Reports on presentations by Free State, Gauteng, KwaZulu-Natal, Northern Cape and Western Cape
AIDS eats into Free State health budget
Identifying HIV/AIDS as one of its key health problems, the Free State told the portfolio committee that the burden of this epidemic along with TB was diverting funds and other resources needed for transformation.
“This makes it difficult to put in place other key primary health care programmes,” the province said in its report.
It also said that hospitals experienced problems in dealing with the needs of chronically ill patients who have to be admitted for longer than the average seven days.
“The Free State is now beginning to experience the consequences of an epidemic that started eight to 10 years ago. During the late phases of the HIV/AIDS disease, patients have prolonged periods of illness.
“The burden of this care is being carried mainly at regional hospitals and by families. Due to the limited resources, the health sector needs to position itself to manage 90% of the patients at primary health care level and to support families by ensuring a good home care infrastructure and having step down facilities.”
The province anticipated that in subsequent years the consequences of the disease on the health services and society would worsen.
Another challenge facing the province this year is a policy decision to integrate mental health into primary health care.
The province is planning to train primary health care providers in mental health and to increase the number of psychiatric team visits to the districts.
A longer term goal is to train the community service doctors and nurses in mental health and substance abuse.
In an attempt to address maternal child health and nutrition, the Free State will also be providing all women with a high dose of Vitamin A after delivery to improve resistance to diseases.
Gauteng supports healthcare far beyond its borders
With millions of people flocking to Gauteng every year for healthcare, the province is constantly under pressure, trying to bring health services to millions of South African beyond the province’s borders. And in many cases the patients are from beyond South African territory.
The province’s key strategic objectives is to improve the health of people in the province and beyond, to provide better health care services and to secure value for money and an effective organisation.
Dr Laetitia Rispel, Chief of Operations in Gauteng, told the portfolio committee that several policy decisions had been made around hospital services and would be implemented by next year. These included step-down and home based care facilities for HIV/AIDS patients, improved revenue generation, the decentralisation and strengthening of hospital management and the appointment of hospital boards, the appointment of an accreditation committee, and clinical audit and peer review committees at institutional level.
Rispel said significant problems and constraints facing the department in trying to achieve these key objectives included the effect of cross-border flows, especially self-referral and a lack of an effective system of referral links between different levels of care.
Inadequate data on the impact for HIV/AIDS for future planning and resource utilisation also posed problems.
Chris Hani Baragwanath Hospital indicated that at least 80% of HIV/AIDS patients could have been managed at primary healthcare level with tuberculosis a major reason (30%) for all admissions to the hospital.
Key health problems identified by the department were in the areas of women and reproductive health, infant and child mortality and morbidity, tuberculosis, hypertension, diabetes, trauma and violence, HIV/AIDS and mental health.
Maternal deaths in the province have decreased slightly, but a worrying factor was an increase in septic abortions (a national trend). This despite the fact that Gauteng has significantly more Termination of Pregnancy facilities than any of the other provinces.
In an effort to address infant and child mortality and morbidity, Rispel said the province would be expanding its immunisation coverage of all vaccine preventable deaths and strengthen the integrated nutrition programme interventions through Vitamin A supplementation, the promotion of exclusive breastfeeding, targeted supplementary feeding and growth monitoring.
She said there also needed to be a focus on poverty reduction as a key intervention.
The province also committed itself to improving TB case detection and preventing and decreasing multi-drug resistant TB.
On the issue of trauma and violence, the province estimated that R500-million was spent annually on the health impact of road traffic accidents and violence related injuries.
This amounted to 85% of expenditure in hospitals
Beleaguered KZN notes progress in primary health care system
Still reeling from a major cholera epidemic, an outbreak of foot and mouth disease and an HIV/AIDS infection rate of almost 30%, the state of KwaZulu-Natal’s hospital facilities remains the worst in the region.
“This is because of the enormous backlogs built up over a number of years,”
Professor Ronald Green-Thompson Superintendent-General of the KwaZulu-Natal health department told the portfolio committee.
Green-Thompson said conditional grants received for the central hospitals services remained a problem area in that the grant is not addressing the equity question and is totally inadequate for the number of people the province is required to serve.
In terms of primary health care delivery, Green-Thompson said the MEC had committed the department to providing 11 new community health centres and between 90 and 120 new and replacement clinics in the next five years.
He provided statistics to “show that the primary health care system is starting to show dividends and reach more people”:
- Stillbirths at clinics and community health centres decreased from 288 in 1999 to 156 in 2000
- Ante-natal visits increased from 625 982 in 1997 to 782 232 in 2000;
- Attendance of children under six increased from 1 783 202 in 1997 to 3 565 116 in 2000;
- A total of 201 maternal deaths were notified in 2000 “which we intend to reduce.” He said, however, that HIV/AIDS was emerging as the major contributory cause of maternal deaths.
Green-Thompson said the province needed to train more nurses adding that it was unethical and immoral that other countries were poaching from a developing country.
An ongoing programme in Cuba was also training 63 medical students from the province. Community service has benefited the province with 272 medical doctors, 79 pharmacists and 24 dentists making “a big difference”.
“We would have not survived without the community service doctors and we would not have been where we are today without the Cuban doctors,” Green-Thompson said.
Turning to TB services, the province expressed concern over the increase in multi-drug resistant TB that was costing R2,6 million per year. This was mainly due to lack of compliance when taking the medication, HIV/AIDS and different drug schedules used.
Green-Thompson said the province was also planning to increase the number of ambulances to serve rural areas.
Key health problems identified by the province were:
- Malaria in the northern part of the province. There has been a dramatic increase in malaria cases during 2000 with 37 934 case being reported, representing an almost two fold increase in reported cases compared to 27 238 in 1999 and 14 575 in 1998.
