However, the direct costs of funding the SANTA hospitals is expected to be R16,1 million this 1999/2000 year; equivalent for 2000/2001 = R18,1 million.

• TB drugs for 1999/2000; R1,799,260 budgeted (inclusive of the BCG vaccines).

1. 10 of 16 districts are now training and demonstration (T&D) districts.

2. DOTS care has been included within the Home-Based Care Programs for people with AIDS.

3. Mpumalanga and North-West Province are the two pilots sites in South Africa for an electronic TB Register - the pilot is showing that this remarkably improve the quality of management information

4. Completeness of reporting is constantly improving - 1997=81%; 1998=84%; 1999=87%)

5 Bacteriology coverage for diagnosis has consistently been above 95% for the past three years

6. Combined successful treatment completion and cure rates for patients that completed therapy in 1999 was 75.7%. The death rate due to dual infection with HIV is increasing to 10%.

7. Eight districts/sub-districts achieved a level of cure/completion of greater than 80%.

1. Key Problems experienced in relation to the budgeting process:

None

2. Ability to realise national policy objectives generally

Yes

3. Implementation of revenue retention policy:

Realistic Targets are being negotiated with the Provincial Treasury to introduced Revenue Retention from 1/4/2000.

• Why the deviation from the budget occurred?
• What policy consequences resulted?
• What is to be dome to deal with the surplus/deficit?
• Any disciplinary actions resulting
• Thus far, a projected saving is expected to be R39.8m
• All expenditure needs to be reconcilled to ensure that the projections are correct, as it appears there be

The year started on a high note with the appointment of 14 District Health Promotion Co-ordinators. The very first objective was therefore capacity development and training of the 14 Co-ordinators and 2 acting Co-ordinators in the Districts.

The objective was to develop a Health Promotion Policy for Mpumalanga. The cue for this policy document was taken from national policy guidelines. The policy includes the definition, approach, principles, methodologies, aim, objectives, functions at provincial and district level and community participation.

• Health Promoting Schools

A Health Promoting Schools is a place where parents, teachers and pupils work together with resource people from their surrounding community to maintain and improve the health of all people involved with the school. This in turn impacts on the health status of other in the broader community, both through the dissemination of ideas and through practical solutions arrived at to tackle health issues in the school environment.

The first Health Promoting School was launched in the Lydenburg District in Mpumalanga on 11 August beginning a new era in Health Promotion. Two more were launched in Shongwe (21.09.99) and Philadelphia (22.09.99). Another 65 schools are in the process of becoming fully-fledged health promoting schools. This places Mpumalanga firmly in second place on a national level.

.

This radio programme on Radio Ligwalagwala has ensured that the objective of reaching communities was achieved. The radio programme has become ever increasingly popular with the support and commitment from all the health programmes.

• Mother and Child Health Radio Programme

The Provincial Health Promotion Unit coordinated and monitored the successful radio talk shows on Radio Ligwalagwala and Ikwekwezi. SmithKline Beecham SA sponsored these radio programmes.

The Provincial Health Promotion Unit has facilitated and co-ordinated the:

• mass communication component for the project and
• development of an information pamphlet for teachers and parents and
• a ‘worms and stars’ game for school children.
• District Health Promotion Activities

In addition to the above activities District Health Promotion Units have organised education, health promotion activities, workshops and campaigns.

• Peer Education

Mpumalanga is leading the Peer Education project within South Africa. Training and co-ordination for this project is based within the Ermelo District Office. Peer Education is a preventive programme that seeks to reach vulnerable communities in critical areas such as condom promotion, STD awareness and risk factors for HIV and other important health issues.

Through the Peer Education Projects we aim to reduce the STD rates by 33%. The main target audiences for these projects are adults, out of school youths and commercial sex workers.

1999 was a productive year for Communicable Disease Control (CDC) in Mpumalanga Province with increased activity demanded by the prevailing challenges facing both the health sector and Mpumalanga population.

• AIDS epidemic and resultant increase in new tuberculosis (TB) cases
• an expanding youthful population at risk from vaccine-preventable diseases
• a rural community vulnerable to water-borne disease outbreaks and emerging diseases
• re-emergent malaria as large-scale migration and climatic change continue to make an impact;
• problems with sustainable drug delivery and
• significant changes in the structure of health services, including progressive decentralisation and the termination of district surgeon services.

Highlights include the expanded district response to the AIDS and TB epidemics led by district Communicable Disease Control Coordinators (CDCC’s).

Enhanced collaboration with other government departments has characterized this year. Close cooperation with the Department of Agriculture: Veterinary Services has resulted in more effective combating of a number of zoonotic diseases of public health importance, including rabies, plague, sleeping sickness and a number of outbreaks. A number of departments are also actively involved in tackling HIV/AIDS but greater commitment is still required.

Notable progress is evident in the TB program with sustained high reporting rates and bacteriology coverage, and the majority of districts have achieved excellent smear conversion rates for the first time.

There are early indications that innovation in AIDS prevention focused on Peer-education in core transmission groups may be slowing the progression of the HIV

epidemic with an early plateau evident in this year’s ante-natal HIV survey.

Peer-education projects are successfully operating at 30 sites and an estimated 20% of Mpumalanga’s population are currently reached through this mechanism alone.

The introduction of female condoms in Peer-education projects sites in Mpumalanga has been heralded internationally as a major step forward.

The accelerated expansion of home-based care initiatives, with 12 projects already established within Mpumalanga and an additional 8 about to be launched, is remarkable for South Africa. This will need to be expanded even further as AIDS care needs increase.

The CDC Unit is also providing national leadership in a number of fields, including rabies and travel medicine. Activities have included co-authorship of a rabies handbook, development of a post-graduate travel medicine training program and chairing a national task group for drafting the constitution of a South African Travel Medicine Society.

The Unit is exploring cost-effective community control measures against malaria, taking account specific vector behavior and community practices.

Tuberculosis (TB) is increasing in Mpumalanga Province due to the impact of HIV infection in the community. TB was identified as one of the priority focus areas for the integration of health programmes in Mpumalanga during 1999. There has been notable cooperation between the TB and AIDS Units in particular training of peer educators on tuberculosis, and some peer-educators serve as DOTS supporters. Home-based care programmes include information on tuberculosis and TB care is an integral part of the package of care for AIDS patients.

Operational research to explore methods for further improving TB management are important, not only for individual Mpumalanga TB patients but findings may impact TB control internationally. One such study is the DOTS Blister-Pack study implemented in August 1999 in the Highveld Region.

DOTS has proven essential to achieving high cure rates, necessary to reduce the TB risk in the community. Voluntary workers were trained as DOTS supporters in Tonga, Standerton, Piet Retief, Bethal, Barberton, Middelburg, Lydenburg, Witbank, Shongwe and Ermelo districts by district CDC coordinators with assistance from Trainers from the National Directorate and SANTA.

A high-quality unit to secure optimal therapy of MDR-TB patients and protect the Mpumalanga Province community against these potentially lethal organisms has been designed by SANTA, MRC and Mpumalanga Department of Health. Building has started and the unit should be completed by mid-2000.

As the Mpumalanga TB Program remains a National and WHO pilot site, quarterly meetings with representatives of the Medical Research Council are mandatory. These continue to be active forums for resolving technical issues. There is wide-ranging active participation from districts, National TB Control, DFID, provincial CDC and Curative & Diagnostic Units, Pharmaceutical services and the laboratory services. The Provincial TB Coordinator chairs the Steering Group.

• Technical specifications for the MDR-TB unit
• Drafting of the MDR therapy policy
• Structured input into the National MDR management policy
• Implementation of new combined 4-drug therapy
• Study on the Annual Risk of TB Infection
• DOTS pack study

A detailed separate report on the vast number of innovative health promotional and awareness activities conducted throughout Mpumalanga was prepared and distributed to key members of the Department of Health as an advocacy exercise.

As Mpumalanga rapidly moves into the mature phase of the HIV epidemic, with increasing numbers of AIDS deaths, orphaned children and a vivid demonstration of the impact of HIV, the AIDS Program has sought to adjust to this epidemiological transition. Care issues have become a priority with a rapid expansion of activities such as supportive counselling for those infected or affected by HIV, and home or community care initiatives.

Prevention efforts have continued to adopt the focus of the World Bank, which recommends targeted interventions even for mature epidemics, such as Mpumalanga. The number of peer education projects have continued to increase while existing projects have been consolidated. Currently an estimated 20% of the population are reached through these proven interventions.

Attitudes towards HIV are changing. Greater vocalisation and demands for a visible commitment to managing the epidemic by politicians, provincially and nationally, is evident. Increased personal contact with HIV is promoting an environment of greater openness within communities in the Province.

The National Interministerial Committee chaired by President Mbeki developed the Government AIDS Action Plan. The Plan seeks to develop partnerships in the public and private sector, promoting increased awareness and mobilisation of communities. A number of activities have been focused on profile days. These include, National Condom Week, Human Rights Day, Workers Day, Youth Day and International Women's Day. Twenty activities were held throughout the Province in different districts during the course of the year, for example 700 people welcomed a train of dignitaries at Bethal Railway station and spent the day listening to AIDS messages and speeches on International Women’s Day. In addition a two-year project, "Women in Partnership Against AIDS", has been launched which seeks to promote women’s involvement in AIDS issues.

The National AIDS Directorate released R1.125 million to support Mpumalanga NGO's, a greater than proportional allocation. Organisations focusing on care and support issues, such as home based care, counseling and support for People with AIDS were prioritized for funding. Six organizations received R20 000 each as seed funding in an attempt to expand the NGO capacity within the Province.

