PRESENTATION TO THE PORTFOLIO COMMITTEE ON HEALTH IN PREPARATION FOR THE HEALTH BUDGET VOTE: 1999

HIV/AIDS/STD’s

INTRODUCTION
The HIV/AIDS epidemic is well established in South Africa and continues to spread relentlessly. Currently 3.2 million people are infected and projections indicate that within three years almost a quarter of a million South Africans will die of AIDS each year and that this figure will have risen to more than half a million by 2008. HIV/AIDS contributed to infection as the second most common cause of maternal deaths in the First Interim Report on the Confidential Enquiry into Maternal Deaths in 1998.

A Review of the National AIDS Programme was done in 1997 and the following recommendations were made;

- increase political commitment
- increase resources and build capacity
- strengthen initiatives with persons with HIV/AIDS
- strengthen inter-departmental and inter-sectoral support
- protect human rights, reduce stigmatization

FUNDING OF THE HIV/AIDS AND STD PROGRAMME
The Departmental budget was increased from R14 million in 1994/1995 to R106 million in 1998/1999 inclusive of the budget for the Government AIDS Action Plan. Five key focus areas have been identified.

Life Skills and HIV/AIDS education in schools.
A learning programme for secondary school learners has been developed and introduced into the schools. The programme aims at increasing learners’ knowledge, developing skills, promoting positive and responsible attitudes and behaviour, as well as providing motivational support regarding HIV/AIDS issues.

The training of teachers commenced in November 1997, to date more than 10 000 teachers have been trained. Education materials were printed and distribute to all secondary schools.

In 1999, a pilot project of a similar nature is to be piloted in the primary schools.

Financial assistance was granted to NGO’s providing programmes for youth-out-of-school.

STD Management.
The Department has conducted training courses in the Syndromic Approach to STD Management for groups of health service managers and clinicians at provincial level. To date the Department has trained over 600 managers and 500 clinicians.

In 1999 training will be conducted in the private sector by way of Continued Professional Development Seminars. Training will be extended to Traditional Healers. The Department has appointed two Traditional Healers to assist in the implementation of this programme. To date over 400 traditional healers received basic courses in HIV/AIDS/STD’s and TB.

Production of Sexual Health Promotion Materials.
A wide range of materials has been produced by the Directorate. Examples of these include Flip-charts for community education on STD’s Protocols for the management of STD’s Training manual on the Syndromic Management of STD’s.

Barrier Methods.
The number of condoms distributed has increased from 90 million in 1995/6 to 140 million in 1997/8.

To improve on the procurement and distribution of these, a policy document has been prepared. A barrier methods consultant will be appointed to monitor the quality of condoms, their procurement and distribution in the provinces

The Female Condom
Research on certain aspects of the Femidom is being done by the Reproductive Health Research Unit. Results of this will inform the Directorate on the feasibility and sustainability of freely providing the Femidom to the public. The use of the female condom is being piloted in 18 sites in the various provinces. Mpumalanga and Northern Province will start next month. The pilots look at the reason for continued use, and for discontinuing. In general, there was an initial high demand, but this has fallen down to low but sustained levels. The province that is persistently showing high usage is Kwazulu-Natal, probably because many people have had relatives and or friends dying of AIDS.

Care, Counselling and Support
30 Lay counsellors were trained and appointed in every province. This area was identified as one of the weaker spots in the National AIDS Programme.

Plans to improve include the training of more lay counsellors. Increasing the capacity of existing sectors like NGOs and CBOs to provide this service.

Pilot projects for Home-Based care will commence in five provinces in 1999. A best practice model will be identified from these, consultation with all relevant stakeholders will be held to determine norms and standards of care. Extension to other provinces will follow this process.

Mother-to-Child-Transmission.
Advice has been given to the provinces on modifying maternity practices in order to reduce mother-to-child transmission.

Discussions on the use of alternate forms of feeding are going on with regard to the feeding of children of HIV positive women. Currently, women are informed of the risks for transmission to the child through breast milk. These discussions are part of the broader discussions on infant feeding.

HIV is also being included in the Integrated Management of Childhood Illnesses.

Partnership against AIDS and political commitment.
The Government has demonstrated its unquestionable commitment to fight the epidemic by establishing the Inter-ministerial Committee on AIDS. This Committee is chaired by the Deputy President, consists of Ministers and Deputy-Ministers and meets monthly to review progress and tackle issues around HIV/AIDS.

In October 1998, the Deputy President launched the Partnerships Against AIDS where all South Africans from the various sectors were invited to join hands in the fight against the epidemic. All the pledges that have been received are being followed up in order to escalate the response to the epidemic.

CLINIC UPGRADING AND BUILDING PROGRAMME (CUPB)
Since the new Government came to power in 1994, it committed itself to the upliftment of the previously disadvantaged communities. This was mainly achieved through the application of RDP funds. With regards to health service provision, the new Government decided to focus on Primary Health Care, this policy leading to the increased requirement for clinics on a national basis. As a result, one of the programmes funded by the RDP was the Clinic Upgrading and Building Programme.

The First Phase of the Clinic Upgrading and Building Programme commenced in the 1994/95 financial year, followed by Phase Two in 1995/96 and Phase Three 1996/97. Final activities related to Phase Three are still currently underway.

The nine provincial health departments supplemented the RDP funds, while the Independent Development Trust also invested in a clinic building programme, that formed part of the overall CUPB programme. The total government expenditure on the CUPB Programme, (including the Shopping List) up to 31 December 1998 amounts to R757 080 281 with the RDP contribution totalling R285 00 000 (37.64%). The rest of the money was provided by the provinces’ own capital programmes.

Progress on the CUBP since 1994 may be summarised as follows:

Of the new clinics built, 92% are commissioned already in operation. The remaining 8% (41 clinics) have not been commissioned yet, either as a result of no staff being available or no equipment available.

Since this information is of 19 January there already be some improvement in these figures. We know that its usually takes four months before full commissioning after a clinic has been built.

Number of clinics completed and commissioned per Province since 1994 as at 19 January1999

As a direct result of the CUBP nearly 20 000 temporary jobs in the building industry were created mostly for people from local communities:
In addition 11 000 permanent posts were created at new clinics. Most of these were filled by absorbing staff from hospitals and elsewhere.

Herewith a summarising overview:

The above employment figures were extrapolated from information received from KwaZulu-Natal. The employment created by the IDT visiting points is not included.

Future perspective
RDP funding for the CUBP ends in March 1999. A further 59 clinics will be built and commissioned between April 1999 and June 2000, with funding being committed out of the alternative sources available.

HOSPITAL REHABILITATION & RECONSTRUCTION PROGRAMME
A vital component of hospital transformation is the Hospital Rehabilitation and Reconstruction (Hospital R & R) Programme. The neglect of proper maintenance over many years and the consequent serious state of disrepair of public sector hospitals is well known in all the provinces. Based on a National Health Facilities Audit, coordinated by the CSIR in 1996, Cabinet was informed in December 1996 that about R10 billion would be needed over a period of 10 years to replace or repair the hospitals. An estimated additional R5 billion would be needed over the same 10 years for normal maintenance to prevent further deterioration. The audit include all hospitals and 108 community health centres but excluded clinics.

The Hospital R & R programme was approved by Cabinet as a capital programme in direct response to the results of a National Health Facilities Audit. The programme is aimed at ensuring that a network of hospitals will be developed which is appropriate to the needs of the South African population well into the 21st century.

For the first year of implementation (1998/99) an allocation to the total value of R100 million was made available for equitable distribution among the nine provinces. These funds are additional to the normal Provincial Budget and may not be used for maintenance or clinics. Instead, the main purpose of the funding is to help provinces achieve structural change in line with current government policy and the White Paper on Health and aims at achieving equity of distribution of hospital services.

FUND ALLOCATIONS TO PROVINCES 1998-1999

By 15 February 1999 six provinces have submitted draft strategic plans and the appointment of a panel of consultants has been approved by the National Tender Board and is in the process of being advertised. A survey is underway aimed at identifying the provinces needs with regard to assistance required - e.g. in terms of human resources and training as well as in the area of Information Technology, the establishment of appropriate data bases and the development of organisational structures and systems related to health facilities planning.

The Directorate also facilitates relationships between the various stakeholders involved, including for instance contact with other directorates like the one dealing with disabled people as well as with national and international specialists.

