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Provincial priorities

Written by Health-e News

Seven of the nine provinces recently presented their health budgets to the portfolio committee in Parliament. Gauteng and KwaZulu-Natal have still to appear. Health-e sat in on the presentations.

Inequity gap widens in Eastern Cape
By Anso Thom

Identified as the province with the highest levels of inequity in the country, the Eastern Cape is struggling to address the widening gap.

Speaking to Parliament’€™s Health Committee, Eastern Cape Health MEC Bevan Goqwana explained that the economically active sector of the province’€™s population migrated to the Western Cape and Gauteng for work where they were counted as part of the population, allowing the ‘€œadopted’€ province to access larger portions of the national budget.

‘€œBut when they have full-blown AIDS they are sent back to the Eastern Cape where they need to access healthcare,’€ said Goqwana.

He said the province was planning to start its anti-retroviral programme at two sites ‘€“ Ukhahlamba and Alfred Nzo – by the beginning of July, expanding it to a further five sites during the year. The biggest hurdles in terms of expanding the programme were lack of access to viral load tests (currently done outside the province) and a shortage of CD4 test facilities.

He said 8 000 patients had been tested to establish their readiness to receive anti-retrovirals, but he expressed reservations about the dangers of resistance developing as patients failed to take their medication regularly. ‘€œOur patients tend to move around making it difficult to keep track,’€ said Goqwana.

The province aims to have 2 700 patients on treatment by early 2005 and 147 200 on treatment by 2008.

Another major challenge facing the province is recruiting and retaining professional staff such as doctors and nurses.

‘€œIt is difficult to convince a doctor or nurse to work in a rural area in the Eastern Cape if he or she can work in a rural area in the Western Cape. The choice is clear,’€ said the MEC.

Goqwana said it was almost impossible to attract professionals with families to rural areas where there were few schools for their children and no entertainment facilities.

Currently 1 584 of the 5 161 nursing posts are vacant, 687 of the 1 081 doctor posts, 169 of the 300 specialist posts and 45 of the 72 registrar posts.

Goqwana said it had been a major challenge to increase the number of health facilities in a province that had historically been underserved. Despite this the province has managed to improve health access from one health facility per 100 000 population in 1994 to one per 10 000 in 2004.

The MEC acknowledged that the infant mortality rate (IMR) was still unacceptably high. Standing at 72 deaths per 100 000 live births, it is the highest in the country and well above the average of 59. Its neighbour, the Western Cape has an infant mortality rate of 30.

It is widely accepted that the IMR is a good indicator of the success or quality of a health system.

Health MEC: Mr Bevan Goqwana
Director General: Mr Lawrence Boya

High marks for Free State
By Kanya Ndaki

The Free State department of health cut through the red tape of lengthy presentations by distributing an impressive ‘€œreport card’€ of its performance during the 2003/2004 financial year.

No large entourages or fancy slide shows ‘€“ the achievements of the department did the talking.

According to the report card, the department achieved 87,5 percent of the promises made in the Health MEC’€™s budget speech last year.

Health services in this flat, often bleak, central province are stable and the quality of care is improving, despite a lack of expertise and massive health challenges.

Head of the health department Victor Litlhakanyane told Parliament that nine new clinics had been built, six had been upgraded and revitalisation projects at Boitumelo and Pelonomi hospitals were underway.

The MEC had promised the building of eight new clinics and the upgrading of eight existing clinics.

But the implementation of the district health system still had a long way to go, Litlhakanyane said.

The department still had to ensure the smooth transfer of municipal health services to district municipalities and take over primary health care services from local municipalities.

But he envisaged problems with the scaling up of salaries of health care workers who previously had been paid by municipalities.

Up to 106 community development workers have been recruited from villages and farm areas to strengthen the ‘€œwell-functioning’€ district system, Lithlhakanyane added.

The ‘€œcross border flow from [neighbouring] Lesotho and inappropriate self-referrals are definitely having an impact on our health budget,’€ the head of department admitted.

Identified as one of the provinces in the ‘€œtop three’€ of HIV prevalence figures in the country, HIV/AIDS was one of the department’€™s ‘€œbiggest priorities’€ Litlhakanyane said.

