Madlala-Routledge, at the HIV and AIDS Civil Society Conference
27 October 2006
The role of the Department of Health (DOH) in a national response to HIV and
AIDS and healthcare
Thank you for the invitation to this important civil society initiative on
"Building Solidarity, an Action Plan to Save Lives". Government welcomes the
opportunity to share with you, our most important shareholder, our thoughts on
the role of government through the Department of Health as the lead department
in a national response to HIV and AIDS and healthcare. Represented here is
labour through the Congress of South African Trade Union (COSATU), the churches
through the South African Council of Churches (SACC), non-governmental
organisations (NGOs) through South African National Non-Governmental
Organisation Coalition (SANGOCO) and the National Association of People Living
with AIDS (NAPWA), through the Treatment Action Campaign (TAC). Government sees
you as representing an important section of our society.
Later this morning our Deputy President, the honourable Phumzile
Mlambo-Ngcuka will be addressing you on the important issue of partnerships and
building solidarity in a national effort to save lives. She addresses you with
a full mandate from government which has tasked her to unite all of us as a
country behind a common comprehensive programme to combat HIV and AIDS. Our
Deputy President has attached much importance to this task. Government sees you
as important partners, as leaders who helped us develop the National Strategic
Framework for HIV and AIDS and Sexually Transmitted Infections (STI) 2000/05.
You also helped us put together a comprehensive operational plan for HIV and
AIDS care, management and treatment plan for South Africa. As partners your
role remains huge, helping us to evaluate the National Strategic Framework and
the Comprehensive Operational Plan. This is a process that has begun under the
leadership of the Deputy President as Chairperson of South African National
AIDS Council (SANAC), which is itself undergoing a review.
It has been a hard and bumpy road from Durban to Bangkok, to New York and
Toronto. Having the process of reviewing our common commitment to helping our
people conquer HIV, we can now march together and not against each other.
Our country is in pain. We are all in pain. Tremendous efforts are being
made and resources being invested in combating HIV and AIDS by government and
civil society, but we continue to see unacceptably high levels of new
infections and deaths from AIDS defining illnesses. We are losing our children
and youth, our future. We are losing mothers and fathers and seeing an ever
growing number of orphans and child-headed families. We are losing teachers and
health care workers and we are losing the life blood of our economy, the
workers. Our health professionals are in pain facing a pandemic for which there
is as yet not cure.
According to the World Health Organisation (WHO) report of 2005, globally
more than 65 million people are infected by HIV, and 95 percent of them live in
Africa. In South Africa the population is estimated at 46 million. The national
HIV prevalence among pregnant women is 30,2 percent according to the 2005
Ante-Natal Care (ANC) report and 18 percent in the general population. The ANC
report further indicates youth HIV prevalence (15+ years) is estimated at 16,2
percent. The estimated number of people living with HIV and AIDS is 5,5
million. The "Mortality and Causes of Death in South Africa" report based on
the Statistics South Africa (StatsSA) study of about three million death
notification forms received by the Department of Home Affairs, South Africa's
adult death rate had risen by 62 percent in the five years between 1997 and
2002.
The 2005/06 Medical Research Council (MRC) estimates that every day in South
Africa about nine hundred people die and there are one thousand new infections.
The Public Service Commission report has warned, "By 2012 up to a quarter of
the public servants may have died of AIDS". This will affect service delivery
in a profound way.
As the Statistician-General has observed, the data provides indirect
evidence that HIV is raising the mortality levels of prime aged adults in that
associated diseases are on the increase.
However, since the adoption of the operational plan on HIV and AIDS care,
management and treatment in November 2003 and the new efforts being put into
streamlining our communication messages on HIV, there is new hope in this
country. Our people now have the opportunity to come forward and test for HIV
so that they know their status.
With more and more sites being accredited for the rollout of treatment, care
and management of HIV and AIDS, more and more people have an opportunity to get
free life saving treatment. Now is the time for unity and dialogue on HIV and
AIDS in particular and healthcare delivery as a whole. Now is the time for all
of us to provide decisive leadership in every way we can. It is in all our
interests.
The beginnings of a co-ordinated public policy response to HIV and AIDS date
back to 1992 with the formation of the National AIDS Coordinating Committee of
South Africa (NACOSA). Progress in implementing the NACOSA plan was assessed in
1997 by the South African National STI and HIV and AIDS Review. This review
identified major strengths in the response but also highlighted areas for
substantial strengthening and improvement.