The following challenges with regard to the Hospital R & R programme are highlighted:

- South Africa is suffering from a lack of people with appropriate skills and experience in the field of strategic and health facilities planning. Training and capacity-building is therefore urgently required.

- The funding available for the Hospital R & R programme does not make provision for maintenance - whether back-log or ongoing. This may defeat the purpose of the programme, if not addressed appropriately through annual budgetary commitment by the provinces.

- The impact of public-private partnerships has not been taken into consideration.

- Long-term budget planning must make provision of the funding required for the Hospital R & R Programme over a period of approximately 10 years.

Future perspective
Robust and flexible strategic plans are awaited from all provinces. These plans are aimed at providing a long-term vision for the development of Health Facilities in each province, in line with the objectives of the White Paper on Health.

NEW ACADEMIC HOSPITALS

New Durban Academic Hospital (NDAH)
In the late ‘80's work commenced on designing a new academic hospital for Durban. This design was completely revised after the 1994 elections in order to incorporate changed needs. In 1997 the phased construction on the New 846-bed Durban Academic Health Service Complex began. A R200 million grant was provided by the National Department of Health towards the project during the 1998/99 financial year. Commissioning of the hospital is assisted by a specialist consultant from the United Kingdom. Also, a Commissioning Manager has been appointed.

The total estimated cost of the project is R1,12 billion, including equipment.

CASHFLOW OF TOTAL PROJECT INCLUDING FEES AND EQUIPMENT

Prior 1 March 1998 R269 440 000,00
1998/1999 R200 000 000,00
1999/2000 R246 976 000,00
2000/2001 R273 000 000,00
2001/2002 R132 752 000,00
TOTAL PROJECT COST R1 122 680 000,00

The following challenges with regard to the New Durban Academic Hospital are highlighted:
- No Chief Executive Officer has been appointed to date.
- Details staffing profiles and budgets must still be drawn up.
- Staff training must be accelerated.
- Clinical content and management issues must be finalised.

Future perspective
Building operations are scheduled to be completed by March 2000.
First admission of patients at New Durban Academic Hospital is scheduled for January 2001.

New Umtata Academic Regional Hospital
The New Umtata Regional Hospital is being developed adjacent to the existing Umtata Hospital. A national grant amounting to R100 million was provided for the 1998/99 financial year by the National Department of Health, which is contributing R164 million towards the total cost. The balance is paid for by the province. The total estimated cost is R367 000 000,00

The following challenges with regard to the New Umtata Academic Hospital are highlighted:
- The project is currently running behind schedule, which means that only approximately R23 million of the national grant will have been utilised by the end of the current financial year.

- No robust commissioning strategy or team is in place as yet.

This is being attended to between the National Department and the province.

Future
Building operations are scheduled to be completed by November 2001.
First admission of patients at the Hospital is scheduled for April 2002.

DEVELOPMENT OF THE DISTRICT HEALTH SYSTEM AND EQUITABLE DISTRIBUTIONS OF RESOURCES.
A review of district health development was conducted in October/November 1998. The report that follows provides an overview of what has been achieved to date and lists some of the challenges facing us in ensuring the development of well-functioning health districts.

Demarcation and establishment of health districts
The rationale and process for the establishment of a DHS was outlined in the 1995 document ‘A policy for the development of District Health System for South Africa’, and later summarised in the "White Paper on the Transformation of Health System in South Africa".

Provinces began with the process of demarcating district boundaries in 1995. Currently a total of 42 health regions and 174 health districts have been defined. The three statutory options for facilitating district governance are still national policy, although most provinces have opted for a mixture of Provincial and Local Government, dropping the Statutory District Health Authority option. In all the provinces, the lack of a legal framework has been identified as an obstacle to the formation of integrated health districts.

Several provinces have defined organograms for their districts (EC, FS, MP, NW and NP). All provinces have established structures for community participation, at clinic and hospital level. In addition, strategies to train and orient health workers towards Primary Health Care have been drawn up and implemented.

Province-local government co-ordinating structures
The following provinces have formal structures to co-ordinate activities between the provincial Department of Health and local government: NP (MECCOUN: which includes the MEC, local government councillors, the head of department and local government officials); EC which has a structure composed of provincial and local government officials which meets quarterly; the FS is in the process of discussions with stakeholders on how to structure their participation in DHS development; KZN which established a Provincial District Health Systems Committee composed of provincial and local government officials; GG which has a structure in which the MEC meets with local government councillors and also has a Provincial District Health Systems Committee made up of provincial and local government councillors; NC which has regular meetings with local government; and WC had a Ministerial Committee with various sub-committees (these committees have not met for the last six months given the uncertainty of local government transformation but were recently asked to reconvene by the MEC of health). Neither the NW nor MP has established similar structures at the time of writing this report.The following provinces have formal structures to co-ordinate activities between the provincial Department of Health and local government:NP (MECCOUN: which includes the MEC, local government councillors, the head of department and local government officials); EC which has a structure composed of provincial and local government officials which meets quarterly; the FS is in the process of discussions with stakeholders on how to structure their participation in DHS development; KZN which establish__•

Managerial systems and processes

Health management structures
All nine provinces have appointed regional managers (mostly at director level) with support staff. Several provinces have appointed district managers. These include: EC (15); MP (16); NP (24); NW (16). In the other provinces Interim District Health Management Teams or Interim District Co-ordinators have been appointed.

District planning
All provinces have reported that district level health planning is in progress. In some provinces (e.g., NP), plans are ready for implementation; in WC districts have conducted situational analyses; in KZN district planning has commenced with the appointment of interim district co-ordinators; and in the EC provincial strategic plans have been converted into district level operational plans.

District Health Information System
The District Health Information System (DHIS) is an important strategy to improve management and service delivery, within the framework of the National Health Information System for South Africa, has been accepted by all provinces. All provinces are involved in developing strategies for information collection (by Community Health Coordinators in NW, and use of Routine Monthly Reports in the EC and WC) and information exchange. A provincial DHIS directorate has been established in GG. Only the EC and WC have implemented a coherent plan to develop a district-based information system. All other provinces have expressed an interest in the strategy and software used by the EC and WC and the use of a similar strategy in these provinces is likely to increase the pace of the development of a DHIS in these provinces in 1999.

Training
Extensive management training has been undertaken by all provinces using a number of agencies (e.g. universities, NGOs, and Technikons). Training of district health managers has been done through the Oliver Tambo Fellowship and DFID run programmes (e.g., in the NC). In the WC, training in budgeting and personnel management have been conducted by the UWC School of Public Health. MP has been implementing management training with CHESS and AMREF.

Some provinces have also reported extensive PHC training for nurses (clinical management). However, there appears to be a lack of consensus on the scope and practice of nurses operating in the clinical domain, e.g., the diagnosis and treatment of common complaints. Basic training remains largely hospital based. There is also a lack of uniformity in the treatment guidelines and PHC tools which are being used at present, e.g. in some districts both the old and new Road to Health Cards are being used and academic institutions sometimes use different treatment guidelines to those used by the health services.

Service provision
All provinces have noted successful implementation of curative services, although there is concern over the slow progress made in the integration of Provincial and Local Government services in some provinces. Specific problems are in the integration of curative and preventive service (NP) and staff integration between health workers employed by Provincial and local government (all provinces). Problems with the integration of services in former Homelands were cited in EC and NP.

The lack of enabling legislation was viewed as an obstacle to integration (FS, NW and WC) while the existence of multiple negotiating structures has also been cited as a problem (GG). Inadequate planning between Province and District, between Hospital and Clinics, and between Province and Local Government has also contributed to problems in the provision of integrated health services.

Improved mechanisms and strategies in service provision are being tried in most provinces through the use of demonstration districts. The ISDS is working in all nine provinces. Five provinces are involved in a Learning Site Districts Approach (promoting successful initiatives in one district with minimum external resources).

Strategies for integrating district hospitals with other district health services need more attention.

With regard to improvements in service delivery the EC has reported a 20% increase (to 84%) in the availability of EDL drugs at clinics. This improvement was the consequence of improved communication and stock management. We need to complement this pattern by increasing the availability of trained pharmaceutics personnel.

