SUBMISSION TO THE SELECT COMMITTEE ON SOCIAL SERVICES


This submission is presented to the Select Committee on social Services by the Department of Health :Kwazulu-Natal. Each aspect is presented under the following headings:

:. Provincial Health Priorities
:. Expenditure Patterns and Provincial allocations for 2003/4; and
:. Health Programmes aimed at pushing back the frontiers of poverty

PROVINCIAL HEALTH PRIORITIES

The priorities of the Department of Health are aligned to the priorities of the Province of
Kwazulu-Natal. The six priorities have been revised to eight priorities by the Province.
These are:

:. Eradication of Poverty and Inequality
:. Addressing the HIV/AIDS Pandemic
:. Providing Social Security Nets for the poor
:. Investing in infrastructure
:. Developing human capability
:. Strengthening governance
:. Promoting rural development and urban renewal
:. Investing in job creating economic growth

These priorities have been categorized by the Provincial Cabinet into 2 goals and 6 strategies. Hence the two first mentioned priorities are the goals and the remaining six are the strategies.

VISION. MISSION AND CORE VALUES OF THE DEPARTMENT

Vision

To achieve optimal health status for all persons in the Province of Kwazulu-Natal.


Mission

To develop a sustainable, co-ordinated and comprehensive health system at all levels based on the Primary Health Care Approach through the District Health System.


Core Values

Trust built on truth, integrity and reconciliation;
Open communication, transparency and consultation;
Commitment to performance;
Courage to learn, change and innovate.
The strategic objectives of the Department are in synchrony with the Provincial Priorities
and the Strategic Plans of the Department for 2003/04 are in synchrony with the National
Department of Health 10-Point Plan, the National Priorities and the NEPAD Priorities.
These are described as follows:

:. Address the effects of poverty and combat it in relation to health;
:. Combat and control HIV/AIDS, emerging and re-emerging diseases
:. Reduce the burden of disease through decreasing morbidity and mortality by focusing on priority diseases, clinical protocols, clinical audit, catchment areas, referral patterns, definition of appropriate levels of care in concert with institutions ranging from central to district, defining entrance and exit criteria and networking;
:. Promote good governance throughout the Department by ensuring optimum systems, audit and risk management, monitoring and evaluation, observance of "Batho Pele" and the "Patients' Rights Charter", sound fiscal discipline in keeping with the PFMA and observance of all other relevant legislative prescripts, rules and regulati6ns;
:. Rural development and urban renewal in keeping with the nodes and developing areas of poverty and inequality with regards to health;
:. Consolidate and advance basic infrastructure;
:. Improve the establishment of an integrated human resource management framework that will result in the provision of the right people with the right skills mix working in the right place at the right time for the right reasons delivering the right services to the right people; and
:. Providing a safe and secure environment for patients and staff.


POLICIES, PRIORITIES AND STRATEGIC GOALS


Policies and Priorities


The policy of the Department is geared to provide the best quality service within the resources available but which are value for money, efficient, effective, appropriate and with the intent of equity within the Province.

The Department will comply with the Provincial Priorities and the Department will continue to apply the following strategy in order to accomplish the priorities in the 2003/2004 period:

:. Ensuring that the emphasis on prevention of disease is given high priority;
:. Ensuring that HIV/Aids and tuberculosis are given specific attention;
:. The continued development and upgrading of basic services in the under-served areas through the primary health care approach to ensure equity of access;


:. Ensuring good governance that leads to the provision of quality services at all its institutions;
:. A shift towards equity allocation between the Districts that addresses urban renewal and rural development, particularly of the nodes;
:. Maintaining the present services at lower costs and not sacrificing basic health care
services; and
:. Expanding the Emergency Medical Rescue Services into the under-served areas of the Province.
The following policies introduced in previous fiscal periods are in various stages of the roll-out process:


:. The roll-out of the Counselling and Voluntary Testing for HIV/Aids;
:. The roll-out of and sustaining the programme to prevent the transmission of HIV/Aids from mother to child;
:. The care of HIV positive patients, inclusive of home-based care;
:. The continuation of the establishment of Crisis Centres throughout the Province;
:. The provision of anti-retroviral drugs to rape survivors and pregnant HIV positive women and their babies at birth;
:. The increase in the intake of student nurses to combat the high attrition rate;
:. Implementation of Primary Health Care through the District Health System;
:. The immunisation of all newborns and children;
:. Continuation with the appointment of Community Services Doctors, Community Services Pharmacists, Community Services Dentists, as well as other Community Services professionals;
:. The development of multi-skilled unprofessional staff, ward clerks, medical orderlies and senior clinical professional nurses;
:. The use of Community Health Workers to disseminate information on health
promotion at grass roots level;
:. Continuation of a vigorous capital works and maintenance programme in an effort to
upgrade facilities;
:. Provision of an Integrated Nutrition Scheme; and
:.. Improved financial discipline and revenue generation.
Strategic Goals

The strategic goals, which the Department has formulated for the improvement of service delivery within the 2003/2004 Medium Term Expenditure Framework period are in line with the Provincial Priorities and the National Health Ten-Point Plan.