The department plans to have its antiretroviral programme running in all of its five districts. The first site was launched in May at Bongani hospital in Welkom.  

‘€œWe have decided to take a phased approach to the roll-out and we are taking it district by district,’€ Litlhakanyane said.

MEC: Sakhiwo Belot
Director General: Victor Litlhakanyane

Limpopo pleads poverty
By Anso Thom

National government is failing to give Limpopo its rightful share of the budget hampering efforts by the provincial health department to address issues such as inequity and accessibility in the health sector, head of the health department Dr Nelly Manzini has told Parliament.

She explained that health was also being shortchanged as a huge chunk of the provincial budget was diverted into paying social grants. Despite this at least half of those who are eligible for grants are not yet receiving the money.

The 2001 Census recorded that there were 5,2-million people living in Limpopo, but Manzini said the figure was now closer to 5,6-million preventing the province from receiving its rightful portion of the equitable share from national treasury.

Limpopo is one of the poorest provinces in South Africa with 89 percent of the population living in poverty and the official unemployment rate at 36 percent in 2001.

‘€œWe plan to deal with the under funding (of the health department), but it remains a challenge. We use all available forums to plead our case and we have asked the premier to highlight it as well,’€ Manzini said.

But all is not lost.

The province is in the process of procuring anti-retrovirals.

Eight sites have been designated to provide the drugs to people living with HIV/AIDS.

A total of 112 clinics are on tender to receive water while a large number will be receiving electricity in the next financial year. A number of clinics have been upgraded while 109 new clinics were built.

Over 100 vehicles have been converted to mobile clinics.

A 24-hour service is being offered at 292 clinics with 414 voluntary counseling and testing sites established.

Construction of a unit to deal with multi-drug resistant tuberculosis has started.

The cure rate for new TB cases has improved from 42 percent to 69 percent. Nine percent of patients defaulted on their treatment compared to 19 percent the previous year.

Routine immunization coverage for children under one year has increased from 64 percent to 82 percent.

Although one of the biggest challenges in the province remains the number of staff vacancies in rural areas, nurses increased from 10 520 in 2002/3 to 11 432 in 2003/4.

In an effort to attract professionals to underserved areas, national government introduced the scarce skills and rural allowance. However, a predominantly rural province such as Limpopo received only R31,8-million of the R500-million pie.

The province’€™s per capita health expenditure remains the lowest in the country with R627 allocated per uninsured person in 2003/4, 36 percent below the national average.

This translates into a negligible increase of 2,6 percent from 1997 (R611) to 2004.

By 1997 Limpopo was spending R24 per person on medicines compared to the national average of R42 per person.

Currently the province spends R40,70 per person, three times less than that of Gauteng.

Health MEC: Mr Seaparo Charles Sekoati
Director General: Dr Nelly Manzini

Mpumalanga shaping up
By Kanya Ndaki

Mpumalanga’€™s health department is finally getting its act together, Parliament’€™s Health Portfolio Committee found during budget hearings held earlier this month.

But turning around a department once viewed as corrupt and incompetent is no easy task, particularly when delivering health-care services to a largely rural population of over 3 million people.

The department has inherited a poor track record of under-spending and when the national department of health analysed the province’€™s performance over the past few years, it decided not to increase the conditional grants allocated to Mpumalanga, department head Hussein Verachia noted.

Although spending in the department increased by 19 percent in 2003/4, the health committee noted with concern the large amounts of money euphemistically referred to by the provincial department as ‘€œsavings’€ which were still not being spent. In 2003/4, the department failed to spend R143 million of the R2 152 billion it was allocated.

Careful to side-step the problems caused by bad management of the department, perhaps because one of the committee members Sibongile Manana was the former health MEC and was viewed as responsible for these problems, Verachia attributed this to ‘€œadministrative problems and a lack of capacity’€.

Nevertheless, since then, progress has been made. Hospital complexes have now appointed CEOs to ensure more efficient hospital services. A small range of tertiary services are now offered at two hospitals in the province, reducing the number of trans-provincial referrals. However, recruiting specialists to offer more of these services remains a problem.