Building on this review and on an extensive consultation process, government
launched its five-year strategic plan for HIV and AIDS in 2000. The plan
provided the framework within which interventions geared towards initiating and
executing a comprehensive response to the epidemic are undertaken. The
strategic framework identified four key areas of intervention:
1. prevention
2. treatment, care and support
3. research, monitoring and surveillance
4. legal and human rights.
In April 2002, after reviewing its approach to HIV and AIDS, Cabinet
reiterated its commitment to the strategic plan. Noting progress in the
implementation of the plan and the impact beginning to be made with regard to
the prevention campaign, Cabinet decided on a number of measures to strengthen
and reinforce these efforts including:
* strengthening partnerships especially via the South African National AIDS
Council (SANAC)
* continued use of nevirapine in preventing mother to child transmission
* development of a universal incremental expansion plan.
In 2003 the South African operational plan for comprehensive HIV and AIDS
care, management and treatment was launched. Its main pillars were:
* to provide comprehensive care and treatment for people living with HIV and
AIDS including the free provision of antiretrovirals (ARVs) in the public
health sector
* to strengthen the national health system in South Africa.
In sharing with you the role of the Department of Health in a national
response to HIV and AIDS and healthcare, I want to acknowledge the tremendous
work that was put by various groups and individuals in developing the national
framework, strategy and the comprehensive operational plan. It has been a
national effort. I also want to acknowledge and appreciate the work being done
by our frontline health professionals who are working under great strain to
implement the plan and to look after people, all our patients.
I want to appreciate the volunteers and home based care workers who are, on
an ongoing personal basis, helping so many of those infected with HIV and AIDS,
including family members. I also want to appreciate 16 NGOs and various
sectors' print and audio visual mass media, who continue to do sterling work in
prevention and treatment literacy and support for people living with HIV. I
salute organisations representing people living with HIV and AIDS for helping
government to successfully wage a campaign against pharmaceutical companies,
whose aim was to reduce the cost of ARV drugs. As a result of this joint
campaign South Africa is now able to manufacture generic drugs and make them
available at a much lower cost than the imported patented version. Your courage
inspires hope that working together we can conquer the HIV epidemic.
In his State of the Nation Address in February 2005, the State President,
honourable Thabo Mbeki urged us to accelerate the implementation of the
comprehensive operational plan on HIV treatment, management and care. Clearly
even with the successes we have achieved in accrediting treatment sites and
putting people on the treatment programme, we must aim to improve access. The
commitment to achieve universal access must drive all of us to work tirelessly
until every South African who needs treatment can access it easily. This would
help ease the financial and physical burden on those patients who presently
have to travel long distances and at a high cost to get their treatment.
Former President Nelson Mandela once said, "AIDS is no longer just a health
issue, it is a human rights issue." It is a human rights issue if people who
need and qualify for treatment cannot get it because they have been put on a
long waiting list or that they cannot afford transport costs to the HIV clinic.
It is a human rights issue that babies continue to be infected by their
HIV-positive mothers because the clinic sister has not bothered to tell the
pregnant mother about how she could reduce the risk of her baby being
infected.
It is a human rights issue when babies cannot access treatment and when
people die because they are poor. It is a human rights issue that HIV has the
face of a woman; that the female species and children get infected as a result
of rape or other forms of gender-based violence.
Since January 2004 we have made progress in the implementation of the
comprehensive operational plan. An estimated 178 635 patients were on
antiretroviral treatment (ART) by end of June 2006. Around 10 percent were
children.
Paediatric guidelines have been printed and distributed from the beginning
of November 2005. A clinician's helpline is available at the University of Cape
Town (UCT). The accreditation of new sites continues in all the provinces. All
districts have at least one service point.
Two hundred and fifty-five facilities are accredited covering 53 health
districts, 72 percent of 252 sub-districts have at least one service point and
the target 2006/07 is 75 percent. Targets help us measure progress. The
government's implementation and evaluation programme on various targets set by
the President in his State of the Nation Address is done at least on a
quarterly basis. This includes reporting on the implementation of the
comprehensive plan.
National Health Laboratory Services (NHLS) has certified about 250
laboratories nationally. In two years, CD4 count machines were increased from
10 to 43 and the viral load machines were increased from three to 11. There are
seven laboratories performing Polymerase Chain Reaction (PCR). The average
tests per month are as follows: CD4 count is 60 000: viral load (VL) 15 000:
PCR 4 000. Laboratory Information System (LIS) is in place in some
provinces.