- Cholera outbreak. The cholera outbreak that began in August still presented huge challenges, but the department performed beyond expectation with a death rate of 0,2% compared to a usual death rate of between 5 and 50%. Green-Thompson stressed that clean water and sanitation were the most urgent needs.
- Establishment of crises centres. 48 fully equipped service centres for rape and abuse victims will be up and running at provincial hospitals. Medical and SA Police Services staff will be on hand to deal with traumatised survivors.
- Lack of basic infrastructure and facilities. More than a million people in the province are without sanitation and clean water. These shortcomings have been highlighted by the cholera outbreak. It is also estimated that some 2 million people have no or limited access to a health facility.
In another interesting development Green-Thompson revealed that the province would be using HIV tests to establish how recently a person had become infected.
“This is in the light of the fact that there is a 19% risk of an HIV negative mother attending a clinic returning to test positive a year later,” he said.
Northern Cape feels impact of HIV/AIDS
Swallowing 30% of South Africa’s landscape, but only 2% of the total population, the Northern Cape is starting to feel the effects of the HIV/AIDS epidemic.
Superintendent-General for health in the province, Dr Michael Hendricks, said Kimberley Hospital alone had spent over R26-m in one year treating AIDS-related illnesses. The province estimated that 20% of inpatients at the hospital were treated for AIDS-related illnesses.
A major concern for the province is the high treatment interruption rate recorded among those on TB drugs (17,7%).
Hendricks said provincial cure rates had increased by 10% and that all five districts were implementing national indicators for managing TB at district level.
In the Kalahari district the cure rates have improved from 55% in 1999 to 80%.
The province currently has 129 registered cases of multi-drug resistant TB ‘ these cases were being managed at Gordonia Hospital in Upington and West End Hospital in Kimberley.
Another key health problem identified by the province included access to Termination of Pregnancy (TOP) services. The Northern Cape currently has three designated facilities, two government and one private with 85 midwives trained in pre- and post abortion counselling.
In an effort to reduce the maternal death rate in the province, Hendricks said facilities and equipment were being upgraded.
To ensure the availability of skilled midwives on the periphery, an additional 18 midwives are being trained in advanced midwifery in a collaborative effort between the health department and the University of the Free State.
Since maternal death reporting commenced in the province on December 1 1997 there have been 62 reported deaths with causes attributed mostly to cardiac arrest and septic shock.
An achilles heel for the province is the high number of trauma cases mostly related to assault, followed by homicides (gunshot and stab injuries), suicide and motor vehicle accidents (high percentage of pedestrian casualties).
Hendricks agreed with most of the other provinces that the community service and Cuban doctors had made a huge impact on healthcare delivery.
“If we didn’t have the Cuban doctors we would have no specialists at Gordonia Hospital.”
The Northern Cape had 20 full-time doctors in 1994 compared to 111 last year.
Politicians accuse W Cape health services of going their own way
Do the Western Cape health services see themselves as part or South Africa? This appeared to be the question ANC members of the health portfolio committee wanted officials to answer when they “grilled” them at the recent budget hearings in parliament.
While there is no doubt that the province has made huge strides in delivering healthcare to large parts of the province, the department was severely criticised for offering drugs for the prevention of HIV transmission from a pregnant mother to her child (MTC), to only a small section of the community.
Committee members also questioned the officials on a decision to dispense Nevirapine for the prevention of mother to child transmission while the Medicines Control Council is yet to register the drug for this use.
“The whole mother to child transmission issue is so controversial and has become even more controversial. It feels as if I am making a state of the nation address,” said Dr Gilbert Lawrence Superintendent-General for Health in the province.
He said MTC was part of many other initiatives in the Western Cape to address HIV/AIDS.
“We made a decision that we were going to dispense AZT to treat patients and the core was around MTC.”
Lawrence said the Western Cape had been ready in January to proceed with the pilot projects around Nevirapine announced by the national health minister.
“We were ready quite soon because of our experience around dispensing AZT at the Khayelitsha (MTC) project,” Lawrence said.
He said the province went ahead with the project, dispensing Nevirapine, thinking the Medicines Control Council (MCC) had registered the drug.
“We very recently received a letter from the MCC questioning why were using Nevirapine while it was not yet registered,” Lawrence said.
He said the province has since undertaken not to continue giving Nevirapine, but to provide it off-label.
“We wish to comply with the MCC,” Lawrence said.
Lawrence told the committee that the Western Cape viewed its key health problems to be HIV, TB, sexual abuse and cataracts.
The province was planning to spend R23,7-million on specific HIV prevention and control programmes in this financial year. The province is planning to distribute 21 million condoms and train general practitioners to treat sexually transmitted diseases.
The mother to child project has now been established in Khayelitsha, Gugulethu and Nyanga and will be rolled out to another six sites at a cost of R6,1-million (excluding infant feeding costs).
In an effort to deal with rape survivors a one stop centre will be opened at GF Jooste Hospital in Mannenberg with dedicated centres opened at Groote Schuur, Hottentotsholland, Somerset and Red Cross (survivors under 14 years). AZT is also expected to be widely available for rape survivors by early next year.
The number of TB cases in the province has increased from 31 000 to 34 000. Lawrence said this was mainly due to HIV, but he pointed out that the cure rate had also increased from 60% to 71% with over 15 facilities recording cure rates in excess of 85%.
The province has also introduced the new four-drug combination TB tablet, which reduces the number of tablets from between 12 and 15 to four.
The province estimated that it had a backlog of 8 000 patients waiting for cataract surgery.