Primary health care has been bolstered by the commissioning of four new PHC facilities and the introduction of an outreach service by hospital staff to feeder clinics.

During the 2003/4 financial year, the provincial HIV/AIDS programme trained 60 health care workers and 30 lay counsellors in voluntary counselling and testing services. Up to 680 home-based care volunteers received a stipend from the department and 2 500 home-based care kits were ordered and distributed to facilities.

Despite the identification of 12 sites for the roll-out of antiretroviral (ARV) treatment, only six sites have been accredited. Shongwe hospital, situated in the rural Nkomazi district, and Witbank hospital are the only two sites to have started distributing the drugs. The other four were undergoing ‘€œminor infrastructural adjustments’€ and would be ready by the end of July, Verachia said.

The implementation of the comprehensive ARV treatment plan at all hospitals and some PHC facilities by March 2007 was one of the key priorities identified by the department.

Over the next three years, the department also hopes to establish four more regional hospitals and to ensure that properly trained primary health care nurses are available in half of all clinics by 2007. It will also expand the Directly Observed Treatment Programme for TB to all districts by 2007.

Health MEC: Mr Sipho William Lubisi
Director General: Mr Hussein Verachia

Vast challenges in Northern Cape
By Anso Thom

The challenges in the Northern Cape are big – vast distances, high levels of violence and a raging tuberculosis epidemic.

Addressing Parliament’€™s health committee, Director General for Health Deon Madyo spoke of instances where health care providers needed to travel 1 680km, the furthest point in the Northern Cape.

The province was looking towards expanding its flight service in an effort to cut down travel time. He sited an example of a patient in Alexander Bay who would have to travel 14 hours by road to access specialist services in Kimberley.

‘€œWe have had discussions and at this stage the air force is committed to some form of co-operation,’€ Madyo said.

The Northern Cape has also built two new hospitals at Colesberg and Calvinia while tertiary services will be upgraded at Kimberley Hospital.

The province was also in the process of collecting statistics around injuries involving violence from all its facilities with a view to formulating a response.

Madyo said multi-drug resistant tuberculosis was of concern as it cost R30 000 per patient to treat.

In an effort to recruit professionals to the rural, sparsely populated province, the Northern Cape will start paying a rural allowance from August. At least 300 student nurses are being recruited from ‘€œdeep’€ rural areas to start training in January 2005.

Forty matriculants have also been selected to study medicine at the University of Free State from January 2005. This is in addition to a number of students on the Cuban scholarship programme.

Both the student doctors and nurses sign contracts undertaking to serve the province for an amount of time equal to their study period.

Madyo said community service had been a major plus point, enabling the province to significantly increase its outreach service.

He said the province had specifically put measures in place to ensure that these professionals were supported, trained and received ongoing professional development.

Madyo said the Northern Cape had opted to reduce its mobile clinic service as it was ‘€œdehumanizing and uncomfortable’€ for the patients.

‘€œWe would rather build visiting points and have opened 12 in the Namakwaland district with great success,’€ he said.

This meant that a team of professionals could travel to an outpost on specific days to serve the community.

‘€œWe also find that farmers are often difficult about health service points being on their farms, so we often resort to using containers clinics that can be moved if we encounter hurdles.’€

Madyo said systems were in place to start offering anti-retrovirals, but that he was concerned about the reported shortage of some drugs.

He said drug supply was currently a problem.

‘€œYes definitely, people need the drugs, but we need to be responsible. Even as provinces we are fighting among ourselves to access the small number of drugs available.’€

Health MEC: Mr David Molusi
Director General: Mr Deon Madyo

North West in disarray
By Kanya Ndaki

The North West province is looking to consolidate the gains made over the past years and forge ahead with service delivery ‘€“ despite being one of the poorest provinces in the country.

North West Health MEC Mandlenkosi Mayisela was making his first presentation to the parliamentary health portfolio committee this month, appearing ill at ease and out of his depth, he seemed only too aware of the challenges faced by his department.

One of the most pressing of these challenges is to implement an antiretroviral (ARV) treatment programme in a rural population of up to 65 percent facing escalating HIV prevalence, he admitted.