Three correctional services' facilities, Grootvlei, Qalakabusha and
Westville have been accredited. The Department of Health has the responsibility
for the health of all, including offenders. In partnership with the Department
of Correctional Services, the Department of Health is taking steps to improve
the delivery of healthcare services in the correctional facilities.
We see these both as a human rights issue and a public health issue. About
seven South African National Defence Force (SANDF) facilities were accredited
to provide antiretroviral treatment services. The SANDF programme caters for
members of the SANDF and their immediate families. This has helped extend
access, illustrating that working together we can scale up treatment.
Nationally, there are 45 step down care facilities, 732 support groups and 1
176 home-based care organisations.
In 2005/06 financial year 391 206 patients were served including 59 799
orphaned and vulnerable children. To ensure sustainability, government funds 90
percent of the HIV programme. The total budget for HIV and AIDS programmes in
all government departments is R11,2 billion. The DOH budget allocation
increased form R264 million in 2001 to R2,8 billion in 2007/08.
Nutrition assessment and screening of all HIV positive and tuberculosis (TB)
patients is done routinely in all public health facilities. Nutrition
counselling and education is offered at clinic level and also by home and
community-based care organisations.
Targeted nutritional supplements and provision of food aid or other
resources has been strengthened. Micro and macronutrients have been provided to
more than 480 000 qualifying TB and HIV positive patients. It is important that
we protect this programme from abuse. Identification of destitute and food
insecure individuals is the task of the Department of Social Development, in
partnership with community leaders like you. While health can give advice on
good nutrition, the Department of Agriculture has the overall responsibility
for ensuring food security.
Research into traditional medicines forms part of the national strategy on
HIV and AIDS, and is ongoing. Funded by the Department of Health, the Medical
Research Council (MRC) is doing research on the safety and efficacy of some
traditional medicines.
The Traditional Health Practitioners Act passed in 2004 sets the legal
standards for the practice of traditional medicine. According to this law all
traditional health practitioners must be registered with the interim health
council in order to practice. It is a criminal offence for people who are not
registered with the interim council to be seeing patients and administering
medicines.
The interpretation of patient numbers on comprehensive HIV and AIDS
treatment plan should take into account the effects of patients who are lost to
follow up, de-registered and those who died after the commencement of
treatment. This information is not currently captured. Provinces are in the
process to start reporting on these indicators, including assessment.
The Western Cape Monitoring Report of their ARV programme which covers the
period up to March 2006 illustrates the importance of monitoring the
implementation of the comprehensive plan.
From a total of 16 234 patients on treatment in the province, it has been
shown that seven out of 10 treatment-naive patients are still in care. Without
treatment almost all of these patients would have died in this time period.
Looking just at those who are known to have died, cumulatively 15 percent of
adult patients had died by four years duration on ART, although some of the
patients lost to follow up may in fact have also died. Of children followed up
for three years, eight out of 10 are still in care.
The simple paper based standard of data capturing in the Western Cape has
been shown to be a feasible and appropriate system though cumbersome in bigger
facilities.
Although an electronic patient information system is nearing completion,
this is likely to bring infrastructural and human resource challenges of its
own.
As has been shown in other countries the e-health record is not the panacea
of all health information problems. Computers need staff that know how to
operate and manage them. The staff need regular training in data capturing and
storing. Machines don't run themselves.
The rapid expansion of services in the Western Cape has resulted in patients
accessing care with less advanced disease in more recent years, which in turn
has seen a decline in early mortality on the programme, from 13 percent in 2001
to six percent in 2005, in the first six months on ART. The programme has
demonstrated the dramatic impact on the health of those accessing ART. However,
the overall patient numbers accumulating on ART poses a huge service challenge
and the increase over time in the proportion of patients lost to follow up in
the first six months on ART is an early signal pointing to the health system
challenges in this regard.
The location of ART services within primary healthcare (PHC) appears to have
contributed to the success of the Western Cape provincial programme; however,
innovative approaches to sharing the service load across the entire primary
care service platform are urgently required.
Although access to Voluntary Counselling and Testing (VCT) services in our
health facilities has reached almost 80 percent nationally, we have not seen
any serious uptake. As a way to kick-off this campaign, we need leaders at all
levels to lead by example by offering themselves for public voluntary
counselling and testing. I am encouraged to see that in the entertainment
industry this is picking up momentum with musicians and radio deejays testing
publicly.