Community involvement
In nearly all the provinces, structures to enable communities to participate in health service delivery have been defined. These include clinic committees, Health Forums, and Local Interim Coordinating Committees. In some provinces district level structures exist and these include the RDP and District Health Forums.

Resources management
In the case of finance, several provinces have delegated responsibilities to Regions and Districts. In a few instances (FS, MP, and NW), a limit of R10 000 to purchase supplies has been set for regions and districts. Others (EC, GG, KZN, NC, and NP) allow Regions and Districts to make recommendations, but the Province does all approvals.
With regard to personnel management, some provinces (FS, MP, NC, and NW) have allowed Regions to make recommendations, leaving approval to the province. In the case of EC and KZN, the responsibility for staff management is shared between Province and Region, while NP has not specified any kind of delegation as yet.

The WC permits regional directors to manage all services (finance, personnel, and procurement) within the limits of their own budgets. Both EC and NW have reported budgetary allocations to districts.

The financial management system used by Local Government is different to that of the public sector. This may create problems should districts be managed by local government but be monitored by the province. Attempts should be made to harmonise all systems between local government and the provinces to ensure that the national health system can be smoothly managed.

DISTRICT FINANCING
The Department of Health has finalized work, which shows the extent of inequities within Districts and has proposed mechanisms to move towards a more equitable allocation. This work has now been placed within the context of a larger DHS committee, and will inform financial allocations and management as districts are established. Over time the national health accounts mechanism would be used to monitor equity at this level.

HOSPITALS

Policy Directions
Policy relating to Central Hospitals

The central hospitals take the largest slice of the health budget at present. The delivery of high quality affordable and accessible health services to all South Africans is underpinned by the creation of a network of dynamic, efficient, responsive and affordable hospitals. A strategy to address the multiple and severe problems of the public hospital systems is clearly articulated in the Hospital Strategy Project. This was a widely consultative process involving all provinces supported by a group of private and public sector technical experts.

The key policies driving the process to develop efficient and accountable hospital management are:

• Management decentralisation

• Delegation of substantial powers over personnel, finances, procurement and other critical management functions.

• Establishment of accountable and representative Hospital Boards.

• Development of modern, efficient management structures and systems.

• The appointment of general management heads of hospitals and the recruitment of other skilled and motivated managers.

• Attract paying patients and retention of part of the revenue generated.

Hospital management decentralisation is a priority of the Department and central hospitals are part of the pilot programme to implement incrementally the above policies.

The conditional grants are attached. These grants are now linked to certain
conditionalities that provinces and central hospitals must adhere to and report on. The main initial conditions for the grant for central hospital services (the largest grant) is that strategic plans must be developed and presented to all provinces, and that patients from all provinces must have equitable access to all services funded from this conditional grant.

Implementation of the hospital strategy project recommendations

Hospital Management decentralisation
The implementation of this policy is being done in fifteen pilot sites. This includes the ten central hospitals and five regional hospitals in each of the provinces without central hospitals. The intention is to takes aspects of the hospitals strategy project, develop implementation plans for each of the institutions, monitor the implementation process, and then extend the benefits to remaining hospitals in an incremental way.

The implementation addresses the following areas:
• Agreeing a minimum set of delegations of powers to hospital level.

• Agreeing a set of core management competencies for hospital management teams.

• Developing personal development plans for existing hospital management teams.

• Developing appropriate structures and systems to support management.

• Agreeing Performance Management Agreements (PMA) between institution and province as a reporting and
monitoring tool.

• Assisting hospitals to develop business plans that reflect link volume and range activities to budgets.

• Twinning each of our 15 hospitals with equivalent UK hospitals and each of the provinces with appropriate Regional Health Authorities in the UK. This includes 90 SA managers spending up to a month at a time getting hands on experience in the UK.

• Complementing national, provincial and institutional expertise with additional international and local technical consultants to drive this programme.

The above are only a few of the interventions. The programme is now gaining momentum. The enactment of the new Public Service Act and the treasury control bill will provide an enabling legislative environment for the realisation of above policies. This phase is supported through external donor funds from the EU and DFID.

REVENUE RETENTIONREVENUE RETENTIONRETENTION
While the principle is supported up until now there was no regulatory framework for its implementation. The passing of the new Treasury Bill will enable this to happen. New fee structures are being discussed and a new billing system is being looked at to support the collection of revenue. Both of these processes are nearing completion and a the task team set to advise on this aspect will have a proposal for discussion with provinces soon. All provinces are in discussion with their provincial treasuries to get agreement on this principle. The Gauteng MEC for Finance in his budget speech on Feb 23, 1999 announced that any revenue over and above the budgeted revenue would accrue to the health department in addition to its normal allocation. This is a very important step forward.

Current process for coordinating policy for hospitals
Current process for coordinating policy for hospitals process for coordinating policy for hospitals
The National Hospital Coordinating Committee (NHCC) is in place as a vehicle for the coordination and monitoring of policy implementation. This structure is a sub committee of the PHRC and reports regularly to it. Every province has senior provincial managers responsible for hospital service serving on this structure. The committee meets every six weeks. In addition there are regular visits to provinces from national level to provide technical support where requested and to examine difficulties that provinces are experiencing with implementation.

Proposed legislation in relation to hospitals
During the 1998/99 period no legislation was proposed specific to hospitals. The proposed National Health Bill deals with aspects related to hospitals.

Policy in relation to fees charged
A task team is presently looking at this issue and is linked to the hospital billing system. This team will be reporting shortly on its recommendations. In the interim many provinces have implemented the schedule of fees as proposed by the hospital Strategy project.

Current Performance of public hospitals
The health and management information systems remain one of our key challenges for now. At this time the only data collected nationally is on hospital utilisation viz. Bed occupancy and average length of stay.

There is no routinely collected Information from private hospitals.

Quality of Care assessments

There is no national initiative at this stage on assessment of quality of care in public hospitals apart from the inclusion of some quality targets in the Performance Management Agreements being drawn up by the fifteen pilot hospitals. However, there are a number of important provincial programmes in place to improve the quality of care in hospitals and in the Department of Health the chief directorate under the leadership of Ms Matsau is looking at tools for the assessment of quality of care. Four provinces have initiated programmes for the accreditation of some of there public hospitals. Addington Hospital in KZN and Klerksdorp and Tshepong Hospitals in North West are the first Public sector hospitals that have been accredited by COHASA.

SURVEILLANCE, HEALTH INFORMATICS AND NORMS AND STANDARDS

KEY PLANS FOR 1999

RESEARCHRESEARCH
Establish the essential National Research Committee
Establish proper mechanisms for managing clinical trials
Establish Ethics Council /Committee
Review of MRC Act of 1991
Improve dissemination of research results and support capacity building for research through "research
Update"
Co-ordinate development of Health research policy
Establish a contact database of South African research organisations
Identify National, Provincial and District research priority objectives
Develop and strengthen dissemination and feedback mechanisms for health systems research findings. e.g.
research Update and Health Systems research Forum
Monitor the allocation of resources for health systems research terms of equity

MONITORINGMONITORING
Evaluate progress on Health Objectives for year 2000 and prepare preliminary report
Identify and ensure that data are collected to measure key indicators
Begin process of streamlining the objectives for the period 2000 – 2005

SURVEILLANCE & EPIDEMIOLOGYSURVEILLANCE & EPIDEMIOLOGY& EPIDEMIOLOGY
Make available a comprehensive programme for HIV surveillance
Conduct HIV antenatal survey amongst pregnant women for 1999
Ensure AIDS surveillance mechanism is functional
Strengthen data reporting for notifiable diseases, Termination of pregnancy etc. (more epidemiology training, review of systems)
Develop (with MCWH) long term plans for Maternal Mortality monitoring
Continue information dissemination – Statistical Notes, Epidemiology Comments
Assist IT with making all disease surveillance data systems Y2K
Develop routine immunisation system (data collection tools) that provide information on number of children full immunised at the age of one full immunisation coverage.

ACHIEVEMENTS FOR 1998/99 IN HEALTH INFORMATION
NHISSA Committee:

*Staff members sent to assist in strategic planning and implementation of Health Information projects in provinces
Committee meetings were strategically linked to three important workshop on Vital Registration, Primary Health Care reporting Patient carried health records workshop
The NHISSA Committee has spearheaded and co-ordinated the implementation of the Patient Billing System developed by the Gauteng Department of Health, known as an interim solution, in other provinces.