The goals of the National Health's Ten-Point Plan are as follows:
:. Improving quality of care;
:. Reinforcing the Primary Health Care and District Health System approach;
:. Decreasing morbidity and mortality rates;
:. Revitalisation of hospital services;
:. Improving resource mobilisation and management of resources without neglecting the attainment of equity in resource allocation;
I:. Improving human resource management and human resource development;
:. Re-organisation of support services;
:. Improving communication and consultation with the health services and between the health system and communities;
:. Legislative reform; and
:. International co-operation in conjunction with and through the National Department of Health.

The Departments goals, in summary, for the 2003/2004 Medium Term Expenditure Framework are:


To continue to provide and improve the quality of health care in the Province; To continue to enhance Primary Health Care services through the District Health System approach, with special emphasis on underserved areas; To continue with the vigorous campaign in regard to HIV/AIDS and the roll-out of the CVT and the PMTCT programmes, as well as the introduction and provision of anti-retrovirals to rape survivors;
To continue to strive towards decreasing morbidity and mortality rates, especially amongst infants and mothers and to encourage preventative rather than curative treatment;
To continue investing in the health infrastructure through the Clinic Upgrading and Building Programme and the revitalisation of hospital facilities; Working towards resource mobilisation and management of resources to attain equity in resource allocation;
Striving towards improving Human Resource Management and Human Resourcp Development through the training of sufficient personnel to meet the needs of thp Department;
To continue to improve access to Support Services through effective monitoring and improved distribution systems; and
To continue to encourage and improve communication and consultation with the Health services and between the Health System and Communities.

With reference to these goals, the Department's activities for, specifically 2003/2004, arp set out below in priority order. The figures shown in brackets reflect the 2002 ranking.
1. Clinics and Mobile Clinic Services (1)

These facilities are the first level of Primary Health Care and provide service mainly to those patients who do not require admission to a more sophisticated facility.
2. Clinic Building and Upgrading Programme (2)

This programme is specifically geared to provide access to health services in thp underserved areas of the Province and to upgrade the present clinic infrastructure.
3. Community Health Centre Services (3)

These facilities provide a 24-hour health care service and have a doctor in attendance. They provide facilities for, inter alia, childbirth and those cases that cannot be treated at the clinic level, but do not necessarily require hospitalization for more than 24 hours.
4. HIVIAIDS - Awareness and Prevention (4)

Kwazulu-Natal has the highest incidence of HIV/AIDS in South Africa. This service provides for the special programmes for education in and the prevention of HtV/AIDS.
5.7? Communicable Disease Control (5)

This service/activity is aimed at improving the awareness and control of communicable diseases and covers immunization of children for, inter alia, polio, measles and HIS.
6. Training and Education (HRD) (6)

This service/activity provides training for doctors, nursing and ambulance personnel, health workers and personnel in health management, administration and health promotion.
7. Health Promotion (7)

Through communication, this service/activity encourages the general population to live more healthy lifestyles, thereby playing a preventative rather than a curative role in health management.
8. District Hospital Services (8)

These facilities cater for patients who require admission to a hospital for treatment at a general practitioner level.

9. TB Hospitalization

This activity provides hospitalisation for patients especially suffering from resistant strains of tuberculosis as well as those who become TB infected as a result of
HIV/AIDS.

10. Environmental Health
I
(10)

This service ensures that, inter alia, the standards of food, domestic housing, water supplies, sanitation and refuse management are maintained in order to provide a safe environment for the general population. The inspection of ports and border posts, also fall under this activity.

11. Integrated Nutrition Services
(11)

This service/activity supports a number of feeding schemes for the poor providing supplementary nutrition in order to prevent diseases that accompany inadequate nutrition.

12. Regional Hospital Services
(12)

These services cater for those patients who need admission to hospital for treatment at specialist level.

(13)
13. Patient Transport Services

This service/activity provides transport to indigent patients who have no other means of transport.