When more and more leaders come forward to test, this sends a positive
message and reduces the stigma around HIV and AIDS. It has been shown worldwide
that knowing your status is one of the key strategies of preventing the spread
of HIV and behaviour change.
We need to assess the impact of all our interventions. While much money has
gone into condom distribution, we do not know the impact this is making. The
implementation of the prevention of mother to child transmission (PMTCT)
programmes has been most uneven, with some provinces showing positive trends,
while others have performed dismally. Although the PMTCT is available at 80
percent of our fixed health facilities, coverage of target population remains
high. The prevalence of HIV among the antenatal care clinic attendees indicates
that large numbers of babies are at risk of infection by their mothers. In
2005, a national household survey estimated that 3,3 percent of children aged 2
to 14 years are HIV positive. Yet only about half of all pregnant women receive
an HIV test and only 13 percent of those who are HIV positive receive ARV
prophylaxis to help prevent their babies becoming infected.
The success of the programme in the Western Cape indicates that the use of
dual therapy in the PMTCT programme can save large numbers of babies from
getting infected by their HIV positive mothers. We need to amend the protocols
on monotherapy, as per the recommendations of the Medicines Control Council
(MCC) and MRC in order to remove the lack of clarity in the provinces. Very
importantly we have identified the great need to monitor those babies we have
saved to see that they are properly supported to stay HIV negative. ART
programmes for those born HIV positive need to be scaled up and adequately
monitored. It has been shown that treatment does not always target our
children.
Post exposure prophylaxis for occupational accidents and sexual assault must
be evaluated to assess impact. Our infection control measures must be evaluated
for effectiveness.
The WHO has declared 2006 a year for accelerated prevention of HIV. The
African Union (AU) has adopted a framework on reproductive health and HIV which
aims to reach the goal of providing universal access to comprehensive sexual
and reproductive health services in Africa by 2015.
The Department of Health has participated actively in the development and
adoption of this policy which we regard as a critical aspect of preventing the
spread of HIV. Strengthening the delivery of sexual and reproductive health
will enhance the schools-based life skill and HIV and AIDS education programme,
which has resulted in the training of 41 872 teachers covering 14 545 primary
and secondary schools in 2005/06 financial year.
The Youth Risk Behaviour Survey 2002 indicated that about 74 percent of
learners (12 to 19 years) have high levels of HIV and AIDS awareness. The
learners' awareness needs to be translated into sustainable change. Awareness
is only the first step.
The high teenage pregnancy rate indicates that a huge challenge remains to
achieve behaviour change. We need to understand this problem and to address it.
We need to get the youth and parents to engage in a frank dialogue and joint
action. We must courageously confront the problem of drug and alcohol abuse in
our country which is on the increase, and is contributing to the spread of HIV
and AIDS and other STI. Addressing drug and alcohol abuse needs the
co-operation of the community, churches, business and government. Parents must
be taught how to identify the signs of drug and alcohol abuse. Health and
social development must invest in facilities for detoxification and
rehabilitation.
The criminal justice system needs specialised training to deal effectively
with drug offenders.
We have begun an important process, under the leadership of our Deputy
President on behalf of government, of assessing our work on HIV and AIDS. We
need to speak honestly about the challenges we face as we begin to experience
the strain resulting from the growing burden of disease and staff shortages. It
is right that you use this platform to engage government and to show us our
blind spots.
Some of these challenges are:
* the shortage of doctors, pharmacists, dieticians and ordinary nurses
especially in the remote areas
* there are infrastructure problems in most facilities
* slow expansion of PIS to other provinces
* acquisition of portable lactate test machine in the remote areas for ADR
Management (Lactic Acidosis)
* integration of comprehensive HIV and AIDS care, management and treatment with
other services like PMTCT, VCT, post-exposure prophylaxis (PEP) and TB
* collaboration with other departments including correctional services which
has special needs
* management of conditional grants
* the Traditional Healers Council (THC) has not yet been established
* down referral of ART patients to PHC and Community Healthcare (CHC) needs
urgent attention
* offenders access to ART
* children, pregnant women and TB patients access to ART
* marketing of the comprehensive plan
* adherence rate calculation or estimation
* conduct post accreditation visits in all facilities.