Mpumalanga introduced the development and piloting of a computer-based stock monitoring system, including every major distribution site. This was installed in September 1999.

The system should ensure greater efficiency through:

• regular supply with lower risk of expired condoms
• better retrieval and quality control
• improved monitoring of distribution to end users
• better management by districts and ATICC’s

Currently 25% of the Province is already on the new system and completion of this process is expected during the first half of 2000.

The Department of Health continued to provide male condoms to the public free of charge. Health departmental facilities, the private sector and NGO/CBO’s distribute these. The annual condom audit conducted in February/March 1999 found that on average the Province is distributing between 800 000 and 1.2 million male condoms per month of which, 85% is through the public sector, and 15% through the private and NGO sector. This rate is probably the highest in South Africa.

Female condoms, although twenty times more expensive than male condoms, appear to enjoy greater acceptability by both males and females, especially in very poor communities. One million female condoms were purchased by the Provincial Department for distribution through peer education projects and social marketing in some municipality clinics where STD rates are extremely high. An effective saving of R600 000 through VAT exclusion was negotiated. This initiative has engendered global interest and support. The opportunity to empower women in core transmission areas has been greeted with enthusiasm by activists and scientists alike.

These projects based on the successful Zimbabwe experience, target vulnerable groups for effective HIV prevention and behavior change. Each project uses community volunteers from vulnerable groups to promote correct condom use, STD awareness and empowerment of women.

Evaluation of the lead Mpumalanga Project in Kriel has demonstrated that:

• there had been a 38% reduction in STD’s during the 6 months prior to review
• 32 000 STD’s had been averted as a result of the project
• 97% condom usage during paid sexual acts had been achieved
• condom usage during non commercial sexual acts had also increased

Peer Education Projects are successfully running at 30 sites. Over 600 community volunteers and an estimated 20% of the population within the Province are currently reached. An expansion initiative commenced in March 1999 which seeks to have four projects running in every district/sub-district by the end of 2000.

During 1998 Mpumalanga Province had an estimated 100 000 pregnant women attending ante-natal services for the first time in the public sector. With a 27.4% provincial prevalence it is estimated that nine to ten thousand children were born with HIV in Mpumalanga this year.

Mpumalanga Province is currently developing the infrastructure needed in certain pilot areas, where there is either high HIV prevalence or obstetric capacity, for rapid introduction of mother to child medical prevention if this is decided as the correct and appropriate way forward.

World AIDS Day, 1^st of December, remains a key day in the AIDS/HIV calendar for promoting general awareness, advocacy for the AIDS cause and greater community involvement. The theme, "Listen Learn, Live", encouraged community dialogue and interaction for finding solutions to the AIDS epidemic.

A total of 57 activities were held in 11 of the 16 districts. An estimated 24 000 people attended a range of activities which reflected the creativity of district staff, including rallies, sports events, competitions, street campaigns, health displays and individual awareness sessions. People with AIDS [PWA’s] participated in a number of events.

Forty-two people have been recruited and trained as community facilitators of district-based home care initiatives. Facilitator training seeks to establish a person in each district to drive the home based care initiative.

Using similar strategies to community-based peer education projects, the home care initiative seeks to support family members as the primary care-givers for those who are terminally ill.

All Home Based Care Projects within the Province are currently based outside of formal government structures, however they are working in close collaboration with the Departments of Social Security and Health. Currently the approach is to develop CBO structures and get them formal recognition as Non Profit Organisations. Support in the areas of nursing care and training, welfare, nutrition and analgesia are the focus of these projects.

Twelve home based care projects have already been established within Mpumalanga, with an additional eight projects about to be launched and support being provided to eight projects outside the Province, including Northern Province and Swaziland.

The lead project at Masoyi has now begun to focus on developing a community response to orphan care. Over 160 orphaned children and 15 orphan-headed households were identified within the first four months of this initiative.

The tenth national annual HIV survey of women attending government ante-natal clinics was conducted during October 1999. These surveys form the cornerstone of HIV surveillance in South Africa.

The HIV prevalence among women attending ante-natal services for the first time in their current pregnancy was 26.8% (24.3% - 28.7% [figure1]).

This is 0.7% lower than 1998 and may provide the first evidence that the HIV epidemic in Mpumalanga has begun to plateau (figure 2).

Although this trend will need to be confirmed during the 2000 survey, it is a promising finding that may reflect the success of the rapid expansion of peer-education projects targeted to highest-risk groups and provides a clear mandate for an even greater commitment to this scientifically sound strategy.

The Lowveld has again overtaken the Eastern Highveld as the Region with the highest prevalence (figure 3). Since 1994 the Lowveld has had the highest prevalence in all but two years (1996 and 1998).

The growth of Nelspruit as the Provincial capital combined with the Maputo Corridor development could be contributory factors to the rise in this Region.

When considering the prevalence of HIV by age-group, it is seen that during 1999 the 25-29 year age-group had the highest prevalence of 34.6%, whereas the 20-24 year-olds held this position for the past 3 years (Figure 4).

There has been a significant decrease in HIV prevalence in the 15-19 year age-group, from 27.3% in 1998 to 22.2% in 1999. A smaller decrease was seen in the 20-24 year age-group from 33.2% last year to 30.9% this year. This might be the result of targeted education of the youth, through initiatives including peer-group education and life-skills training and provides impetus for further support and expansion of these interventions.

The prevalence in the 25-29, 30-34 and 35-39 year age-groups is increasing as the highest prevalence groups of the past few years begin to age. The most marked rise was in the 35-34 year age-group, from 14.3% in 1998 to 20.0% in 1999.

There is a devastating relationship between tuberculosis and HIV infection. With dual infection the risk of active TB disease increases from 10% during a lifetime to 10% per annum.

We determined the HIV prevalence among patients admitted to SANTA Hospital in Barberton. Patient records were reviewed to determine whether an HIV test was done in keeping with Provincial policy. Results were analysed and compared to those of the second quarter of 1998.

There was a 36% increase in admissions compared to the same period in 1998.

Sixty Percent (60%) of admissions tested were HIV positive. (Figure 5).

• determine the HIV bed occupancy rate in adult male and female medical wards
• describe the proportion of adult medical patients admitted with HIV/ AIDS related conditions.

The survey was conducted in three hospitals in Mpumalanga during a six-week period: Ermelo, Themba and Witbank Hospital.

A third of all admissions had an HIV related condition but this varied across hospitals:

• 56% at Ermelo Hospital
• 27% at Themba and
• 18% at Witbank,

The average age was 36 years.

The survey found that:

• 11% of patients who were HIV positive died before discharge compared to 4% of those who were HIV-negative.
• the average length of stay was 7 days for patients with an HIV related condition and 5 days for those without.

Primary health care facilities have completed monthly STD forms since 1996 to reflect, by STD syndrome, the number of patients managed.

An annualized STD rate was computed for each health district as a proportion of the total district population (Figure 6).

The highest STD first visits treatment rates were in Standerton (10.3%), Tonga (16.4%), Nelspruit (10.2%), Kabokweni (16.2%) and Lydenburg (18.2%).

Mpumalanga was the first Province to introduce intradermal BCG (Id BCG) in the country. The experience has been invaluable for developing a national plan of action for the implementation of Id BCG in the rest of the country during the second half of 2000.

The introduction of HiB-DPT vaccine in July 1999 was another milestone in the expansion of the program to incorporate newer vaccines. The vaccine was donated by national EPI for the first year. The Province however will be responsible for future funding of this vaccine, at an additional budget of R5 million per year.

The lack of reliable data on routine immunization coverage was one of the areas highlighted by the April 1997 Provincial EPI review. There has been a remarkable improvement in the processing of information on routine immunization at district and provincial level as seen by 1998 immunization coverage data.

However the main challenge facing EPI is highlighted by the 1999 routine coverage data. Reduced coverage has followed vaccine stock-outs at the Provincial pharmaceutical depot due to delay in payments of suppliers. Vaccines most affected include Trivalent Oral Polio, Measles, DPT and Hepatitis B (Figure 7).

This has directly resulted in missed opportunities at clinic level, eroding the confidence of mothers and threatening gains made through routine immunization. This may yet prove a very costly mistake if outbreaks of these vaccine preventable diseases occur.

Malaria remains a serious public health problem in the Mpumalanga Lowveld Region where seasonal transmission of malaria parasites by Anopheles arabiensis mosquitoes occurs. Despite adopting proven preventive and curative control strategies, malaria is on the increase (Figure 8).

During 1999 there were 11 348 notified cases compared to 6 338 cases during 1998. This represents the highest malaria caseload in Mpumalanga in four decades.

• Favorable climatic features conducive to mosquito breeding and parasite

development

• uncontrolled flow of parasite carriers from neighboring countries without control programmes
• modified feeding and resting behaviour of malaria vectors with more outdoor resting and feeding
• inadequate indoor coverage of sprayable surfaces and
• possible vector resistance to synthetic pyrethroids

During 1999 the CDC unit conducted thorough epidemiological and entomological investigations, detailed monitoring of the malaria control programme and explored supplementary means for malaria control.

Combination antimalarial therapy has the potential to improve treatment cure rates, reduce transmission, decrease morbidity and mortality and delay the emergence of resistance to affordable first-line anti-malarial therapy. This potential, and its cost effectiveness need to be evaluated in Africa where the burden of malaria disease contributes significantly to underdevelopment.