(14)
14. Emergency Medical Rescue Services
I

This service provides emergency transport and paramedic personnel for victims of, inter alia, trauma, maternity, motor vehicle and other accidents.
15. Maintenance of Buildings and Equipment (15)

This activity ensures the maintenance of existing buildings and equipment in order to avoid the necessity for major works and replacements at a later stage.
16. Malaria Control (16)

Malaria is endemic in parts of the Province of Kwazulu-Natal and its incidence is monitored and controlled by means of this service.
17. Mental Health Hospitalization (17)

This activity provides facilities for those patients requiring psychiatric care and psychological management. This also includes the management of substance abuse.

18. Central Hospital Services (18)

This service provides the facilities and expertise needed for sophisticated medical procedures as well as a platform for training health workers.
19. Convalescent Hospitalization (19)

This service/activity provides facilities for those patients who require nursing care with minimal supervision by doctors. It is becoming increasingly important because of the increased HIV/AIDS incidence necessitating care for the terminally ill.
20. Community-Based Care (New)

This service is aimed at the provision of health services by Community Health Workers and other community health care-givers. The service will play an increasingly important role in combating HIV/AIDS and TB as well as playing a role in the health promotion campaigns of the Department.
21. HIV/AIDS: PMTCT and CVT (New)


46
The PMTCT activity is aimed at high-level intervention to prevent transmission of HIV/AIDS from HIV positive mothers to their babies. The intervention per se is not the main cost driver of this programme but a holistic approach, which includes counselling, follow-up systems, formula feeding and family counselling. The aim of the CVT programme is to make the population aware of their HIV status to ensure that planning can be done effectively to deal with the problems and challenges associated with HIV/AIDS in the broader sense, taking into consideration the socio-economic implications.
EXPENDlTURE PATTERNS AND PROVINCIAL ALLOCATIONS 2003/2004
1 Comparison of the 2002/3 and 2003/4 Global Allocations

Revised Budget for 2002/03 R7, 419,706,000

Budget for 2003/04 R8, 055,650,000

Increase in nominal terms is 8.57%

· Increase in real terms according to Treasury inflation guidelines, 2.58%--

· Decrease in real terms if additional mandates and health inflation are taken into account 1.29%

2. Financial situation 2002/03

The Department over-expenditure in 2002/03 of R121,117 million, resulting from the following:

· R39,5 million for old nutrition accounts written back to budget as agreed with the Provincial Treasury;

· R26,7 million for the additional cost of the Primary School Nutrition Programme;

· R6,5 million for the expansion of the Community Service to other Health professions;

· Ri 4,617 million for the enhancement of the ambulance fleet delivered early;

R33.8 million resulting from general service and inflationary pressures.

What is important to note, however, is that the Department had to freeze posts, curtail maintenance and capital programmes, limit items on prescriptions and slowdown the expansion of services to underserved areas during the year, to ensure the overrun is manageable.
3. Comparison of the 2002/3 and 2003/4 by Programmes

GENERAL OBSERVATIONS IN HEALTH EXPENDITURE TRENDS

Over the last five years the nominal value of the annual budgets has increased substantially. The situation in practice, however, clearly indicates enormous pressure on the budgets mainly due to the following:-

· An increase in the demands for services especially in the under-served areas where the access to services has been improved. (The headcount at clinics increase from 10 mu in 1997/8 to 17 ml in 2002/3).

· An increase in demands for services in areas where little or no services exists. (Request for clinics in deep rural areas and informal settlements as well as the demands for the provision of Emergency Medical and Rescue services in the previously neglected areas).

· An increase in the training of Nurses and other health workers due to the loss of nurses resulting from early deaths and recruitment abroad.

· The impact of HIV/AIDS on the services resulting in prolonged treatment
and hospitalisation.

· The major backlog in the upgrading physical facilities and medical equipment.

· The impact of medical inflation, especially since September 2001, on imported goods such as medicine, surgical sundries, medical equipment and major plant. This inflation in generally higher than the CPIX normally used to calculate increases.
· New Mandates such as-
- Roll-out of the PMTCT programme;
- Roll-out of the VCT programme;
- Increase in the PSNP to more schools
- Expansion of Community service to other Health Workers.


HEALTH PROGRAMMES AIMED AT PUSHING BACK THE FRONTIERS OF POVERTY

Eradication of poverty and inequality

According to the World Health Organisation:
"Good health is an essential foundation for Social and Economic development and access to basic health care is a human right - the enjoyment of the highest attainable standard of health is a fundamental human right".

