recognised in provinces where DOTS is least established.
The Health Summit, held in November 2001, was enormously successful as a communication and consultation initiative. It drew more than 600 participants from a wide range of health stakeholders and generated extremely positive interaction.
The four main theme areas - Quality of care; Human resources for health; Communicable diseases, especially HIV, AIDS and TB; and Public-private interactions in health - won a high approval rating from participants as the correct focus for the Summit. While few of the recommendations for action were entirely new, the consensus that these recommendations represented was important - and new.
Some of the recommendations were translated into further action early in 2002. But keeping faith with the original intention of the Summit, and using the mandate of that significant gathering as we persist in addressing some of the most stubborn blockages to transformation, remained a task essentially for the 2002/3 year.
In this age of global markets, no national health department can afford to treat international interactions as an optional luxury. The choice between attending to the needs of our country´s own citizens and addressing international issues is an artificial one. The interests of countries and continents are interdependent and global decisions may be felt in the least of our villages.
As a Department, we have taken particularly seriously our responsibilities as chair of the Southern African Development Community´s health sector. The Minister of Health has at all times provided strong – yet accountable — political leadership in this context, and the Department has endeavoured to strengthen co-operation through committed participation at a technical level.
The SADC health sector has come to function as an effective and visible bloc in the international arena. In the last year it played a significant role, as a collective, in shaping the Abuja Declaration on HIV, AIDS, TB and Malaria; in developing the guidelines for the Global Fund to Fight HIV, AIDS, TB and Malaria; and in formulating the core content of the health clauses in the draft declaration for the 2002 World Summit on Sustainable Development.
In January 2002, the Ministry convened an inter-ministerial consultation on health and sustainable development at the request of her SADC counterparts, to develop positions on health from the perspective of developing countries. The meeting was attended by a number of representatives from G9 countries and the final document, known as the Johannesburg Declaration, was to be carried forward through various international processes to influence the WSSD draft declaration.
The Department has a dual focus in relation to human resource recruitment, development and management: The health sector as a whole (with greater emphasis on the public sector) and the Department´s own functioning.
Looking at the situation close to home, we find that our Departmental personnel expenditure of R156,5-million secured the services of 1 355 individuals. While the establishment grew quite substantially – by 270 posts – the actual number of employees did not expand correspondingly.
The Department has sustained the decisive moves towards equity in terms of gender and race that were made during the early years of transformation and has a positive picture in terms of representivity. Overall, we managed to meet – and sometimes exceed - our targets in terms of transformation. This held true for the senior management group as well as all other salary levels. Where we fell short this tended to be by a narrow margin and in relation to some of the smaller categories where the loss of a few employees can make a critical difference.
The Department´s main shortcoming in terms of attaining a representative workforce was in the employment of people with disabilities. The number increased slightly during the year, but we were still just over half way to meeting our target for 2002.
There were also indications that the Department needs to pay attention to dimensions of equity beyond recruitment and promotion. In particular, there appear to be challenges in terms of skills development and performance rewards.
A detailed report on human resources in the Department, in compliance with the Public Finance Management Act, appears on pages 96 to 109.
In the public health sector as a whole, the question of transformation for equity is considerably more complex. The reality of a nurse-based service and the history of nursing as an overwhelmingly female occupation dominate the picture.
The Health Summit justifiably highlighted issues of equity in relation to medical training, including specialist studies. Debate at the Summit indicated that the issues ran far deeper than setting targets for admission – they involved revised admission criteria, creative recruitment strategies, effective support for students from disadvantaged circumstances and bursary arrangements that would, hopefully, serve the dual purpose of providing opportunities for a wider range of students and ensuring a supply of graduates for the under-served areas of the country.
We believe we are building the kind of co-operation that is required to achieve this multi-pronged approach.
The urban-rural divide in terms of human resources for health remains one of the most critical dimensions of inequity. Recruitment and training of more health professsionals from rural areas is an end in itself in terms of representivity, but it does not automatically imply a solution to this problem. However, it does begin to create more favourable conditions for filling rural posts, provided that some of the current disincentives to working in rural facilities can be overcome and some positive attractions created.