The South East African Combination Antimalarial Therapy (SEACAT) study, will be a comprehensive evaluation of the phased introduction of combination antimalarial therapy at provincial and national level in Mozambique, Swaziland and South Africa (KwaZulu Natal, Mpumalanga and Northern Province).

The Lubombo Spatial Development Initiative (SDI) provides a legal and logistical framework for collaboration between Mozambique, Swaziland and South Africa. The evaluation of regional malaria treatment policy is mandated under the SDI.

The foundation of the SDI is the Lubombo project which was launched by the governments of Mozambique, South Africa and Swaziland. It provides for full commitment by all ministries and departments of the three countries to the development programme.

The area under discussion for accelerated agri-tourism development falls within a historical endemic malaria area. Malaria control measures are in place in the South African and Swaziland sectors of the proposed development area, but it still encompasses the highest risk areas for malaria in the two countries. No control measures are in place in the Mozambique sector.

The extension of malaria control to the Mozambique sector would not only have the effect of dramatically reducing disease transmission in this area but would result in a dramatic reduction in transmission in the highest risk malaria districts in South Africa and Swaziland.

There is no doubt that malaria has had serious detrimental economic effects on development in the proposed area and will continue to do so if it is not managed in a co-ordinated manner.

During 1999 there were a number of important infectious disease outbreaks in Mpumalanga Province. The most common were re-emerging malaria, suspected measles and individual cases of meningococcal meningitis. It has been heartening to note improved primary district response in terms of speed and correct measures taken.

Three non-zoonotic outbreaks necessitated Provincial intervention. These were a large-scale outbreak of diarrhoea and dysentery in the Matsulu area, a case of diphtheria in a child in the Bethal/Ermelo District and a limited cholera outbreak in Highveld Ridge, with one confirmed case and two epidemiologically suspected cases. In addition there were individual suspected cases of viral haemorrhagic fever and whooping cough.

As part of the US-SA Bi-national agreement, scientists from the Center for Disease Control and Prevention will be working with South African counterparts to develop early warning systems for rapid response to outbreaks.

Our Province has provided a formal review of the role of Hospital Infection Control Nurses (ICN’s) in rapid response, for tabling at this seminal meeting. The report is entitled "Hospital ICN’s – sentinels for outbreak surveillance".

Infection control in hospitals is a vital part of controlling communicable diseases in our Province. It not only protects staff and patients, but also community members from infections originating in hospitals. In addition many studies in different countries have demonstrated that having high-quality infection control policies practiced and monitored in hospitals, results in enormous savings in terms of costs associated with nosocomial infection, namely increased length of hospitalisation, complications, death and litigation.

Although Mpumalanga has already achieved the elimination levels established by the World Health Organisation, there are still 82 active leprosy patients on multi-drug treatment, 260 patients under surveillance and 272 who are receiving care after cure.

To increase awareness amongst health workers and the community a number of activities were embarked upon.

• New WHO Treatment wall-charts were produced and distributed to all districts treating leprosy patients.
• A public awareness video was also produced by the Leprosy Mission and distributed to clinics.
• World Leprosy Day was used as an opportunity to create community awareness through radio broadcasts and involvement of religious groups.

The magnitude of infestation with schistosomiasis and intestinal helminthiasis is often an accurate reflection of the level of development or degree of poverty in a community. Although economic upliftment is the only sustainable solution to reducing helminth infestation, much can be done to alleviate the impact on affected communities.

The design of an appropriate control plan depends on accurate information on the prevalence, intensity and distribution of helminth infections in a specific population.

As a precursor to developing a control program in Mpumalanga a randomized cross-sectional survey in primary school children at 90 randomly selected schools in the three Mpumalanga Regions was conducted in collaboration with the Department of Education.

The proposed amendment of Yellow Fever regulations and termination of district surgeon services, have considerably increased the workload of the Nelspruit Travel Advisory and Immunization Clinic. This joint venture provided by the Nelspruit Local Authority and the Provincial CDC Unit, continues to serve the burgeoning population from the Lowveld and Eastern Highveld. CDCC are available in other districts to provide advice on immunization and medical requirements.

Objective:

To ensure that an estimated 461 420 needy primary school pupils from poverty stricken areas, including farming, rural, deep rural and informal settlements, are provided with a daily nutritious snack.

• Total number of schools 1 213
• Total number of helpers appointed 2 653
• Total number of pupils fed: 457 695

To alleviate poverty in underdeveloped poverty stricken areas with 36 sustainable projects to be implemented by end March 2000, ensuring self reliance of communities involved in the projects.

• At district level, all the projects are a joint effort of two or more of the Departments (Health, Agriculture, Environmental Affairs, Education)
• A total of 46 new business plans have been submitted by different health districts, in addition to the 36 project proposals submitted before March 1999.
• Of the initial 36 projects, approximately 31 project will start with implementation by end March 2000.

To build the capacity of the community members taking part in 36 poverty alleviation projects, enabling them to implement sustainable projects by March 2000.

• Training on small business management, basic nutrition, as well as skills training relevant to the project, e.g. vegetable gardening or poultry farming is currently being done.

Objective

• The cross sectional survey was completed in May 1999, establishing the burden of parasite infestation in primary school children in Mpumalanga Province.
• A final report on the prevalence and intensity of Helminthic infection amongst primary school children in Mpumalanga province was presented in July 1999

The DEPAM training curriculum has been submitted to the Nursing Council for approval.

The DEPAM trained midwives of the 1998 group were followed up in three institutions, i.e. Phola Nsikazi Health Centre, Barberton and Themba hospitals.

The 1998 Report on the Confidential Enquiry into Maternal Deaths in S.A was launched on 15 October 1999. All maternal deaths need to be followed up and feedback given to the hospitals concerned as required by National Department of Health. Our provincial maternal death assessors committee facilitates this process.

The demand for Termination of Pregnancy (TOP) services is increasing in our province. A total of 2554 terminations were done during 1999.

The trend over the last 3 years has been as shown below.

The 16 days of activism on violence against women commemorations went well in the province. The provincial planning team comprised of interdepartmental staff, i.e. Social Security, Office on the Status of Women and Health. A commemoration event was held at Drum Rock hotel for provincial staff.

Two major events were organized in the Tonga and Standerton Districts. Both of these events were funded by the National Women’s Health Directorate.

The province is committed to the implementation of the IMCI strategy. Skills development was addressed.

• AMREF and UNICEF are assisting with the family and community component.
• SmithKline Beecham is still the main funding partner for the Well Child Initiative and the IMCI implementation in Mpumalanga.

The IMCI training (skills development) is as shown in the table below

Mpumalanga has made world history by starting the Extended IMCI Training Course. This course is done once a week for 11 weeks instead of the original 11 days block course as devised by the WHO. The Kabokweni / Sabie District piloted the training programme and was evaluated by the WHO.

The first S.A IMCI implementation Review took place on 08-12 November 1999. It was a WHO initiative aimed at reviewing the IMCI implementation process.

Routine eye clinic consultations were available at the major hospitals i.e. Themba, Rob Ferreira, Shongwe, Bethal, Philadelphia, Witbank / Middelburg Hospitals.

Our community approach attracts more patients, because of the proximity to their residence. The Ophthalmic Nurses are managing these Primary Eye Care Services at Clinic level. Most of the clinics in the Lowveld and the clinics of the Eerstehoek District of the Eastern Highveld and Philadelphia District of the Highveld Regions are covered by these services.

Patients who required further surgical treatments, especially Cataract and Glaucoma are referred to the nearest hospital with ophthalmic operation facilities.

The Community Eye Care Project

• proposed by the National Department of Health and
• sponsored by the Lions Operation Bright Sight and Optometrists Association
• launched at the Town Council Clinic at Nelspruit on the 27^th of August 1999
• 457 patients were screened and
• 78 pairs of spectacles distributed

The project at Matibidi Hospital on the 26^th of November 1999 was a great success. 331 Patients attended and 69 pairs of spectacles distributed.

BUREAU FOR THE PREVENTION OF BLINDNESS

The Bureau is still rendering service in the Province as per agreement. Several tours were conducted and Cataract Surgery performed. The province still depends on this service due to manpower shortage. The hospitals covered by this service are Philadelphia, Piet Retief, Embhuleni, Standerton, Middelburg and Tonga Hospitals.

Ermelo Hospital was identified for the establishment of the Regional Eye Care Centre with assistance of the Bureau and International funding.

On the 9^th of September the Department of Health:

• renewed a service agreement with the Disabled People South Africa (DPSA)

to implement a Community Based Rehabilitation Program

• entered into an agreement with the Mpumalanga Provincial Council for the Blind. For the first time blind and partially sighted people will have access to some form of rehabilitation services in the province

The Provincial Occupational Unit will be amalgamated with the Occupational Health Unit at Witbank as a cost saving measure from the 1^st of April 2000. This will avoid fragmentation and ensure a leaner provincial structure.

They will be able to offer the following:

• Supportive role - Advising districts and assisting them manage problems.
• Managing cases referred by the districts.
• Resource centre - scanning government gazettes and other literature, and disturbing copies to appropriate sections of the department.
• Assisting districts with occupational hygiene issues, and setting up Occupational Health and Safety committees.
• Providing training to Occupational Health and Security representatives.
• Liaising with the National Department of Health, NCOH, the Compensation Commissioner, and other departments.
• Investigating issues such as Injury On Duty management and advising the Department of Health.
• Developing relevant policies and procedures.

An Oral Health Audit was done during 1998 by the National Health Department. This forms the baseline for planning and preparing for the community service Dentists that will be coming to the province in July 2000.