The highest percentage of the population in our Province is in the age groups of nineteen years and younger which is 44% while at the same time there are more women than men, 53% to 47% respectively. This demographic distribution of the population of our Province
45;=_increases the demands on health care and the utilization of health facilities and resources by our patients.

Our Province is a bi-modal one in many ways. There is a first world and a third world component in the same Province, which manifests itself by first and third world economic development as well as first and third world disease patterns. Our Department has to provide health care for both components while at the same time moving towards equity. Resources are being shifted from the more urban advantaged parts of the Province in order to develop the previously disadvantaged and rural areas. Hence disease patterns are also showing a shift and a change of spectrum and our records show increasing utilization of clinics. In 1996,1 145 630 people attended our clinics, compared to 14 616 184 people who visited our clinics in 2001. In 1996, 5 259 819 patients presented at the hospital out patient's departments, compared to 4 312 151 in 2001 (who are sicker because of HIV/AIDS). The objective is to close the gap between the two worlds in terms of basic infrastructure, human resources, financial resources in terms of health care, morbidity and mortality patterns and disease profiles.

The Department is committed to ensure that poverty does not preclude access to health care while at the same time initiatives related to health are being effected that will alleviate poverty. The Pholela experience and the Valley Trust initiatives have shown how health is intricately related to the access to basic social services, nutrition and self-empowerment. This is the basis of our primary health care approach. The vegetable gardens and other initiatives at both these sites proved to be invaluable in improving the health care of the people and moving our people from dependency to personal independence in the addressing of food security. The Department recognizing this, is embarking on community capacity building in identified areas to alleviate the poverty, which in turn will enhance nutrition and health. The outbreak of Cholera occurred in areas where poverty was rife; and in which poor water and sanitation and unemployment coexisted in a demonstrable manner. In such areas health education and promotion has had tremendous impact.

The promotion of improved nutrition through an integrated nutrition programme is being effected by the Primary School Nutrition Programme (PSNP), Protein Emergency Malnutrition Programme (PEMP), formula feeds and Emergency Food Relief Programme (EFRP) by the poverty alleviation and Household Food Security Programme while at the same time to prevent loss of nutritional benefits, children at risk of worm infestations are being treated. In order to prevent continued dependency on nutrition provisions, the Integrated Nutrition Programme (INP) comprises capacity building and empowerment to ensure sustainability. The success of all these projects depends on the intersectoral co-operation between Department of Health, Social Development, Education and Agriculture. The PSNP will be transferred to the Department of Education from 2003/2004.

The provision of free health care through the District Health System and hospitals is a part of a social wage designed to alleviate the burden of poverty on the people of our Province in that all treatment at clinics is free and all children under six years of age, pregnant women and those who cannot afford payment are provided with free health care at hospitals. A further measure to alleviate poverty will be the introduction of free medical care for the disabled from 1st April 2003.

Our Department is strengthening its network of Community Health Workers. A Director has been appointed whose responsibility is to ensure that the Community Health Workers Programme is strengthened, that the services of the Community Health Workers are Co-ordinated and covers the entire Primary Health Care package profile such that they provide a full outreach care and are an effective conduit between the homestead and the Clinic or Community Health Centre and/or District Hospital. The Director also ensures that the recruitment and training is optimized, that the distribution is in accordance with the norms and that the contracts with the NGO's are carefully supervised.

There are currently about 5 000 Community Health Workers deployed in the Districts providing Home-Based Care, DOTS supervision, nutrition oversight, health education and promotion inclusive of EPI, basic surveillance and basic health care. The Department will recruit and train approximately 1 000 community health workers every year to reach a target of 20 000 by the year 2020 which will mean one community health worker will be responsible for less than 500 people on the current census of October 2001 of 8,416 000 people.


Addressing the HIV/AIDS epidemic

HIV/AIDS is the most serious threat to the existence of humankind on our planet. This threat is most severe in Sub-Saharan Africa, South East Asia and South America. There were in the year 2001 approximately 40 million people who were HIV positive globally. Of these at least 95% were in developing countries and of these 28,1 million were in Sub-Saharart Africa, that is approximately 70%. Death from HIV/AIDS in 2001 was calculated at 3 million. In South Africa it is calculated that in 2001 there were 4,7 million HIV positive people between the ages of 15 and 49 years and of these 2,7 million were women. There were approximately 250 000 children infected with the virus.