NHC/MIS Implementation NHC/MIS Implementation

The National Care Management Information System, the Patient Registration System being implemented, has seen the awarding of tenders in the Free State, Western Cape and Gauteng. Mpumalanga has published their tender. North West and Mpumalanga will implement the interim patient registration system from Gauteng.

Developing of Health Information Standards
Final process of payment for a National Public sector licence for the International Classification of Diseases from WHO

Vital Registration
The revised death form was promulgated and implemented in all provinces.

( Target not achieved in regard to the implementation of the new death notification form and new birth notification form. The computerised population register requires additional staff on the Department of Home Affairs establishment to capture the extra "Health Data Fields." As new staff were not appointed, a contingency plan to capture data has been implemented for the death form with Statistics south Africa. The Birth form implementation will be reviewed in 1998/99 )

Telemedicine
The Telemedicine sites have been identified and the Telemedicine Tender has been evaluated, through not yet awarded

ReHMis Revision and Update
* Following a review of the infra-structural design of the system a comprehensive review and update of the GIS data set was started and has been collated.

Web development
* Extensive consultations were held with all the departmental units to ensure an accurate reflection of the DOH profile, available databases and processes occurring in all units. DOH web-site currently hosted by GCIS

Establishment and improved information services
* Our continued improvement has culminated in our Information Services being recognised with the Best Library award in the Civil Service.

KEY PLANS FOR 1999
Awarding of Telemedicine Tender and ensuring delivery of the provincial pilots

(Delivery of 28 Telemedicine sites in 6 provincial pilots. Priority: very high. Tender process completed and contract to be signed with bidder/s in May 1999)

Hosting of the telemedicine national conference
Co - ordination and management of the HHC/MIS roll-out
Video conference linkage to six provinces
Finalisation of health facilities GIS dataset
Continuation of Vital Registration project Birth registration
Ongoing development of co-ordination and management of Health Information Standards

SPECIFIC POLICY AREAS

HOSPITALS
Private Hospital data collection system it was transferred from regional office of the Department of Health. The System is being re-written to allow for the changes in provincial boundaries and transferred to a modern computer platform. Once the repair and upgrade to the system are done the paper system will be revised to allow for provincial management of the system

POLICY ISSUES - HEALTH SERVICE NORMS AND STANDARDS
General
u An under expenditure on the 1998/99 budget of R 270 000 (surplus). The reasons for under spending are:

Limited costs were incurred in terms of professional and special services, i.e. the buying-
in of specific expertise to assist the Directorate in the development of norms and standards, did not take place. Donor funds were partially used in the process of developing norms and standards. An amount of R 160 000 was budgeted and only R 20 000 spent (Surplus:
R 140 000).
- A National Patients’ Rights Charter was not nationally launched. Therefore, no costs were incurred to translate the Charter into the official languages, to have it printed into inter alia large print, braille and sign language, or to popularise the Charter in communities. For these translation and printing services, R 43 000 was budgeted. No costs were incurred (Surplus: R 43 000).
As a direct result of (ii), a surplus in terms of transport including government, private & air tickets) and subsistence developed, because provincial visits to popularise and to train did not take place. Furthermore, two budgeted overseas visits did not take place, because the requests were not approved. The surplus generated for not performing the said activities, came to R 87 000. An amount of R 110 000 was budgeted.

The surplus has had no policy consequences.

u The surplus has been offered to the Chief Directorate: HIER to fund other operational projects within the Chief Directorate, such as Telemedicine.

The surplus does not require any disciplinary actions.

The Directorate’s specific performance targets for 1997/98 fiscal year were he following:

(i) To formulate a National Policy on Quality in Health Care for South Africa.
(ii) To develop a National Patients’ Rights Charter and a Code of Conduct for Health Care Workers.
(iii) To define comprehensive primary health care services to be rendered at mobile/fixed clinics, community health centres and PHC services that are to be community-based.

The Directorate’s specific performance targets for 1998/99 fiscal year were the following:

(i) Formulate a National Policy on Quality in Health Care for South Africa.
(ii) Develop a National Patients’ Rights Charter.
(iii Develop a National Complaints Procedure.
(iv) Define Comprehensive Hospital Services to be rendered at District Hospitals.

(i) The target that was set in terms of formulating a Policy on Quality was achieved. The target was to have finalised a discussion document and obtain comments from the Heads of Provincial Health Departments as well as from all departmental units. The target was viewed as a high priority.

(ii) The target that was set in terms of developing a National Patients’ Rights Charter was not achieved, the reason being that the process whereby all relevant work on Patient Charters in South Africa was to be identified and collated, took longer than was anticipated. Obtaining the approval from key stakeholders to utilise and for them to provide their own efforts to the Department of Health, delayed the process of developing a national proposal. The target was viewed as a high priority.

The target that was set in terms of developing a National Complaints Procedure to support a National Patients’ Rights Charter was achieved. The target was to have a proposal ready and obtain all comments. The target was viewed as a priority.

The target that was set in terms of defining Comprehensive Hospital Services to be rendered at District Hospitals was achieved. The target was viewed as a priority.

The performance targets for the Directorate: Health Services for the 1999/2000 fiscal year are the following:

(i) To develop and introduce a National Policy on Quality in Health
Care.
Develop norms and standards for health care services (level I), i.e. for
clinics, community health centres and district hospitals.

* Priority of the target : Very high.

(ii) Implement a National Patients’ Rights Charter and develop and implement a National Complaints System for South Africa to support the Charter.

* Priority of the target : High.

(iv) Develop norms and standards for health care services (level II), i.e. for regional hospitals.

* Priority of the target : Very high.

(v) Develop and introduce a National Patient Satisfaction Questionnaire.

* Priority of the target : High.

Specific policy areas
Primary Care Package : a Progress Report

The current package (Draft 5) is divided in three sections:

(i) Community services which cover the whole catchment population and as such includes three different types of services, i.e. non-personal services such as environmental health services & school health services, personal services such as home-based care, and district management functions such as ensuring proper referral from community, to clinic, to community health centre (CHC), to district hospital and beyond.

(ii) Clinics/mobiles which were defined, not by their size, but by the level of skills of the staff. As such they include, as part of the common package, services which can be delivered by a professional nurse. Additional services could be delivered if regular visits by doctors or specialists (psychiatric team, ophthalmologist, rehabilitation specialists etc.) are organised. Draft 5 suggests a proposed organisation of clinics into three service points, i.e. one for children, one for adults and one a fast-queue/repeat.

(iii) Community health centres which are structured with three components, i.e. a clinic for the local catchment area, a referral section with specialists, and a 24 hours unit with maternity and casualty.

For each of the above-mentioned sections, detailed components of services are listed, with a proposed timing for implementation, the overall aim being to reach delivery of comprehensive services across the country within 5 years.

The estimations of the probable costs of delivering the proposed Package were made for an average urban population of 100 000, using a crude utilisation rate of 2,44 visits per person per year, and assuming that, (i) a standard of quality may not yet be a reality in many public clinics, and (ii) the costing of certain services already take it that the services are integrated. A reasonable package could start being provided at ± R 160.00 per person per year for an urban population, at current staff productivity levels. Further improvements in service and coverage could lead the package to cost ± R 200.00. The largest component of these costs are staff and drugs. Piloting of the Package to verify this theoretical costing, still needs to take place.

The co-ordinating structure for ensuring implementation will be seated within the National Department of Health. A basic set of indicators to monitor implementation still needs to be developed. The Directorates Health Finance & Economics and Health Information System will play a crucial role in this regard.

No legislation is proposed at this moment in time.

The Package has been designed to serve as, (i) a planning tool to guide the move towards comprehensive primary health care services and to monitor this move, (ii) a tool to ensure the integration of non-personal services into PHC, and (iii) a tool to assist health care workers identifying the scope of services to be delivered. This Package therefore becomes a mean through which the provinces could actually negotiate budgets for PHC and actually implement the Package.

3.2 Current performance of public hospitals : Progress Report
A variety of initiatives do exist within the nine Provincial Health Departments whereby the quality of care in their public hospitals are assessed.

(i) Ad hoc assessments of various services and/ or systems within hospitals, e.g. the sporadic assessment of the standard of nursing care to patients or the auditing of record keeping. These assessment are usually undertaken by staff members, but from time to time consultants are brought in.