• During October 1999 a provincial co-ordinator and three potential Regional co-ordinators was identified.
• Provincial oral health strategic and operational plans were developed.
• The process for conducting a full Clinical Capacity Audit for oral health has started. To be completed by March 2000.
• A personnel staff establishment for current oral health personnel has been completed.
• A new statistical format has been developed.

The focus was mainly on emergency oral health care (pain and sepsis relief) during 1999/2000.

Emergency Medical Services received 45 new ambulances under a full maintenance-leasing contract with Stannic. These ambulances were issued and each station received at least one new ambulance. The busier stations received two. There are still 108 old government ambulances in use. An audit is being done to assess how many of the old vehicles are still viable.

The financial expenditure pertaining to the maintenance of these old vehicles decreased with the introduction of the new ambulances.

All E.M.S vehicles from Kwamhlanga, Philadelphia and Mmamethlake (14) are under Provincial Management.

The EMS Transformation Report was discussed with all stakeholders determining the implementation process.

• Environmental Impact Assessment ( EIA)
• Strategic Environmental Assessment (SEA)
• Safety to our People (STOP) Project
• Basic Subsistence Facilities Evaluation Programme (BSFEP)

The World Health Organisation (WHO) ratio for EHO per population is 1: 10000 people. Our 1998 average ratio of EHO’ s per population was 1: 24000 people. Some Districts had a ratio of up to 1:49000 people.

The Department of Health did a survey regarding the provision of water and sanitation at schools. The finding revealed serious water and sanitation problems.

In assisting the schools the Department of Health identified a sponsor for R113,041-90 which benefited rural schools and clinics as follows:

• Seven rural schools got 52 VIP latrines
• Two rural clinics got 6 VIP latrines

• Hazard Analysis Critical Control Point Guidelines

A workshop on Hazard Analysis Critical Control Point (HACCP) guide was held on the 18 January 1999 at Middelburg TLC Office. About thirty (30) EHO’ s from Local Authorities, Districts Council and Provincial Health Districts were trained on HACCP guidelines.

Apart from the Local food-sampling Programme to investigate disease and other outbreaks, we have an annual National food sampling run. This programme focuses on selected types of foods for specific purposes.

For the year under review the sampling runs were focused on amongst others the following health risk factors:

• Caffeine levels in Cola drinks
• Afflafoxin levels in peanut butter
• Afflatoxin levels in maize meal

• Patients are referred from the clinics and health care centres to the community hospitals.
• Patients requiring further treatment are referred to Witbank hospital.
• The psychiatrist in Witbank has the authority to refer patients to Weskoppies hospital.

The Psychiatric unit in Witbank Hospital is not fully operational due to shortage of personnel. Only sixteen of the twenty six available beds are utilised.

The Department of Social Security has offered the health department a facility in Belfast. Social Security’s contract with Life care will come to an end at the end of March 20001 and therefore scaling down of activities has been started.

The facility has 250 beds and is suitable for chronic care. Negotiations are underway between Health, Social Security and Life Care to transfer the facility. Acquiring this facility will make it easier for some Mpumalanga patients in Life Care to be transferred into the province.

Twenty-nine (29) Mental Health nurses and one Social worker has been trained in counseling and trauma support

The center started operating on the 1^st November 1999 in Kanyamazane with 2 Professional nurses and one administration clerk. Referrals are received from the community hospital, health care centre and clinics.

A Provincial Forensic Forum consisting of Health, Justice, Social Security, SAPS and MHF meets regularly.

A multi-disciplinary provincial clinical team was developed. Responsible for the assessment of Mpumalanga forensic patients re discharge and conditional discharged through regular clinical meetings

Forms part of the integration strategy to integrate mental health into the health system.

• 36 medical officers have been trained in mental health skills
• Medical Officers responsible for mental health in each community hospital will receive further training at Witbank Hospital.
• Hundred and sixty PHC professional nurses have been trained in mental health skills using the Gauteng training manual.

Transcultural Committee meetings are conducted and deliberations carefully documented by the Department at Psychology- Pretoria University.

The Anxiety and Depression Support Group funded by WHO was given an opportunity to run a Primary Health Care project. This group has run the project in seven of the districts in the Province, mainly the Eastern Highveld and the Highveld.

1999 will be noted for the implementation of Community Service, with medical practitioners being the pilot group of graduates doing a compulsory year for the Public Service, after completion of their clinical training.

In Mpumalanga Province 65 Community Servers were appointed, which allowed for the opening of Impungwe Hospital and the equitable distribution of doctors to the under-served communities. The redistribution of the CSD to the district health system has allowed the province to terminate the district surgeon services.

The Cuban doctors have remained an important component and their experiential development over the past three years have made many of them valuable assets to the District Health service delivery.

The process for Laboratory Transformation was given a boost by the appointment of a project team at National level.

Radiography services have improved with additional staff appointments, the training of supplementary Radiographers, and the improved maintenance of old equipment. The project of the year was the installation of the CT scanner at Witbank Hospital and the installation of the TeleRadiology and Telemedicine equipment at the proposed Regional Hospitals. With the completion of the linkages in the 2000 the system can be operationalised.

The Tender adjudication was done in February / March 1999 at National level. The hospitals that are involved in Mpumalanga for the initial phase are Witbank, Ermelo, Philadelphia and Themba.

The National launch of the project was on the 28^th of May 1999. The Teleradiology demonstration was done between Ermelo and Witbank.

Telkom has not yet completed the links between Pretoria Academic Hospital and the 4 pilot hospitals due to delays in providing the necessary ISDN network cabling.

Mpumalanga has been a leader in the provision of a structured programme of Continuing Professional Development (CPD), for not only medical officers, but also the integrated team of health workers. This programme supports the National Drug Policy of Effective Prescribing and has prioritised disease management training in line with Provincial and National needs.

The Pharmaceutics and Therapeutic Committee have completed the Primary Health Essential Drug List (EDL), Hospital List and Medical Class II Surgical Sundries. The Standard Treatment Guidelines (STG) for hospital Adult and Paediatric care, as well as the revised second edition of the STG and EDL for Primary Care have been distributed and training given.

The termination of district surgeon services was a major breakthrough, in that services can now be rationalised, which will have a major impact on effective prescribing. All patients are currently in a review process, with the target of reducing non-EDL drugs by 20% per annum.

Geriatric Care in the province is improving, with district doctors taking over the visitation of old age homes and all clinics providing an integrated service to the elderly with the management of chronic diseases.

The year of 1999 was the International Year for Older Persons. The International Day for the Elderly was on the 1^st October.

It is estimated that by the year 2005 33% of the World Population will be over the age of 60 years, and that they will be playing an important role in both Voluntary and Paid work, especially considering the impact of AIDS on the productive sector of the population.

The Active Aging concept is in line with the Health Goals of improving the quality of life for older persons, and ensuring optimal physical health.

Together with the SANGALA movement (National Games and Leisure activities) under the auspices of the Department of Sports and Recreation the department targeted 500 000 older persons to participate in physical activity programmes to enhance the concept of keeping the elderly mobile for as long as possible.

Future challenges in Geriatric Care are:

• the mobilising of resources to provide for the needs of an ageing population
• improving the quality of health in the aged and
• preventing disabilities in the aged.

Services will have to become more accessible to the aged, and the districts in this province have gone a far way in decentralising the services.

The Tertiary level of Prevention in relation to the needs of the terminally ill was also catered for through the Palliative Care Provincial workshop where ethical issues, as well as clinical and social support where introduced. This should make a noticeable difference in the way that the terminally ill are managed in the future. Collaboration with the Cancer Association and Home Base Care programmes will be re-enforced through these efforts, and support the accelerated expansion of home-based care initiatives.

The links with the Joint Provincial and University Satellite Campuses has proved very successful. Various courses have been offered at district level, enhancing the service standards, as well as the Family Medicine Programme run by both of the Universities. An apprenticeship programme in Anaesthetics has proved to be very successful, with the rotation of doctors from districts to Witbank Hospital. After completion of this rotation doctors have returned to their base hospital capable and confident in managing most routine and anesthetic emergencies.

The transformation and restructuring of Laboratories at National Level is progressing well under a Nationally appointed project team, which has been tasked to complete the process by the end of 2000. All SAIMR laboratory services are now state owned, but still function under a separate management system to the provincial laboratories.

All Provincial and SAIMR stakeholders, together with their respective unions and associations are being kept informed of progress.

The Mpumalanga Provincial Laboratories will be amalgamated with the SAIMR laboratories in the Province together with laboratories from the eastern section of Gauteng, eg. Pretoria, forming a new branch of the National Health Laboratory Service. This will be in line with our referral axis, rationalising the referral network.

The numbers of tests that are being requested at district level have been reduced substantially, by the introduction of clear protocols to ensure efficiency and cost effectivity.

The outbreak of malaria following the rainy season experienced during the past year has been one of the biggest burdens on the laboratory service, together with the increased number of patients presenting with AIDS related illnesses and complications thereof.

A stepped care approach is being initiated in the treatment of chronic diseases. All patients at Primary Level are being reviewed with regard to their chronic medication by medical officers who are now visiting all primary facilities, including Old Age Homes and mobile clinics, on a regular basis. Training workshops on Hypertension were presented in all the districts during the first half of the year, and the National Guidelines extensively distributed.

Trauma due to person-on-person violence, gunshot wounds and motor vehicle accidents remains a worrying phenomenon in our society.The cost of multiple trauma is as high as R 20 000 per day in severe cases.