According to Mayisela’€™s presentation, only one site had begun dispensing ARVs to patients this month (June), the other three accredited sites in the province have yet to launch their treatment programmes.

The department raised concerns about the availability of the drugs. ‘€œThe North-West was ready to order but the pharmaceutical companies told us they didn’€™t have them at hand,’€ Dr Saasa-Modise, chief-director of strategic health programmes, explained.

Meanwhile a lot of work had been done by the provincial department towards laying a foundation for the ARV roll-out.

All provincial health facilities providing maternity services were now providing nevirapine and up to 555 sites were offering voluntary counselling and testing services.

But the department is facing acute staff shortages. An example of this was the lack of qualified psychiatrists in the province. ‘€œWe only have one psychiatrist for the whole of the North-West,’€ Mayisela added.

The province offers health care workers a choice of where they would like to be stationed and this had disadvantaged the rural areas, as few were willing to work in remote parts of the province.

The department was now faced with the task of setting aside enough funds to extend the rural and scarce skills allowance to other categories which are not covered by these resources.

Mayisela added that the department would not pin all its hopes on the rural and scarce skills allowance, but was looking at ‘€œnon-monetary retention strategies’€ to attract doctors and nurses to the province.

The low TB cure rate of 52 percent, in contrast to the WHO target of 85 percent, was another problem. The reason was due mainly to high numbers of people who did not complete their treatment and the lack of transport and staff to follow up on these ‘€œtreatment interrupters’€.

The department will continue with its work in training health workers to manage TB, as well as improve its TB surveillance.

But Mayisela and his team of six directors in the health department failed to convey the direction they would be taking in trying to address some of these challenges. When pressed by members of the health committee, the team was unable to provide answers. Confusion reigned and questions were left hanging.

MEC: Mandlenkosi Mayisela
Deputy Director General:   Obakeng Mongale

Western Cape aims for quality care
By Anso Thom

The Western Cape is going full steam ahead with its plan to increase access to primary health care services and re-organise tertiary and other specialist services.

Newly appointed Health MEC Pierre Uys told Parliament’€™s health committee that he believed the strategic vision of the Healthcare 2010 plan was correct.

Healthcare 2010 calls for far-reaching shifts in the pattern of healthcare provision to ensure equal access to quality care. Many of the planned shifts are towards appropriate levels of care that will make healthcare more affordable.

Uys said there was also a need to decrease the personnel budget that is currently swallowing   61% of the cake. This does not translate into retrenchments, but rather employing people at the appropriate levels allowing them to operate more efficiently.

Among the province’€™s priorities is plans to have a total of 6 000 patients on antiretrovirals by February 2005 and to review the province’€™s joint agreements with universities which also consumes a significant share of the provincial budget.

Uys said the Western Cape would be lodging a special request with the Minister of Health for conditional grants to revitalize and upgrade Tygerberg Hospital and to build a radiation therapy facility for cancer.

Director General for Health Craig Househam said there was a specific plan in place to reduce the waiting times at identified clinics within the next three months.

‘€œWe are serious about making a difference. When a person starts queuing at 4am and by the end of the day is not helped at all ‘€“ that is just not acceptable. There are good models of practice in the province and we need to learn from them,’€ said Househam.

He said the Western Cape was known for providing access, but not necessarily quality.

Househam explained that nurses and doctors would be moved to service levels where they can do ‘€œwhat they do best’€.

‘€œWe need to train primary health care practitioners to take up the load at the entry level, but we need to avoid a situation where nurses feel that they are merely cheap doctors,’€ he said.

The province has also introduced a bursary scheme for nurses – 780 students started training this year. The student nurses are paid a salary and need to work back their time in provincial health facilities. If they choose to leave prematurely they must repay their bursary.

Househam identified the main cost drivers behind the provincial health budget as the flow of patients from neighbouring provinces seeking healthcare in the Western Cape; the increased number of trauma patients; and the combined impact of HIV/AIDS and tuberculosis ‘€“ both in terms of increased numbers and ‘€œacuity’€ of illness.

The Western Cape currently has one of the highest TB incidence rates in the world.

Health MEC: Mr Pierre Uys
Director-General: Professor Craig Househam

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