These challenges can be solved if we co-operate. I had occasion to address
doctors at two recent events of the South African Medical Association (SAMA). I
gained a distinct impression that doctors are keen to help us solve the
problems we are experiencing with the shortage of doctors and other health
personnel. They want to be part of the solution. Similarly nurses want to be
part of the solution. We cannot address these problems without listening
attentively to their problems and seeking their active participation in finding
solutions.
The success of the implementation of the comprehensive operational plan
needs researchers to work closely with government in scientific investigation
and monitoring and evaluation. It needs doctors, nurses and pharmacists. It
needs volunteers and home-based caregivers and it needs each and every one of
us, providing leadership and mobilising all the people of South Africa.
As we review the national strategy and the operational plan, we must look at
how we strengthen our health systems including health information and
laboratory services. We must strengthen our monitoring and evaluation
framework. Health technology must be improved so that it responds to our
growing health needs. When we look at the diagnosis and treatment of TB, one of
the problems is that technology and pharmaceutical research and development
have fallen far behind. This has been brought into sharp focus recently with
the development of multi and extreme drug resistance (XDR) for the treatment of
TB.
These are problems that indicate the (Abstain, Be faithful, Condomise) ABC
strategy of prevention is not succeeding in stopping the spread of new
infections.
Repackaging and strengthening of prevention messages requires a targeted
messaging approach. A United Nations (UN) report has acknowledged the
intersection between gender inequality, poverty and HIV and AIDS. According to
the report women make up 57 percent of those living with HIV. Young African
women aged 15 to 24 years are three times more likely to be infected than their
male counterparts: transactional and trans-generational sex with older men;
high levels of gender based sexual violence. The report suggests promoting
concrete actions to address the reality of women's lives. The interventions
aimed at fighting poverty and gender inequality will help improve the status of
women.
As we build partnerships and solidarity we must strengthen co-operation
between the public and private health sector which will see greater sharing of
resources. There is enough goodwill in our country. The World Bank, the South
African Business Coalition on HIV and AIDS (SABCOHA) and Standard Bank have
joined hands to launch guidelines for building business coalitions against HIV
and AIDS throughout sub-Saharan Africa. Many businesses have adopted workplace
based treatment programmes and are seeing reduced levels of absenteeism and
improved morale and productivity. These are the coalitions government seeks to
encourage.
We must strengthen the co-ordination of all our efforts and learn from best
practice in this country and elsewhere. A recent study by the Health Systems
Trust showed a very low level of HIV treatment literacy among South Africans.
Low levels of treatment literacy result in people not getting reliable,
evidence based treatment information and thus they fall prey to charlatans who
charge them dearly for unproven remedies. The role of the Department of Health
is to protect our people and to help them make informed decisions about their
lives.
Together we can beat the hopelessness and resignation in our communities. We
can do this by sending a message of hope. That message is contained in the
government's comprehensive operational plan and the national strategy on HIV
which emphasise prevention and research, balanced nutrition, treatment of
opportunistic infections and ART for those who qualify and the prevention of
mother to child infection.
The South African Constitution has set down some basic values and principles
governing public administration, of which the Department of Health is part.
According to our Constitution public administration must be governed by
democratic values and principles. Some of these principles are:
* efficient, economic and effective use of resources must be promoted
* people's needs must be responded to and the public must be encouraged to
participate in policy making
* public administration must be accountable
* transparency must be fostered by providing the public with timely, accessible
and accurate information.
Specifically on healthcare, the Bill of Rights says everyone has the right
to have access to healthcare services including reproductive healthcare. The
State must take reasonable legislative and other measures within its available
resources to achieve the progressive realisation of each of these rights.
As I conclude, I want to leave you with the words of Virchow, a German
doctor who was sent to Poland to investigate why people there were dying of the
bubonic plague. His answer was simple. "The people of Poland need democracy."
He further explained, "Medicine is a social science and politics is nothing but
medicine on a large scale. Physicians are the natural attorneys of the poor and
social problems should largely be solved by them." Inspired by Virchow, Paul
Farmer, a Harvard trained medical anthropologist went to Haiti to work with the
poor in their fight against diseases that are fuelled by poverty like TB. He is
presently working with the Russians and Rwandans. I seriously believe we need
him in South Africa. As we look to develop an effective strategy for the
campaign to free our country of HIV and AIDS, and as we seek to mobilise all
our people, I am reminded of how Antonio Gramsci inspired us in the mass
democratic movement. We need to form a united front against the HIV and AIDS
pandemic.
Issued by: Department of Health
27 October 2006