(ii) Monitoring the quality of care through regular monitoring of services and training sessions. Regular morbidity and mortality audits serve as a good example. This is done by staff members, usually clinicians.

(iii) Patient Complaints Systems such as complaints committees, are in
place to deal with patient complaints and to take the appropriate action.

(iv) Provincial Committees that set standards and then
monitors them.

(v) The Continuous Quality Improvement Programme offered by the Council for Health Service Accreditation of Southern Africa. This programme ultimately leads to the accreditation of the facility.

Provisional proposals made in preliminary documentation on a Policy on Quality in Health Care, state that a variety of approaches to monitor quality do exist, each with its own advantages and disadvantages. These approaches still need to be evaluated in terms of its effectiveness and efficiency within a South African context. Providing a definite time-scale in this regard therefore seem to be premature. The following approaches are still to be considered for South Africa :

(i) Routine data collection : As the National Health Information System develops, an increasing proportion of standards will be monitored through routine information collection.

(ii) Ad hoc surveys : Specific surveys are conducted to provide baseline information and then again to determine progress after a defined period of time.

(iii) Patient Satisfaction Questionnaires : This will show how the hospital is doing from the point of view of the patient.

(iv) A standard set of a limited number of indicators for hospitals : These performance indicators summarise essential data.

(v) Service agreements between hospitals and provincial health departments : Such an agreement is an agreement about a service package which is a combination of cost, quantity and quality.

(vi) Clinical audits : Professionals within a hospital are brought together to consider clinical evidence, develop and implement clinical guidelines, enhance information management skills and contribute to better management of resources.

(vii) Inspectorate for Health Establishments : The National Health Bill proposes for each province such an Inspectorate, whose function shall be to monitor and evaluate compliance with prescribed quality requirements.

(viii) A voluntary accreditation system : Accreditation programmes employ a system or process for measuring the hospital against selected standards.

Basic Hospital Package of Hospital Services : Progress Report
(i) The services to be rendered by District Hospitals have been defined by a joint Task Team which was constituted by members of both the National Hospital Co-ordinating Committee and the District Health Systems Co-ordinating Committee. This joint Task Team compiled a proposal based on a World Health Organisation indicative list and on recommendations made by a number of reference groups in Gauteng Province. The proposal was circulated to the above-mentioned two main committees as well as to the various units within the Department of Health. A revised proposal was developed. A specific range of expertise has recently been brought together to form a Task Team that will now proceed to develop service standards for District Hospitals. These standards will cover the clinical and the managerial domains within the hospital and it will address all the dimensions of quality, including access, efficiency and effectiveness. The services and the accompanying standards will be workshopped in order to obtain national consensus on the services and the standards. The national workshop will also serve as forum to discuss the method of monitoring. The latter discussion will, however, be guided by the proposals made in the draft Policy on Quality in Health Care on the monitoring of quality. The process is to be concluded during the 1999/2000 fiscal year. Should legislation be required, it would be done in terms of the new national ‘Health Act’.

(ii) Defining the services that are to be rendered at regional hospitals and developing the accompanying standards, are the joint responsibility of the Directorates Hospital Development and Health Services. This responsibility will be executed through consultation, e.g. by utilising the National Hospital Co-ordinating Committee, and through building consensus amongst the provinces. The method of monitoring will again be guided by the proposals made in the draft Policy on Quality in Health Care on the monitoring of quality. The above-mentioned process will start and will be concluded in the 1999/2000 fiscal year. Should legislation be required, it would be done in terms of the new national ‘Health Act’.

ACHIEVEMENTS 1998/99
* A proposal on the Comprehensive Primary Health Care Services to be rendered at clinics (mobile/fixed), community health centres and
community based services was finalised.
* A discussion document on Comprehensive Hospital Services to be rendered at District Hospitals was prepared.
* A report on all existing norms on staffing and facilities in health care in South Africa was compiled following a research project in this regard.
* A proposal on a National Patients’ Rights Charter and a Complaints Procedure were developed.
A discussion document was developed which reflects on quality in health care in South Africa and which makes certain proposals that need to be considered when a preliminary Policy on Quality in Health Care is drafted in the near future.

KEY PLANS FOR 1999
* Develop norms and standards for health care level I services, i.e. services available at clinics, community health centres and district hospitals.
* Develop norms and standards for health care level II services, i.e. services available in regional hospitals.
* Finalise and introduce a National Policy on Quality in Health Care for South Africa.
* Finalise comprehensive services to be rendered at district hospitals.
* Implement a National Patients’ Rights Charter.

* Finalise and implement a National Complaints System for patients/clients.
* Develop a National Patient Satisfaction Questionnaire for use in annual surveys


PHARMACEUTICALS, FOOD CONTROL AND RADIATION CONTROL

FOOD CONTROL
Target 1. To attend and actively participate in sessions of Codex Committees, coordinate the Codex activities of other components and departments, disseminate Codex documentation and react to Codex enquiries and requests for comment. Priority: High.

A similar target for 1998/99 was met. This is a continuous process and no problems or bottlenecks are anticipated as Ministerial approval for the attendance of relevant meetings is normally given. Codex activities have implications for our legislation as Codex standards and other texts are regarded as the international norm by the World Trade Organization’s Agreement on the Application of Sanitary and Phytosanitary Measures.

Target 2. To submit at least six sets of regulations/draft regulations to the Legal Unit and to write at least three guideline documents. Priority: High.

A similar target for 1998/99 was met. The process is continuous. Legislation is obviously involved. Specific issues to be addressed include regulations on food labelling, microbiological standards, processed meat, beverages, foods for special dietary uses and others, policy document on bio-pesticides and guidelines on food irradiation, interpretation of microbiological analyses, aviation foods, diabetics foods and others. Constraints are caused by the small number of posts. This applies to all the activities of the Directorate.

Target 3. To perform at least 10 toxicological evaluations. Priority: High.

A similar target for 1998/99 was met. The evaluation of agricultural and stock remedies, other chemicals when requested, as well as food produced by means of biotechnology; and the classification of agricultural and stock remedies is a continuous process. The work results in regulations being published. An important potential constraint is the lack of properly trained personnel to conduct this highly specialized work.

Target 4. To facilitate the implementation and maintenance of food import control at least five inland border posts and to update the Standard Operating Procedures on Food Import Control; and to participate in the activities of the Market Access Working Group of the Agricultural Committee of the RSA/USA Binational Commission. Priority: Medium.

This is a new target which is necessitated by the poor standard of food import control conducted by most provinces. Food import control is a statutory responsibility of the Director-General of Health. It is a continuous process and the most important constraint is the inability of the provinces to react to the guidance and assistance that is being offered.

Target 5. To involve all nine provinces in a coordinated annual monitoring programme of six sampling runs and to conduct at least four special monitoring projects. Priority: Medium.
A similar target for 1998/99 was met. The 1999/2000 sampling runs are aimed at aflatoxin in maize meal and in peanut butter, preservatives in tomato juice and in fruit juice, patulin in apple juice, caffeine in cola drinks and colourants in dairy products; and the special projects at pesticides in infant puree and in vegetables, tartrazine in sports/energy drinks, radio-nucleids in imported mushrooms and dairy products, histamine in fish and microbes in herbs/spices and in milk. This is a continuous process which involves determining compliance with legislation. Constraints are the ability of local and provincial authorities to pay for the taking and sending of samples, as well as the ability of laboratories to handle a large number of samples over a short period of time.

Target 6. To commence implementation of a Food and Agriculture Organization Technical Cooperation Project "Improving the Safety of Street Foods in South Africa". Priority: Low.

This project did not commence in 1998/99 because it was not yet approved by the FAO. This could also prove to be a constraint in 1999/2000. It will be a continuous project which does not directly involve legislation but which could result in specific regulations to address the matter.

Target 7. To arrange and/or address six congresses/symposia/workshops, visit six provinces, address meetings of six Food Control Committees and the National Environmental Health Forum and to produce at least two information documents.

A similar target for 1998/99 was reached. This is a continuous process which does not involve legislation directly but includes information actions on regulatory matters.