A comprehensive strategy to address recruitment and retention of health workers, with some specific provisions for rural areas, will be produced in 2002/3. The year covered by this report created a more conducive climate for such a strategy through the redirection of tertiary services grants to provinces with a large rural component and through the institution of a development grant for specialist and registrar posts in such provinces.
The total budget managed by the Department for the period 2001/2 amounted to R6,76-billion and 97% of this budget was spent during the course of the year.
The bulk of the budget comprises conditional grants to provinces and these were transferred in their entirety in accordance with a pre-arranged schedule, as provided in the Division of Revenue Act. Details of spending by Budget programme appear in the Financial Report on pages 110-142.
The Department endeavours in all respects to comply with the provisions of the Public Finance Management Act and continued during the course of the year to strengthen financial management at a number of levels: through the training of non-financial managers in the Department and chief executives of institutions; and through improved budget planning. We aim to establish effective control over spending and procurement through a central Finance Management Committee. We are therefore somewhat disappointed to conclude the year with a qualification in the Auditor-General´s Report. However, the qualification relates to a specific situation and does not refer to generalised problems in the Department.
There are signs, as we look back, that the various programmes we initiated four or five years ago — in an effort to reinforce primary health care – are beginning to gel. For instance, in immunisation, tuberculosis control, management of children´s illnesses, malaria control, STI treatment and outbreak management – there is a growing confidence at both management and service level about the approaches adopted. The scale of intervention is becoming substantial enough for us to expect some influence on health indicators.
While much has still to be done in the area of mental health, disability and chronic care, new approaches have been instituted in these areas. Many of them are patient-centred and developmental – but will no doubt require substantial investment of effort and resources in order to realise their potential.
However, the burden of HIV, AIDS and TB on society and on our health services is already a real factor and one that looms increasingly large, threatening to reverse hard won gains in the health status of our nation and to stretch our health system beyond its limits. There is commitment across the Department´s senior management team to stemming the tide of these epidemics and to containing their impact. All sections are expected to contribute their skills to this common endeavour.
Tracking progress – given the complexity of the delivery system, the complexity of the disease burden and the variety of strategies employed – is a major challenge in health. It has not been simple to agree on key indicators and to establish appropriate monitoring systems that span local, provincial and national activities. But our ability to do this has improved significantly and made it possible to get a sense of the pace and direction of our collective work.
A grave concern is the gaping disparity in health care resources allocated to South Africans living in different provinces. The differences are plain for all to see in the wide range of per capita spending on health across provinces – and these differences translate equally plainly into unequal services on the ground. We need to remind ourselves that equity was the absolute bedrock of our transformation programme and examine ways to reconnect with that foundation. Urgent collective action is imperative. We cannot hope to push back poverty if our public services reflect the deprivation of the people that they aim to assist.
We look, in this matter as in others, to the constructive relationship that exists between the national Department and various provincial health departments. The provincial heads of health have continued to play a vital role in shaping national policy to take account of the differing needs and capabilities of provinces. I thank them for their critical participation and continued support.
I would also like to acknowledge the role of senior managers of the Department and of our partners in the statutory health bodies and nongovernmental sector in enriching the approaches of the Department. The output of managers rests to a large degree on the efforts of their teams and I would like to recognise all our personnel for their contribution to our common task.
Particularly, I wish to mention the sterling work of personnel in my own office who offer unfailing support and willingness to keep up the hectic pace of work. The individuals responsible are Henko Labuschagne, Nomvula Marawa, Portia Mushi, Helene van Wyk, Malungisa Skenjana, Ellie Ramatlo and Anna Phalatse – plus Percy Mhlati, William Boer and Lorraine Mogorosi who joined quite recently.
I would also like to thank members of the Minister´s Office for their cooperation and key participation in policy development.
I wish also to acknowledge the support and direction given by the Minister of Health, Dr Manto Tshabalala-Msimang. I remain conscious of the opportunity that I have, through her continued confidence, to contribute to our democratic project at a critical time.
Finally, we need to remind ourselves that health care is the collective project of some 300 000 individuals who invest their working time to create services that improve the lives of our people. When I visit health care facilities and witness what this means, I am often humbled by the dedication of our professionals on the ground. It is with the great respect, therefore, that I recognise the value of your work and yet urge you to remember our task is far from complete.
Dr Ayanda Ntsaluba
Director-General