Emergency Medical and paramedical services are the important first line of care in the emergency situation. The appropriate quality care provided at the district hospital following stabilisation by the Emergency Medical Services is critical in the morbidity and mortality outcomes of the patient.

The Bus accident in Lydenburg was an example of quality care which demanded International attention, and which could have had serious repercussions if the staff were not able and competent to manage the situation.

With the discontinuation of District Surgeon Services, the management of clinical medico legal services has reverted to the District Health team.

Cases of assault, rape, drunken driving, child molestation and family violence are now referred to the nearest primary health practitioner for evaluation and treatment, as well as the completion of the necessary statutory documents and court appearances to give medical evidence.

This has placed an additional caseload on all casualty departments where most of the cases are handled, and initial resistance by clinicians was due to their perceived lack of knowledge in handling the medico legal processes. This lack of experience has been addressed through the running of Medico Legal Workshops in each of the regions, in an attempt to skill as many clinicians as possible in the holistic manner of dealing with these cases.

As from 1999 the allocation of Interns to hospitals was through a quota system, according to the number of students graduating from each Medical School, computerised at National level and forwarded to the provinces.

The following Hospitals are accredited for Intern Training:

• Development and provision of secondary (level2) services via referral hospitals
• Support to District Health Services (level 1) via outreach and training programs
• Skills development programs via workshops and in-service rotations of professionals
• Academic liaison with Medunsa and University of Pretoria
• Provision of specialised (Currently TB hospitals) services

In addition, the directorate is involved in:

• Providing provincial forensic pathology services
• Representing the department of the National Hospital co-ordinating committee
• The National decentralization of hospital management program
• Representation on provincial health management
• Developing an intra- and inter-provincial patient referral network.

• Witbank hospital

Most of the medical and allied health posts at the hospital have been filled. The hospital receives referrals from all other provincial hospitals in the eight disciplines currently established.

A CT scan is fully functional and has significantly reduced referrals to Gauteng for these investigations. An average of 10 scans is performed daily.

• Outreach services

The psychiatric department has commenced services to the Eastern Highveld. The allied health units continue to reach out to other districts.

• Physical facilities

A 15 bed provincial intensive care unit is scheduled for commissioning in the first half of 2000.

A trauma unit with a ceiling mounted X Ray facility was opened during the year and has been receiving referrals from the rest of the province. A 40 bed orthopaedic ward and a rehabilitation center have been opened, increasing the capacity for receiving referrals.

• Decentralization of hospital management

A two-week visit to the Dorset Health Authority and Royal Bournemouth hospital was undertaken by senior managers during the year. This has facilitated the development of a draft performance management agreement between the hospital and the department. Legal opinion is awaited before implementation of the agreement.

Cost centers have been established at the hospital and the concept will be rolled out to other hospitals after teething problems have been solved.

• Training

Training were provided by various departments at Witbank and Philadelphia hospitals. This took the form of workshops, in-service rotations and accommodating students from the University of Pretoria and Medunsa.

1. Specialised Services

• MDR unit

A 36 bed unit is currently under construction at the Witbank SANTA. It should commence services by mid 2000.

• Forensic services

A strategic plan to take over the services from the SAPS has been developed and is awaiting national department finalisation of the process before implementation.

• Chronic Care

329 Mpumalanga patients are still being cared for at Lifecare institutions in Gauteng. The department commenced payment for these service from April 1999. A feasibility study is to be undertaken early in 2000 to explore the possibility of transferring these patients to facilities in Mpumalanga.

Bongani Hospital and Barberton SANTA are pool areas for the Lowveld, Standerton for Eastern Highveld and Witbank for Highveld.

• Deployment of Staff according to Phola /Ntsikazi resolution completed.
• Management Committee set up together with Unions and D.T.U members.
• Authority decentralised except for Policy and Financial matters.
• Appointment of the Chief Administration Officer effected as from October 1999.
• Account for Pharmaceuticals (MEDICAL and NON-MEDICAL) opened with VUNA.
• Policy (ordering and delivery) on Pharmaceuticals is now available and supplied to Bongani Hospital.

• Agreement document finalised
• Pharmaceutical Policy completed and supplied to these Institutions.
• Accounts opened with Vuna.
• M.D.R ward budget approved, and plans for building are off the ground (Witbank).

Human Resource Development is committed to facilitating and enabling the Department of Health to achieving its vision of providing comprehensive integrated health care in Mpumalanga Province through the Primary Health Care approach.

The aim is rendering a caring and compassionate health service acknowledging that people are its most important resource.

To achieve this the following is required:

• effective human resource development and management
• prioritizing staff morale
• job satisfaction
• motivation
• positive change in attitudes
• upgrading knowledge and
• improvements in skills through continuing education and appropriate support.

With a population of 2,8 million as per 1996 census figures, Mpumalanga needs to have a sound human resource policy that does not only look at the utilization and development of health professionals but also involves communities to take responsibility for their own health needs.

During the period 1996 to July 1999, provincial skills audits were undertaken and training was provided according to the prioritised training needs. The Directorate Training and Development provided management and generic training and co-ordinated financial assistance to serving officials and prospective public servants. Training was provided by the Directorate Training and Development.

During 1999 the Training Directorate hosted a national conference for Trainers in the Public Service to give meaning to the requirements of the Skills Development Act, in the creation of the Public Sector Training Authorities (PSETA) structure and discussing all related issues.

As from July 1999 the training unit was decentralised and the training officers were deployed to various departments in the province. Departmental Training Committees were set up to co-ordinate skills plans and monitor the performance of the training function. Training on how to conduct an organisational needs analysis were given to the departmental training committees. Departmental skills plans for the period April 2000 – March 2001 have been compiled.

During 1999 the following were awarded:

Grading – 641

Merit awards – 449

Rank / Leg promotion – 1 740

• Stock levels in most districts managed well
• Only approved EDL items are supplied and kept at clinics
• the pharmacist and / or assistants visit the clinics to ensure smooth running of orders, stock control, referrals etc.
• The budget for 2000/2001 has been centralised. This will allow monitoring and equitable utilisation of resources.

• Districts have been informed of their 2000/2001. They have also been requested to draw cash flows based on this budget. Their expenditure will be strictly monitored against this budget.
• Disposal of expired medicines causes problems as pharmacists do not have easy access to incinerators. However, we are involved in drafting a new policy for the disposal of these items.
• Space at the Ekandustria depot is still a problem. The acquisition of a new depot at Middelburg will need to materialise if service delivery are to be improved.

• A provincial EDL coordinator has been appointed with effect from January 2000.

His main responsibility is to implement the Essential Drug Programme (EDL).

• PTC’s have been established in all districts to promote rational drug use and to decrease the number of items on the scripts.

There is currently a serious need for pharmacists and new posts will have to be created. Staffing is irregular in most hospitals. According to the Staffing Norms Document, approximately 228 pharmacists are required for the province to render the services. Currently Mpumalanga have 61 full time pharmacists. Only ten (10) vacant posts are available.

The community service for pharmacists in South Africa will begin in 2001.

A refresher and other training courses on Drug Supply Management, Effective Prescribing and Training of Trainers have been provided

• Computerization

Most of our hospital personnel have been trained in PDSX (Stock Control Management Systems). Soft and hardware have been given to hospitals by VHL. Shortage of staff is a major problem for the implementation of the system.

• As a result of PDSX stock control is managed better
• Issues to clinics can be monitored and a monthly summary of invoices issued can be supplied to clinics.
• The Policy and Standard Operational Procedures for both clinics and hospitals have been approved for implementation. Actual implementation would be in May 2000.
• An extensive report on stock issued, budget and percentage of buy-outs was presented to district managers on the 6/10/99.
• Inspections in terms of the Act 101, (Medicines and Related Substance Control Act, Act 101 of 1965) are being done both for occupational health and state facilities. State hospitals that were identified to perform below level were sent inspection reports highlighting the concerns.
• A pilot study on monitoring of pharmaceutical budget allocations has been identified in order to help districts to control their budget. This study will be done in conjunction with Medunsa in Eerstehoek district in 2000.
• The theft of medicines is a problem. Even though not confirmed, it is estimated that 20% of our pharmaceutical budget is lost through theft of medicines. Cases have been re-submitted to SAPS for follow-up. Others cases involve opening of medical practices and use of medicines by doctors who are not entitled to do so, and the possibility of using provincial medical supplies.

• Health Management has been informed about the SAMMDRA, its implications and withdrawal.
• No provisions have been made for the training of nurses to register as dispensers.
• Budget constraints are also preventing many districts from upgrading their pharmacies to be registered with SAPC.

The Daggakraal Health Care Centre has been completed and is now in the process of being phased into operation.

Three new Clinics namely, Lefiso, Mmamethlake and KaBokweni are nearing completion and will be operational within the next few months. One further new Clinic at Verena is also under construction at present and is progressing satisfactorily.

We were very honoured during May of this year to have our Shongwe Hospital Upgrade officially opened by the then Deputy President now President of South Africa, Mr Thabo Mbeki.

The New Tonga 250 Bed Hospital was also officially opened by the then Minister of Health, Dr N Zuma during May 1999.

The Witbank Hospital Upgrade is progressing well with Phase 1 already complete. The National Minister of Health visited Witbank Hospital.

The C.S.I.R. was appointed to undertake facility audits at all our hospitals and this is being followed by projects of hospital upgrades being identified in the Hospital Rehabilitation and Reconstruction Programme funded by the National Department of Health. Piet Retief and Themba Hospitals are high on the priority list for attention. Further phases of the Witbank Hospital Upgrade are also included in the Programme.