Target 8. To update where necessary the Personnel Performance Management System document for the Directorate as well as the Job Descriptions of all members and to have each staff member attend at least two courses and the professional officers in addition to attend at least two congresses, seminars or workshops.

A similar target for 1998/99 was reached. This is a continuous matter which does not involve legislation.

RADIATION CONTROL
The Directorate will strive to execute its responsibilities to the best of its ability, though it urgently needs to increase its capacity (personnel and budget). All the targets involve legislation, i.e., administration and enforcement of part the Hazardous Substances Act, 1973 (Act 15 of 1973).

Target 1. Control the sale and use of electronic products that produce ionising radiation (x-ray units, etc.). Priority: High.

This is an ongoing line function activity.

Target 2. Enforcement of the regulations concerning electronic products and radioactive nuclides. Priority: High.
This is an ongoing line function activity.

Target 3. The control of radioactive material that are used or intended to be used for medical, scientific, agricultural, commercial and industrial purposes. Priority: Very high.

This is an ongoing line function activity.

Target 4. The enforcement of the provisions of the Act where it relates to listed non-ionising radiation and electro-medical devices. Priority: High.

This is an ongoing line function activity.

PHARMACEUTICAL PROGRAMMES AND PLANNING
Target 1. To update Department of Health and provincial staff on legislative changes. Priority: Medium.

This will take place on a regular basis.

Target 2. To develop a Pharmaco-economic evaluation and capacity building plan so as to encourage pharmaceutical expenditure to be according to the Standard Treatment Guidelines. Priority: High.

This will take place over the whole period.

Target 3. To facilitate distribution and implementation of the EDL/STGs for primary health care and hospital level so as to gain acceptance of the Essential Drugs concept and treatment guidelines by all relevant stakeholders. Priority: High.

This will take place on a continuous basis.

Target 4. To facilitate the migration of the Coordinating Committee for Medical Provisions (COMED) System so that it gives reliable management information to National and Provincial Departments. Priority: Very high.

This will take place on a continuous basis.

Target 5. To realign the tenders to be in line with the EDL and that procurement is divided in to EDL and non-EDL items. Priority: High.

This will take place on a continuous basis.

Target 6. To develop human resources. Priority: High.

This will be done on a continuous basis by means of"
* Training of Pharmacists Assistants on Unit Standards based on the NQF;
* Training of personnel in:
l Quantification of estimates,
l drug supply management,
l cold chain management,
l effective prescribing,
l provisioning administration of pharmaceuticals and surgicals.

Target 7. To develop a National Information, Education and Communication strategy for health workers and consumers regarding the essential drugs concept. Priority: Medium.

This will take place over the whole period.

Target 8. To assist in the development of a SADC regional bulk purchasing policy - which will result in affordable prices for essential drugs. Priority: Medium.

This will take place in cooperation with other SADC countries.

Target 9. To initiate the implementation of community service for pharmacists which will provide an equitable pharmaceutical service to all levels and areas of care. Priority: Medium.

This will take place in the first half of the year

Target 10. To assist in the development of guidelines for the appropriate disposal of clinical waste. Priority: Medium.

This will be done in conjunction with other role players.

Target 11. To develop a National Drug Survey methodology that will assist in monitoring and evaluating the impact of the Essential Drugs Programme (EDP) on a regular basis. Priority: High.

This will be done continuously.

Target 12. To facilitate the implementation of the proposed structure for Pharmaceutical Services which will ensure an effective and efficient service to all levels of care. Priority: High.

This will be done as soon as the structure has been approved.

MEDICINES ADMINISTRATION
The targets are all related to the establishment of the South African Medicines and Medical Devices Authority.

Target 1. To have in place within six months a Board, a Management Team and four Standing Committees, Priority: Very high.
This involves the publication of regulations and notices/advertisements and the development of guidelines, standard operating procedures, terms of reference, standard contracts and a code of conduct. A constraint could be the allocation of financial resources.

Target 2. Expansion of in-house technical and administrative staff for the evaluation process to increase the turn around time of application assessment and improved document traceability. Priority: High.

This does not involve legislation. The process includes the appointment of a Documentation Officer The target should be achieved within three months.

Target 3. To reduce the backlog of new medicine applications and updates of all medicines. Priority: High

This involves the administration of legislation. It includes involves training and the building of technical capacity for in house evaluation and administration It should be completed within three months.

Target 4. The implementation of manual systems, business documentation processes and procedures to ensure an efficient system of medicines registration. Priority: High.

This involves the administration of legislation. It includes an in-house Technical Evaluation Team, an inventory of registrable and listable complementary medicines, a gazetted call up notice and software for the listing system. Priority: High.

Target 5. To expand the Inspectorate to achieve better and more effective law enforcement. Priority: High.

This involves the administration of legislation and the appointment of one licensing officer at assistant director level, one licensing officer and two clerks. The target must be reached within six months. This is part of the establishment of a licensing system for dispensing practitioners, manufacturers, wholesalers and distributors.

Target 6. To optimize and streamline the operations of the Inspectorate. Priority: Medium.

This does not involve legislation directly. The objective is to initiate a mutual recognition agreement for international inspections, thereby reducing such inspections and increasing local inspections. This is to be done within three months.

Target 7. To increase fees and facilitate revenue retention for the funding of the operations of the Authority. Priority: High.

This involves the administration of legislation. The objective is to make the Authority less dependent on funds from the national Government.

BENCHMARKS AND PERFORMANCE TARGETS: 1998/1999

FOOD CONTROL
This Directorate is responsible for the administration of food safety and labelling legislation as contained in the Foodstuffs, Cosmetics and Disinfectants Act, 1972, and the Health Act, 1977 (Act 63 of 1977).

Target 1. To attend and actively participate in sessions of seven committees of the Joint FAO/WHO Codex Alimentarius Commission, coordinate the Codex activities of other component and departments, disseminate Codex documentation and react to Codex enquiries and requests for comment. Priority: High.

The target was achieved. Officers of the Directorate represented South Africa at sessions of the following Codex Committees: Pesticide Residues, Food Labelling, General Principles, Residues of Veterinary Drugs, Nutrition and Food for Special Dietary Uses, Food Hygiene, Coordinating Committee for Africa, Food Import/Export Inspection/Certification Systems, and Food Additives and Contaminants. The other duties as National Codex Contact Point for South Africa were performed successfully.

Target 2. To develop the framework for a new national food control system in conjunction with the National Department of Agriculture. Priority: High

The target was achieved. A Joint Agriculture/Health Working Group submitted a comprehensive report with recommendations on a new food control system for the country. The report has been accepted by the Directors-General of both Departments who are now planning a workshop for broader consultation on the recommendations of the Working Group.

Target 3. To submit at least five sets of regulations/draft regulations to the Legal Unit. Priority: High.

The target was reached. The following regulations/draft regulations were published in the Government Gazette: Amendments to Regulations on Food Colourants, Preservatives and Antioxidants, Veterinary Drug and Stock Remedy Residues and on Microbiological Standards for Foodstuffs. Other regulation/draft regulations were submitted to the Legal Unit: Food Premises and Transport of Food, Natural Mineral Waters, Pesticide Residues, Microbiological Standards, Perishable Foodstuffs.

Target 4. To perform at least 10 toxicological evaluations. Priority: High.

The target was reached. Officers of the Directorate evaluated 15 agricultural remedies (including 2 bio-pesticides) for registration by National Department of Agriculture and publication of maximum residue limits. They also evaluated two genetically modified organisms, classified 37 agricultural remedies and determined acceptable daily intakes and maximum residue limits in respect of 5 veterinary drugs/stock remedies.

Target 5. To involve all nine provinces in a coordinated annual monitoring programme on seven sampling runs and to continue with the special programme for oils, aviation foods and milk. Priority: Medium.

The target was reached, except for the survey on the microbiological quality of milk. The Directorate initiated and coordinated national sampling runs on iodine in salt, aflatoxin in peanut butter, colourants in viennas, heavy metals in malt beer, mercury in Thai prawns, preservatives in biltong and colourants in snacks. It coordinated the collection of cooking oil samples for analysis by the University of the Orange Free State and is currently coordinating the survey on the microbiological analysis of aviation foods.

Target 6. To commence implementation of a Food and Agriculture Organization Technical Cooperation Programme Project "Improving the Safety of Street Foods in South Africa". Priority: Low.