The initial phases for the construction of clinics at Moloto, Seabe and Nonkaneng have been initiated.

Clear output outcome targets are limited because of human and financial resources.

NGO's have again remained one of the key focus activities of the Provincial AIDS Programme. The ability of government to respond to the epidemic in its totality is severely hampered and key partnerships with NGO's / CBO's are essential to ensure a wider and appropriate response to the epidemic.

The year began with a two-day audit by provincial staff of a number of suspicious NGO's funded during the 1998 national funding cycle. Performance was not congruent with submitted business plans and resulted in these NGO's not being funded in the 1999 cycle. Mpumalanga also fully participated in a national audit of funded NGO’s within the Province.

The National AIDS Directorate released R1.125 million to support Mpumalanga NGO's, a greater than proportional allocation following two days of advocacy from the Mpumalanga AIDS Unit. A call for proposals was distributed via local radio and 95 applications were received by the closing date and reviewed by a Provincial Committee. Following two days of intense deliberation that included standardised evaluation on pre-determined objective criteria, 19 organisations and two peer education groups were approved for funding. Organisations focusing on care and support issues, such as home based care, counseling and support for People with AIDS were prioritised for funding. Six organisations received R20 000 each as seed funding in an attempt to expand the NGO capacity within the Province. The NGO’s funded are listed in Figure 1.

Communication with respective community groups was then conducted and contracts signed, before cheques were distributed and letters of understanding drafted.

Many smaller NGO's could not be funded according to the rules applying to national funding. Three key under-represented areas received 8 sessions of capacity development conducted by the Provincial Office during 1999 with the aim of increasing the number of organisations that could qualify for future funding.

All funded NGO's/CBO's were carefully monitored over a period of 30 working days during the course of 1999 in keeping with national requirements. Compilation of quarterly reports from each funded NGO with submission to the National AIDS Directorate also occurred as part of the monitoring process.

• Parlimentary memo's submitted since 1997.
• Cabinet presentations
• An assistant director appointed in office of the MEC / HOD facilitate the interdepartmental coordination with the support from the Nationally funded Government AIDS Action Plan personnel.

No hospices present within the province. Once care centre established as an NGO receiving minimal government support.

No policy in place.

Hospice is an unaffordable option of care within the province, benefiting less than one percent of the population need terminal care. Focus is on establishing home based care in all large periurban areas with community care centres offering training support, care for the destitute and respite care.

Vision is to establish other NGO's CBO's to offer care using new facilities, old health clinics, old age homes and other community facilities.

1. Strategy in Place for Home Based Care

A model project has been developed in 1998. In 1999 a fast track process of duplication was introduced with now 15 projects in place or in early phases of being developed. Mpumalanga Project Support Association (MPSA) funds home based care and other community care initiatives. In 1999 over 300 community volunteers were recruited with over 3000 clients being seen and 20 000 individual care activities being supported. Time scale is 2years for a total of 30 projects within the province.

Vision is to consolidate existing projects and to extend to one project in every community with 10 000 population or greater. Projects integrate orphan and palliative care through the use of remunerated volunteers or care supporters. Integration with other programme areas such as rehabilitation and welfare structures. Greatest need currently is for support materials such as wheel chairs, class II medical items and an efficient delivery of non government stocked medications. Greatest government contribution is through the effective delivery of primary health care with consistent supplies of medications.

Provide a detailed report on the implementation of the HIV/AIDS education programme in your province, include information on the process, as well as the number of schools and pupils reached.

2. Life Skills

The Department of Education in Mpumalanga could not successfully implement the first attempt at Life Skills Programme. They are currently in the process of planning their second attempt with the support of the Mpumalanga DoH. Twenty Master Trainers will be trained in the near future to train teachers in Mpumalanga. Teachers and Health Promoters will be nominated to be trained as Master Trainers. Thus, Health Promotion will take an active part in the Life Skills Programme.

However, the Health Promotion Units within the Districts are continuously providing STD/HIV/AIDS education in most of our schools in our province with the limited resources (transport and manpower) to their disposal. An integrated approach is followed and with the support of other health programmes (CDC and MCWH), schools in high-risk areas are identified and targeted for HIV/AIDS education.

Peer Education renders support by providing edutainment (drama / role-plays, etc.) to the schools. This effort is co-ordinated by Health Promotion.

The Health Promotion School concept has been successfully launched within Mpumalanga. To date we have launched four health Promoting Schools and 65 are in the process of becoming health promoting schools. All health promoting schools focus on HIV/AIDS education as an entry point in the school.

1. HIV Discrimination

Public sector employees, Public Hospitals and Clinics

No written policy in place, however health promotion activities advocate the need to discard any form of discrimination. This is the responsibility of the Interdepartmental Committee on HIV and AIDS

Community

Role of NAPWA and NGO legal based organisations have been supported through the NGO funding process.

Provide specific details, time-scales and performance targets associated with any advertising campaign;

2. Advertising Campaign

Regular Information, Education and Communication radio campaigns conducted during the course of 1999; No cost to the Department.

Provide specific policy and targets in relation to providing councelling and testing services:

3. Voluntary Counseling and Testing [VCT]

Key focus for the HIV AIDS Technical Unit for 2000.

Counseling manual adapted for the province.

Strategy in place for the training of health care workers with the hospital sector using the ATICC's and health staff.

Updating of current HIV testing policy.

Targeting all community health centres of the province for offering rapid HIV tests with counseling for pregnant women, off the street youth and any other on demand client.

Private NGO's already working in establishing dedicated HIV counseling and testing sites within the province.

Provide details indicating how your province STD services are to be used to provide an integrated prevention strategy for HIV/AIDS

4. STD Services

Policy already in place stating that all clients presenting with a STD should receive VCT.

On going training of medical staff planned for 2000 in counseling skills and with prevention training.

• The decentralisation of the management of health services by implementing the District Health System.
• We developed a Primary Health Care (PHC) manual to assist all health workers and communities in understanding the DHS and the PHC approach, and in the development of health programmes.
• We appointed District Health Managers and are training District Health Management Teams in the sixteen health districts.
• Community Health Committees are in place and we are in a process of developing governance structures with Local Government and Councils.
• Our capacity building program and development of Human Resources is receiving continuous attention.
• The transformation of systems in the Department will restore efficiency and cost effectivity, thereby contribute to developing a caring ethos and improve the health status of our communities. The improvement of health and health care will play a pivotal role in the transformation of society, guiding and steering this country through political and socio-economic turbulence.

The challenges facing the above Department in the delivery of health and health care although monumental are achievable.

The success of the vision is dependent on the transformation of the rules and regulations in administrative procedures to ensure delivery of services. An active effort has to be made to improve the budgetary process, based on activities, resource budgeting and accounting principles.

Primary Health Care Services, delivered through the District Health System, is Mpumalanga’s highest priority for health. It is the most important vehicle to ensure that health services are accessible, affordable and equitable. The province has defined a basic minimum Primary Health Care package to be delivered at the District level. This package will ensure a more focused delivery that responds to the health needs of the community. Programmes are already in place and being implemented at the District level.

Initially 21 Health Districts were envisaged, but due to cost curtailment measures, the Department had to re-align health boundaries to ensure cost effectivity and sustainability..

In the management of the sixteen health districts, all the District Health Managers have been appointed.

Primary Health Care Co-ordinators

Have been appointed and are undergoing training to ensure the efficient implementation of primary health care programmes.

All District managers and human resource development co-ordinators are undergoing problem based training, so that they will train the rest of the district health team in their respective health districts in management skills.

A Primary Health Care Handbook, providing all health workers with a clear insight into and guidelines on the District Health System, has been published and is being widely distributed to other stakeholders, such as community organisations, councilors and other health providers.

An essential primary health care package in line with national and provincial guidelines is being implemented, but the department needs to ensure broader implementation monitoring the improvement in the quality of care, which will further require us to implement service standards for health facilities; referral systems for the appropriate and timeous referral of patients to the next level of care; develop the range of diagnostic and treatment protocols; improve management capacity at all level of health service delivery.

The Department will present The Mpumalanga Health Facilities and Services Bill to the Legislature during this fiscal year. The Bill has been approved by the Provincial Cabinet. The Bill primarily deals with improving and legitimising Governance Structures, in the form of health committees, thereby ensuring community participation in determining the needs of the communities and the health services required at the local level.

It further ensures the decentralisation and transformation of the health services, to ensure optimal and appropriate management of health services, thereby ensuring efficiency and cost effectively, it further ensures the establishment of health training facilities, with regard to nursing and emergency health personnel.

This will ensures the process of equity, by regulating the registration of health care facilities, thereby ensuring that health facilities serve the broader interests of the total society.

• CCA for PHC ( equipment, personnel, facilities, transport and skill training needs) will be completed by end April 2000
• The District heads is developing a plan how and when the core package will be implemented.

• This function is contracted to Vuna Health Care Logistics
• Determination of Code List for medicine and medical class II is done by the province.
• The National EDL and Standard Treatment Guidelines are used in the determination of the Code List
• The control of the data-base is also done by the province
• The stock is ensured from the supplier until the delivery point i.e. district depots / hospitals by VHL
• Delivery vehicles from Depot (warehouse) to hospitals are provided by the contractor.

1. Monitoring and evaluation:

• Policy and Standard Operational Procedures for the Depot, hospitlas and clinics are in place
• Computerised stock management system is in place from the depot to all hospitals
• District Pharmacist are in place in all the districts and are receiving support from the 3 regional pharmacists.
• Medunsa is contracted as an added resource to provide training, and support in other areas for research purposes.
• Reports on drug usage can be accessed from the system and presented at health management or district health management meetings
• We are involved in training pharmacy personnel, nurses and doctors in Drug Supply Management and Effective Prescribing to improve their drug management and rational use.
• There is a provincial Pharmacist Inspector who ensures adherence to laws and regulations pertaining to drugs both in the public and some of the private sector facilities.

3. Hospital Services
1. Central Hospitals

No Central Hospitals in Mpumalanga

2. Regional Hospitals

1. Reduce referrals to Gauteng by creating capacity at Witbank hospital.

This has been partially achieved and is ongoing (high priority). The main constraint is the moratorium on filling nursing posts which is based on budgetary constraints.

Possible solution: Permission be obtained to use the conditional redistributory grant from National Health to fund nursing posts.

2. Provide outreach services to other hospitals – Achieved by Department of Psychiatry. Other departments will commence after the clinical capacity audit is completed – end April 2000.
3. Extend theater capacity and build 15-bed intensive care unit at Witbank Hospital – currently under construction. Completion scheduled mid 2000.
4. Decentralize hospital management via performance agreement with province.

This has not been achieved mainly due to legislative hitches. The legislative framework is not in place to assign delegations to hospital CEO’s.

5. Establish provincial Multi–Drug resistance TB unit. This is presently under construction at the Witbank SANTA hospital.
6. Develop regional referral hospitals - This is suspended until the clinical capacity audit has been completed.
7. Establish telemedicine linkages between regional hospitals and Pretoria academic hospital. This was delayed due to unavailability of ISDN lines (Telkom). The system should be functional by April 2000.

2. REGIONAL HOSPITALS

1. Strategy – The plan is to establish facilities in each of the regions which will provide a level 2 (specialist) referral service to district hospitals in that region. The earmarked facilities are Bethal / Ermelo, Themba/ Rob Ferreira & Philadelphia Hospitals. Witbank will be developed into a secondary/tertiary facility, which will accept patients from the regional hospitals. The objective is to reduce referrals to Gauteng by 20% per year for the next 5 years.

Improved Management:

2. Improved management – Witbank hospital is one of the 15 hospitals in the country being piloted for management decentralization and cost centre development. The legislative framework and lack of delegations are hampering this process.

Service reprioritisation

3. Service reprioritisation - We hope to have a finalised referral network in place so that patients can be treated at the most appropriate level by June 2000.

Retention of revenue

4. Retention of revenue – Negotiations underway between our department and Finance. This is an urgent need.

Rationalisation of staff

5. Rationalisation of staff – the clinical capacity audit is expected to provide a framework whereby staff and other resources can be deployed to the most underserved areas.

Serious problems

6. Serious problems – The budget for secondary service development is adequate only to maintain services, with a small amount for development. Progressively our dependence on Gauteng will be reduced.

5. Human Resources:

• The development of an appropriate Human Resource Plan was hampered by the actual number and quality of personnel. In the service that were inherited and absorbed, from the previous health authorities such as KaNgwane, KwaNdebele TPA, and National.
• Voluntary severance package in order to facilitate the down sizing of personnel in certain areas.
• Critical important to the health system reform is the better management of personnel, health infrastructure and equipment.
• Clinical Capacity Audit of all health personnel in the province to ensure an equitable distribution of relevant health personnel, with the emphasis on enhancing multi-skilling, which will contribute to the cost effective management of human resources.

1. INTRODUCTION

During the period 1996 to July 1999, provincial skills audits were undertaken and training was provided according to the prioritised training needs. The Directorate Training and Development provided management and generic training and co-ordinated financial assistance to serving officials and prospective public servants. Training was provided by the Directorate Training and Development. During 1999 the Training Directorate hosted a national conference for Trainers in the Public Service to give meaning to the requirements of the Skills Development Act, in the creation of the Public Sector Training Authorities (PSETA) structure and discussing all related issues.

2. DECENTRALISATION AND CAPACITATING DEPARTMENTAL TRAINING UNITS

As from July 1999 the training unit was decentralised and the training officers were deployed to various departments in the province. Departmental Training Committees were set up to co-ordinate skills plans and monitor the performance of the training function. Training on how to conduct an organisational needs analysis were given to the departmental training committees. Departmental skills plans for the period April 2000 – March 2001 have been compiled.

THE HRD ACTION PLAN IS AS FOLLOWS:

1. Each hospital in the province fills in the Hospital Statistics form. In most of the hospitals, this is done electronically.

Some additional data that is required on Hospitals, needs to be filled in on an extra form

2. The Patient Admision and Billing (PAAB) system (Interim Hospital Information System) has been implemented in 21 out of the 24 hospitals.
3. National is busy piloting a new form for Hospitals, the HAO1C, HAO1D and HAO1S forms (see Annex 3) for different category hospitals.

These were piloted in Mpumalanga at:

Witbank as a Tertiary Hospital

Philadelphia as a Regional Hospital

Middelburg as a District Hospital

Bongani as a Special Hospital (TB)

The form was positively accepted, with some suggestions for improvement. The progress on this is still ongoing and not finalised.

• Clinics:

At the clinics, the following is required on a daily basis:

• a daily Data Collection form is being filled in for PHC data

At the end of each month, the Person-in-charge of a facility, has to compile a summary report on the PHC data, and send the data up to the District Information Managers, who compiles a report for the district.

• Register for TB patients

(Until the December 1999, the whole country used the same TB Register. Since January 2000, Mpumalanga and North West Province, pilot a new TB Patient Register – together with an Electronic TB Register.)

The District CDC Co-ordinator collects copies of the Register, throughout the month (as data gets completed), and punch it into the Electronic TB Register. Quarterly, she/he sends it through to the provincial office. These data are patient-based. In the past, the person in charge of TB in a facility had to compile a Quarterly Reports send it to the CDC Co-ordinator and the CDC Co-ordinator sent it up to the provincial office.

• For Mental Health, an In-patient Register (Annex 6.1) and a Daily Register - for clinics, with a Summary (Annex 6.3) at the end of the month. The Mental Health Co-ordinator is responsible for the filling of the reports, and then she/he sends it to the District Information Manager, who summarises it .

(The Mental Health Reports only started to realise in the past few months and there are still areas lacking, but this is now been attended to.)

At the district office the District Information Manager compiles the data into a Health Service Report (Annex 7) and an Indicators Report

Mpumalanga is currently considering the HISP (District Information System) that was developed in the Western Cape, accepted by NHIS/SA and already spread out to all the provinces in the country. This will be an electronic system used in the districts.

The facilities will still be paper-based, with only minor changes to the current forms in use.

1. Minimum reporting requirements for:

1. Each hospital in the province fills in the Hospital Statistics form . In most of the hospitals, this is done electronically.

Some additional data that is required on Hospitals, needs to be filled in on an extra form

2. The PAAB system (Interim Hospital Information System) has been implemented in 21 out of the 24 hospitals.
3. National is busy piloting a new form for Hospitals, the HAO1C, HAO1D and HAO1S forms for different category hospitals.

These were piloted in Mpumalanga at:

Witbank as a Tertiary Hospital

Philadelphia as a Regional Hospital

Middelburg as a District Hospital

Bongani as a Special Hospital (TB)

The form was positively accepted, with some suggestions for improvement. The progress on this is still ongoing and not finalised.

• Clinics:

At the clinics, the following is required on a daily basis:

• a daily Data Collection form is being filled in for PHC data

At the end of each month, the Person-in-charge of a facility, has to compile a summary report on the PHC data, and send the data up to the District Information Managers, who compiles a report for the district.

• a Register for TB patients

(Until the December 1999, the whole country used the same TB Register. Since January 2000, Mpumalanga and North West Province, pilot a new TB Patient Register – together with an Electronic TB Register.)

The District CDC Co-ordinator collects copies of the Register, throughout the month (as data gets completed), and punch it into the Electronic TB Register. Quarterly, she/he sends it through to the provincial office. These data are patient-based. In the past, the person in charge of TB in a facility had to compile a Quarterly Reports send it to the CDC Co-ordinator and the CDC Co-ordinator sent it up to the provincial office.

• For Mental Health, an In-patient Register and a Daily Register - for clinics, with a Summary at the end of the month. The Mental Health Co-ordinator is responsible for the filling of the reports, and then she/he sends it to the District Information Manager, who summarises it .

(The Mental Health Reports only started to realise in the past few months and there are still areas lacking, but this is now been attended to.)

At the district office the District Information Manager compiles the data into a Health Service Report and an Indicators Report

Mpumalanga is currently considering the HISP (District Information System) that was developed in the Western Cape, accepted by NHIS/SA and already spread out to all the provinces in the country. This will be an electronic system used in the districts.

The facilities will still be paper-based, with only minor changes to the current forms in use.