The target was not reached. Formal approval of the Project is still being awaited.

Target 7. To address six congresses/symposia/workshops, visit three provinces, address meetings of Food Control Committees, two meetings of the Inter-Port Committee and two meetings of the National Environmental Health Forum, and to produce at least two information documents. Priority: Medium

The target was reached. Several visits were made and substantial support was given to provincial and local authorities in the North West, Gauteng, Northern, Mpumalanga Western Cape, Free State and Kwa-Zulu/Natal Provinces. Talks were given/papers presented at more than 40 occasions. Translated the WHO booklet "Basic principles for the preparation of safe food for infants and children" into Zulu, Xhosa and Tswana. Printed and distributed several thousand copies. Translated the poster "10 golden rules into several local languages. First Directorate newsletter "Food for thought". Developed a poster "Safe preparation of chicken and eggs".

Target 8. To compile and update where necessary, a Personnel Performance Management System for the Directorate and Job Descriptions for all members; and for each staff member to attend at least two congresses, seminars or workshops. Priority: Medium.

The target was achieved. The Directorate has a comprehensive PMS document and each member has an up to date Job Description. At least 36 formal courses as well as at least 25 congresses, seminars were attended by the 15 members of the Directorate.

RADIATION CONTROL
The Directorate is responsible for the regulatory control of Group III and Group IV Hazardous Substances in terms of the Hazardous Substances Act, 1973, (Act 15 of 1973).

Target 1. Control the use and sale of electronic products that produce ionising radiation (x-ray units, etc.). Priority: High.
This is an ongoing line function activity. Thus far, 54 products were tested, evaluated and approved for sale. 31 Radiation incidents were investigated. 19 Acceptance inspections of teletherapy-, mammography- and diamond security units were inspected. Several inspection procedures were updated.

Target 2. Enforcement of the regulations concerning electronic products and radioactive nuclides. Priority: High.

This is an ongoing line function activity. Thus far 1878 electronic products and 2168 radioactive nuclides used in industry and health care centres were inspected. Officers of the Directorate provided assistance with training courses, workshops, police investigations into theft, etc. Investigations into radiation incidents/accidents, unlicensed x-ray units and industrial radiography practices were undertaken. User licenses were issued and equipment specification scrutinized.

Target 3. The control of radioactive material that are used or intended to be used for medical, scientific, agricultural, commercial and industrial purposes. Priority: Very high.

This is an ongoing line function. Thus far, 1032 new and 914 amended authorities were issued for the import, export, possession, use, disposal, etc., of radio-nuclides. Officers inspected 18 specialized facilities. A range of accidents/incidents were investigated and these persons were referred for biological dosimetry. Litigation in a case of alleged negligence was started. A total of 91 food and 72 environmental samples were tested for radioactive contamination.

Target 4. The enforcement of the act where it relates to listed non-ionising radiation and electro-medical devices. Priority: High.

This is an ongoing line function. Product licenses for the sale of 192 devices and user licenses for Magnetic Resistance Images and Laser premises were issued after evaluation of the applications. Specialist inspection/evaluations were carried out on request. Tender specifications for a series of products were evaluated for openness. Officers participated in workshops, served on various forums and answered media and public enquiries.

PHARMACEUTICAL PROGRAMMES AND PLANNING
Target 1. To make Essential Drug List/Standard Treatment Guidelines books available at all levels of care: Priority: Very high.

The target was reached:
* EDL for PHC was reviewed, printed and distributed
* EDL for Hospital level was developed, printed and distributed
* Posters, Pamphlets and T Shirts were printed and distributed for EDL advocacy.

Target 2. To strengthen drug procurement and distribution. Priority: High

This has been achieved to a very large extent:
* 8 tenders have been realigned towards the EDL
* Provincial estimates are in line with the EDL
* Tenders are separated into EDL and non EDL items
* The first tender for Patient Ready Packs has been advertised
* The European Article Number (EAN) symbology to mark and trace with a bar-code all State pharmaceuticals is being implemented
* Monitoring of provincial expenditure on drugs is to be implemented now that provincial heads of pharmaceutical services are electronically linked to the National DoH
* Monitoring of drug supplier performance to ensure adequate supply of good quality, safe effective drugs is being implemented.

Target 3. To develop Human Resources. Priority: High

This target has also been achieved to a large extent:
* Pharmacists’ Assistants have been informed of the proposed incremental training on Unit Standards based on NQF
* At least 25 trainers per province have been trained in Drug Supply Management
* Training in effective prescribing has commenced
* A study to determine pharmaceutical staffing norms has been completed
* Training in Cold Chain Management and EPI operations has commenced.

Target 4. Monitoring and Evaluation. Priority: High.

This has been achieved. Baseline studies have been conducted in 8 of the 9 provinces to monitor impact of implementation of the EDP, evaluate performance and assess availability of EDL medicines in health facilities.

Target 5 Establishment of a National Reference Centre for Traditional Medicines. Priority: Medium.

This would promote the safety of Traditional medicines. It was not achieved due to a lack of clarity regarding the role that Department of Health has to play as well as the financial implications.

Target 6. Implementation of the proposed structure for Pharmaceutical Services. Priority: Medium.

This would promote the provision of a more effective and efficient pharmaceutical service at all levels of care. Not achieved because of its non acceptance at the Central Bargaining Chamber. This would mean that activities like the EDP cannot be fully implemented, with the resultant cost savings to be gained by using essential drugs.

Target 7. Initiation of training of Pharmacy Support Personnel on the Unit Standards based on the NQF Priority: High

This has been hampered by the non acceptance of the Pharmaceutical Structure at the Central Bargaining Chamber, the delay in implementing the CORE and the delay in the publication of the Regulations relating to Education and Training in the Pharmacy Amendment Act.

MEDICINES ADMINISTRATION
Target 1. To review and transform the Medicines Control Council. Priority: High.

The target was reached. The review of the MCC was conducted by a Ministerial Review Team and a Transformation Task Team released a report outlining proposals for implementation. The South African Medicines and Medical Devices Authority Bill was passed by parliament and assented to by the President on 18 December 1998. A new management structure has been proposed and draft regulations and guidelines have been formulated. These will be published in March 1999.

Target 2. To develop improved systems for an efficient drug registration system. Priority: High

The target was reached. A backlog and a number of inefficiencies were identified and the current registration process was reviewed. The reorganizing, reclassification and streamlining of all applications was carried out. Documentation and tracking was improved, a skills audit of personnel was conducted, an evaluation of outsourced laboratory work was undertaken and a guidelines manual was developed.

SPECIFIC POLICY AREAS

4. DRUG POLICY

4.1 Medicines and Related Substances Control Act,
The process for setting up the pricing committee and who should be on it.

The Medicines and Related Substances Control Act, 1977 (Act 90 of 1997), makes provision for the Minister to set up a pricing committee which will consist of the Chief Director: Registration and Regulation., the Director: Pharmaceutical Programs and Planning, Deputy Director: Procurement, representatives from the Departments of State Expenditure, of Finance, and of Trade and Industry, the Consumer Council, two health economists, a pharmaco-economist, the Pharmacy Council of SA and a pharmacist with expertise in price setting. This can however only be implemented once the interdict against certain sections of the Act has been set aside.

The process for implementing generic substitution.

Generic substitution will be implemented by all pharmacies, whereby a pharmacist shall inform all members of the public who visit his or her pharmacy with a prescription for dispensing of the benefits of the substitution for a branded medicine of an interchangeable, multi-source medicine (generic medicine), whereafter he will dispense an interchangeable multi-source medicine instead of the prescribed medicine, according to prescribed conditions in the Medicines and Relayed Substances Control Amendment Act, 1997. This can however also only be implemented once the interdict against certain sections of the Act has been set aside.

The envisaged process for implementing parallel importation.

The policy with regard to parallel importation is that this will occur with medicines that are still under patent. This will only be implemented for critically essential medicines which can be obtained at a cost effective price as stated in the National Drug Policy. This can only occur when the interdict is lifted. It is not known when this will be.

The envisaged process for implementing the policy on dispensing doctors.

The South African Medical and Medical Devices Regulatory Authority Act, 1998, (Act 132 of 1998), makes provision for the Medicine Regulatory Authority to issue licenses to dispensing doctors according to conditions that will be prescribed in regulations. The Act has been promulgated but not yet proclaimed. Once this has been done, implementation will proceed.

The envisaged registration for drugs in South Africa.

1. Applications received, logged and screened for completeness.
Allocate a reference number for tracking.

2. Application passes screening - admitted for evaluation.
- allocated an application number

Application fails screening - rejected; applicant resubmits application.

Liaison to communicate queries, questions, and or requests for additional data throughout the evaluation process of an application.

Central Documentation Distribution Centre (CDCC) - Coordinates distribution and tracking of the file from the point of admittance to finalisation.

File distributed by CDCC to appropriate Business Unit (viz Orthodox Medicines BU, Veterinary Medicines BU, Complementary Medicines BU or Medical Devices BU).

Business Units assess file:

To establish route of evaluation, i.e. external or internal evaluation
To establish technical completeness of file.

Allocates application to appropriate evaluator.
Evaluation time frames allocated and monitored.

Application peer reviewed and proceeds to a multidisciplinary Standing Committee.
Any outstanding issues or problems with the application are communicated and finalised at this time before application proceeds to Board for a final decision.

Application proceeds to Board for final decision.

Application approved - applicant informed.
Application rejected - applicant afforded an opportunity to appeal
The Boards decision following the appeal is final.

4.2 Procurement, distribution and utilization of drugs in the public sector.
Public sector distribution of drugs.

The Department of Health is currently coordinating the procurement of items on tender so that the provincial depots can have them available and accessible for further distribution to the public sector health facilities at an affordable price given the scale of economies that are involved.

Theft of drugs at depots

The aim is to implement the differentiated marking of State medicines using special identifiers to curb the theft of medicines. Department of Health identified products are to be marked differently from those to be used in the private sector. These products will be marked "for State use only - not for resale". In addition, the companies may also differentiate the product by applying a different colour to the secondary pack than what is currently used in the private sector.

Industry is committed to differentiated marking and have indicated that they will be ready to commence the process in the second half of 1999.

Specific products have been identified to be marked differently for each tender period. All identified products must be marked differently in order to be considered for State tenders.

Problems of professionals being involved in cases of theft of pharmaceuticals have been brought to the attention of professional associations to assist in the enforcement of measures to curb such theft.

Theft of drugs at hospitals

In addition to the measures described under b), an investigation is being conducted into the use of electronic number systems (EAN - European Article Number) to curb the theft of medicines by tracing the medicines through the distribution chain. A pilot study in this regard is planned to commence in April 1999. It will measure the cost benefits of the implementation of the technology in State facilities.

Attention is also being given to the improvement of logistics and the management of medicines in the public sector. Drug supply management courses were held and at least 25 persons were trained per province. Special attention was given to training to control stock and the use of bincards (stock cards) which were identified as instruments lacking in the provinces.

Computer systems to facilitate the control of supplies and provincial drug budgets have been bought by the Department of Health. Provincial Heads of Pharmaceutical Services will now be in a position to monitor drug expenditure and supply management information to the Department of Health.

All National Stock Numbers and coding information have been made uniform in the preparation of standardisation, to eliminate duplications and tighten security. In addition, the introduction of the Essential Drug List will reduce line items and minimise duplications.

Theft of drugs from clinics, both provincial and local authority.

The measures described under c) are also applicable to clinics.

Poor prescribing by clinicians and other hospital staff.
Developing the Essential Drug List (EDL) and Standard Treatment Guidelines (STG) for primary health care and hospital level is the first step in improving the prescribing habits of clinicians and other hospital staff. This is being followed by:

Incorporation of the treatment guidelines into pharmacy, medical and nursing undergraduate training curricula.

Embarking on an in-service training drive to improve prescribing habits of practising clinicians.

Advocacy workshops to professional bodies, institutions and all relevant stakeholders to adopt the EDL/STG concept.

Collaboration with other Directorates involved in developing guidelines to incorporate good prescribing principles in their training programmes.

Putting monitoring tools into place top ensure adherence to EDL/STG principles.

HUMAN RESOURCES
To promote creativity and innovation, focus has been on change management to accommodate a multi-cultural workforce and to accommodate the diverse social needs. A decentralised management system has replaced the rigid bureaucratic systems of management. Personnel have been equipped with skills at all levels of health care towards a participatory management style with progressive leadership. Capacity building has been maintained through fiscal support including donor funds. Managers have been equipped with relevant skills for maintenance of efficiency and effectiveness at all levels of health care.

CAPACITY BUILDING
Support of personnel for acquisition of knowledge, skills and professional values is an ongoing process as directed by national needs at all levels of health care. Programmes are run at national, provincial and district health levels. The activities include health management, primary health care, Epidemiology, communication skills, community governance etc.

AFFIRMATIVE ACTION
The Department of Health has responded positively on the Government policy on affirmative action. The focus is on people with disability, women and other disadvantaged groups.

The Department has the following as the major achievements to establish a more representative workforce within the Department. On 30 November 1998 the representative statistics of the Departments reflected as follows:

White 42,3%
African 49%
Asian 3,4%
Coloured 5,2%

Further impetus was also given to the processes by appointing a full time Special Programmes Officer during 1996 to assist with the implementation of the Government's policies with regard to affirmative action and related issues. This position has been supplemented by the appointment of a person at the Gender Desk during 1998 and the present incumbent is actively involved in all the transformation initiatives.

The Department still has to achieve an appropriate balance at middle management level and this area has been targeted for special attention.

COMMUNITY SERVICE
26 Doctors commenced Community service on 1st July 1998 at Eastern Cape, Gauteng, KwaZulu-Natal, Northern Province, North West and Western Cape with one doctor placed in the South African military health services.

Allocations for 1999 commenced in June 1998 with all 1126 doctors finally placed by end of December 1998. Provincial Administrations made 1134 posts available for community service . To date 1088 doctors are doing community service.

On the whole the process of implementation of community service has been smooth. Positive feedback from outlying rural areas (e.g. The Northern Province) indicates tremendous appreciation from health care consumers in these previously undeserved region thanks to the community service programme. The dentists, pharmacists will commence community service in 1999/2000 and other professions later according to the national planning process.

LIMITED PRIVATE PRACTICELIMITED PRIVATE PRACTICEPRIVATE PRACTICE
In December 1991, the national cabinet took a decision to allow limited private practice by medical practitioners employed on a full time basis by the public service. In March 1992, the same decision was made with regard to dentists. The decisions were taken after an acknowledgement by government that the conditions of employment, in particular salary packages, applicable to medical practitioners and dentists in its employ were not market related at the time. It was made clear at the time that limited private practice was a temporary measure which would be terminated once the conditions of service of medical practitioners were improved.

Limited private practice is the performance of a registered private practice at a state institution or private practice or a private institution in terms of the specific precondition and conditions.

The preconditions include that :

- Personnel must submit applications to operate a private practice for consideration in accordance with the provisions of Section 24 of the Public Service Act;

- Limited private practice is a privilege and not a right. The continuation thereof will be considered from time to time to determine its objectives are still being met;

- Neither the care of state dependent patients, nor the training of personnel or research may in any way be curtailed and may under no circumstances be jeopardized by limited private practice.

- The Minister of Health and the Provincial MECs for Health have now decided to implement the termination of limited private practice with effect from 1st September 1999. In effect the Department is giving a one year phasing out period.

6.1 MEDICAL SCHEMES AMENDMENT BILL
The Medical Schemes Act, 1998 (Act no.131 of 1998) has been promulgated on 2 December 1998, and came into operation in 1 February 1999. The Act aims to expand access of the public towards health care and to provide greater protection to members of medical schemes by means of :

¨ Reinforcing community rating in order to encourage cross-subsidisation between members and non-exclusion with regard to membership of medical schemes . Therefore, the new Act will disallow any form of discrimination against members and potential members on the basis of ages, sex and health condition.

¨ Regulating minimum benefit package available to members and their dependants.

¨ Providing a single regulatory authority for control and supervision of private health care funders.

¨ Enhancing the financial soundness of medical schemes .

¨ DEVELOPMENT OF MANAGED CARE ¨
The DOH held two National Consultative meetings aimed at making recommendations on Managed Health Care. These recommendations have now been consolidated into regulations which will be promulgated by the Minister in terms of the New Medical Schemes Act (Act 131 of 1998)