2. Hospital performance indicators:

1. Daily Average Number of patients per month
2. Percentage bed occupancy
3. Monthly average duration stay

2. Clinic performance indicators:

1. Percentage of Facilities reported
2. Number of Patients seen
3. Number of Services delivered

2. Health Status indicators:

1. The incidence of new STD Infections
2. Smear Conversion Rate
3. Prevalence of Children under the age of 5, under the 3^rd-percentile
4. Incidence of New-borns under 2,5 Kg
5. Incidence of Mental Health Cases
6. Immunisation Coverage (Children under 1 year, fully immunised)
7. Percentage of Women having their 1^st ANC visit , before 20 weeks of Pregnancy, according to expected number of pregnant women
8. Percentage of reported Deliveries, according to expected number of pregnant women.
9. Percentage of Teenage Deliveries:

• Under 16 years of age

Between 16 years and under 18 years

1. Hospital performance indicators:

1. Daily Average Number of patients per month
2. Percentage bed occupancy
3. Monthly average duration stay

1. Clinic performance indicators:

1. Percentage of Facilities reported
2. Number of Patients seen
3. Number of Services delivered

1. Health Status indicators:

1. The incidence of new STD Infections
2. Smear Conversion Rate
3. Prevalence of Children under the age of 5, under the 3^rd-percentile
4. Incidence of New-borns under 2,5 Kg
5. Incidence of Mental Health Cases
6. Immunisation Coverage (Children under 1 year, fully immunised)
7. Percentage of Women having their 1^st ANC visit , before 20 weeks of Pregnancy, according to expected number of pregnant women
8. Percentage of reported Deliveries, according to expected number of pregnant women.
9. Percentage of Teenage Deliveries:

• Under 16 years of age

Between 16 years and under 18 years

1. computer systems and their utilisation

The Department makes use of a Windows NT desentralised Domain architecture running Microsoft Backoffice software. We are using Exchange as our E mailing standard.

PAAB (Patient Admissions and Billing) Interim Solution: The PAAB system is used for Patient Admissions and billing throughout the Province.

Asset Management system: This system is used for asset management in the Information Technology section, and it is proposed that the system be gradually used throughout the Province.

Human Resource Training system: This system is developed to collect a database on personnel skills in the Province. This database will enable management to proactively determine Provincial training and budget requirements.

The demand for TOP services is increasing in our province. We have the statistics from the 5 public institutions implementing the CTOP act. A total of 2554 termination of pregnancies had been done. The number includes 6TOP’s done in Lydenburg hospital (see table below for details). No notification available from the private sector.

Grand Total TOP’s done in 1999= 2554

The trend over the last 3 years has been as shown below.

Rob Ferreira is our provincial MVA training site and the three practitioners include our provincial midwife trainer.

There was a certification/graduation ceremony on 09 December 99, for the MVA trained midwives who have finished their training and submitted their particulars to the S.A.N.C. The ceremony was held at the Chiawelo clinic in Gauteng and it was officiated by the National Minister of Health amongst others.

Constraints: -

• Lack of commitment to the TOP programme from some of our hospitals.
• Unavailability of medical and nursing personnel interested to implement the TOP programme.

1. Maternity Services

The standardization of maternity care and national guideline preparation is in an advanced stage. A national workshop was held on 16 November 1999 to finalise the guidelines. Inputs into the standardised maternity case sheet have been submitted to the National Department. A national midwifery congress was attended by our provincial DEPAM facilitator in Durban on 01-03 December 1999.

The DEPAM training curriculum has been submitted to the Nursing Council for approval. We are still waiting for council’s approval of our curriculum before we can start our provincial DEPAM training. The DEPAM trained midwives of the 1998 group were followed up in three institutions, i.e. Phola Nsikazi Health Centre, Barberton ,Themba and Piet Retief hospitals. The follow up visits are to assess and evaluate the advanced midwives’ practice and problems encountered after they had graduated.

Maternal Death Notification:

Notification process is going well despite few problems related to delays and folders, which don’t get sent with the notification forms at times. Two more deaths were reported in December to add to the last report. The provincial maternal deaths assessors have been meeting regularly and as indicated to assess the maternal death folders. There have been problems with the Eastern Highveld MDN assessor team, which led to the Lowveld and Highveld assessors having to assess the Eastern Highveld maternal deaths.

The maternal death statistics for the year 1999 stands as follows. (Reported deaths from 01 January to end December1999)

• Under or no reporting from institutions

Some hospitals seem may seem to be having the highest number of deaths, but in actual fact it is due to a fact that they are referral centres for other hospitals.

• All maternal death need to be followed up and feedback given to the hospitals concerned as required by National Department of Health. Our provincial maternal death assessors’ committee will facilitate this process. It will be easy to achieve once all hospitals have their maternal death committees in place as requested to over a number of occasions. This doesn’t seem to be happening in the hospitals and it is a matter of major concern. The MCWH programme has raised this and other issues related to failure of institutions to support government policies.
• Teenage pregnancy is a National problem. There is widespread concern about the inaccessibility and lack of family planning services in our province. Contraceptive methods were out of stock throughout most of the year.

Family planning refresher courses are planned for our province from the 21^st to 24^th February 00. 2 days in the Highveld, 1 day in the Lowveld and 1 day in the Eastern Highveld. These activities will be funded by private sector partners. These activities took place as planned and it was a success

• The 1998 Report on the Confidential Enquiry into Maternal Deaths in S.A was launched on 15 October 1999. The report was presented to the provincial and district management meeting in Witbank on the 30^th November 1999. The National Women’s health directorate made the presentation.
• Violence against Women Programme:

The 16 days of activism on violence against women commemorations went well in the province. The provincial planning team comprised of interdepartmental staff, i.e. Welfare, Gender Affairs,Office on the Status of Women and Health. A commemoration event was held at Drum Rock hotel for the provincial staff.

The provincial MCWH organised two major events in the Lowveld(Tonga district) on 03 December 1999 and the Eastern Highveld (Standerton district—Greylingstad) on 04 December 1999. These events were organised jointly with the National Women’s Health Directorate which funded the events.

1. Provincial Policy and activities related to cervical cancer screening and treatment:

There is no National or Provincial policy, as yet in this regard. as yet, There is no formal screening programme in the province. The tests are done in the districts when there is suspicion of these malignancies. A screening programme will be targeting women without any problem i.e targeting women who are at risk but are not having any complaints. It is a worrying fact that in some if not most of our institutions they cannot even do the test to those women with problems because of lack funds to process e.g the slides.

We do however make health presentations over the radio about the cancers as part of our awareness campaigns during some of our radio talk shows.

 

2. The province policy and activities related to breast cancer screening:

See above.

The Department remains seriously under-budgeted, and, despite the tightest controls being in place, the inevitable cost-drivers highlighted during the year (blood products, medicines, medical gasses, electricity, patient’s food etc.) would lead to a projected over-spending of not less than R40 million. The Department is expecting ±R25m from the ICS Grant for salary increases for 1 July 1999 to 31 March 2000. This would reduce the over expenditure to R15m. All efforts and cost saving measures are applied to minimize this.

1. control, management,, administration and Institutional

The new proposed organizational structure was submitted to the MEC who approved it. This will effect a re-organization to improve efficiency and effectiveness by a leaner provincial structure with re-deployment of professionals and expertise to districts enhancing service delivery.

• Clinical Capacity Audit

An extensive Clinical Capacity Audit of all public health services and resources was initiated and is expected to be completed by the end of March 2000. The results would facilitate identifying strengths and weaknesses to be considered in planning for future health service delivery.

• Transformation of Public Service Delivery (Batho Pele)
• Institution building and management and
• Democratising the work place.

Presently all facilities have Service Standards in line with the white paper on Batho Pele, courtesy charter, patient rights charter and a declaration on HIV/AIDS.

• Pilot Launch of the Service Standards

The launch was held in the Tambo Stadium in Moutse Village and was a success. The highlight was the declaration of the Service Standards Package by the honorable MEC for Health, Ms. MNS Manana.

• Health Information Management & Research

The Aim of Information Services is to support health workers at district, regional and provincial levels to obtain and use information to manage health services for the optimal benefit of the people of Mpumalanga.

A highlight for 1999 was the fact that the District Information Managers were appointed on the 1^st of April 1999.

• Decentralization of hospital management

A two-week visit to the Dorset Health Authority and Royal Bournemouth hospital was undertaken by senior managers during the year. This has facilitated the development of a draft performance management agreement between the hospital and the department. Legal opinion is awaited before implementation of the agreement.

Cost centers have been established at the hospital and the concept will be rolled out to other hospitals after teething problems have been solved.

• Human Resource Development

Human Resource Development is committed to facilitating and enabling the Department of Health to achieving its vision of providing comprehensive integrated health care in Mpumalanga Province through the Primary Health Care approach.

The aim is rendering a caring and compassionate health service acknowledging that people are its most important resource.

To achieve this the following is required:

• effective human resource development and management
• prioritizing staff morale
• job satisfaction
• motivation
• positive change in attitudes
• upgrading knowledge and
• improvements in skills through continuing education and appropriate support.
• Human Resource Planning

With a population of 2,8 million as per 1996 census figures, Mpumalanga needs to have a sound human resource policy that does not only look at the utilization and development of health professionals but also involves communities to take responsibility for their own health needs.

During the period 1996 to July 1999, provincial skills audits were undertaken and training was provided according to the prioritised training needs. The Directorate Training and Development provided management and generic training and co-ordinated financial assistance to serving officials and prospective public servants. Training was provided by the Directorate Training and Development.

During 1999 the Training Directorate hosted a national conference for Trainers in the Public Service to give meaning to the requirements of the Skills Development Act, in the creation of the Public Sector Training Authorities (PSETA) structure and discussing all related issues.

• Decentralisation And Capacitating Departmental Training Units

As from July 1999 the training unit was decentralised and the training officers were deployed to various departments in the province. Departmental Training Committees were set up to co-ordinate skills plans and monitor the performance of the training function. Training on how to conduct an organisational needs analysis were given to the departmental training committees. Departmental skills plans for the period April 2000 – March 2001 have been compiled.