Government's strategy to combat the epidemic can be said to have five legs:

The first leg is the programme to control the extension of the epidemic by preventing the infection of HIV negative people. Here the ABC strategy is to protect against the extension of the epidemic from unsafe heterosexual intercourse, which is the most important cause of infection of HIV negative people. Studies have shown that the adolescents aged between 12 - 20 years and young mothers are most vulnerable, while the infection has highest prevalence in informal settlements. Our programme will focus on these groups.

This strategy needs to be constantly reviewed and enriched to target everyone but particularly the vulnerable people who are women, the youth and children.

Our Department instituted the Prevention of Mother to Child Transmission Programme (PMTCT), with effect from June 2001. Results are showing signs of reduction of the rate of transmission of the infection of children born of HIV positive mothers. From June 2001 to February 2003, 60 052 pregnant women have had pre-test counseling, 47 712 that is 79% volunteered for testing and received post-test counseling. 1 7 884, that is 37%, have 3sted positive for HIV. The oldest baby in the Programme is 20 months. The number of babies that have tested positive is 44. The challenge however is to significantly increase ~e number of children who return for review. Out of

1 832 babies older than one year who were given nevirapine, only 395 returned for review. The number of institutions currently in the PMTCT Programme is 98 with more institutions entering the Programme on1st April 2003. It is envisaged that the Programme will be a seamless one by the end of this year.

Our Department has instituted the Post Exposure Prophylaxis (PEP) Programme for the protection of rape survivors and sexually abused patients from infection with HIV. The protocols for this and medication is available at all hospitals that have Casualties and/or Outpatient Departments as well as Community Health Centres and large Clinics that provide a 24-hour service. It is intended to extend this Programme to other facilities. Between October and December 2002, 283 individuals have benefited from this treatment.

The protection of healthcare workers in service is effected through training, instituted protocols and the provision of protective clothing and gloves and prophylactic anti-retroviral therapy for staff who are accidentally exposed via needle stick injuries.

The second leg is the management of HIV positive people. The progressive attack on the immune system of the infected person by the virus leads to a deteriorating resistance to infections and to progressive debility. The protection from and the treatment of opportunistic infections is the hallmark of the management of HIV positive people. Poverty and poor nutrition accelerate deterioration of the immune system and enhances the exposure to opportunistic infections. Overcrowding and poor housing leads to recurrent Upper Respiratory Tract Infections, which in turn put the patient at risk of pneumonia while the lack of safe water and sanitation leads to diarrhoeal conditions including Cholera that may also lead to death. Fungal infections that manifest themselves range from the mild ones like Candida (Thrush) to the life threatening one like Cryptococcal Meningitis. Protocols for the prevention and treatment of opportunistic infections have been adopted by the Department. The Diflucan protocol for the treatment of Oesophageal Candidiasis and Cryptococcal meningitis is well established in the Department. 33 953 prescriptions have been issued for patients who have benefited from this programme representing 895 000 Diflucan tablets which have been dispensed, representing approximately 60 % of the National distribution of Diflucan.

KwaZulu-Natal has implemented all prophylactic recommendations relating to anti-retroviral drugs, and we are currently preparing for the wider utilisation of anti-retroviral drugs for purposes of treatment. Training programmes for staff on the management of HIV/AIDS which include the use of anti-retroviral treatment have been conducted by the department since last year. This will prepare the staff for the management of patients with anti-retroviral treatment. A task team comprised of members from the National Treasury, National Department of Health and the Provincial Departments of Health are formulating a ?port to give guidance regarding the comprehensive management of HIV positive people and the financial and other implications of widespread use of anti-retroviral drugs.

us report will take into consideration all the experience internationally and nationally including the private sector initiatives on the use of anti-retroviral treatment. St Mary's Hospital, Mariannhill and Mc Cords Hospitals are introducing the limited use of anti-retroviral treatment. Funding from the GFATM will be utilized to prepare for the reduction of anti-retroviral treatment in our Province. The lesson learnt from the virapine roll out process, is that policy announcements must always take into account
I
the financial and human resource implications and other practical considerations to avoid creating expectations. I believe that significant progress will be made before the end of the year in the matter of widespread utilisation of anti-retroviral drugs. We shall be meeting the South African Medical Association (SAMA) to seek partnerships on the comprehensive management of HIV/AIDS.

The third leg is to support those affected by those that are infected, these are the families of HIV positive people and the orphans arising from the death of their parents. Joint management of the orphans by Welfare, Education and Health, amongst other Departments is critical.

The fourth leg is the management of those that are severely immuno-compromised and debilitated who are unable to care for themselves. Home-Based Care, collective Home-Based Care, Institutionalized Home-Based Care and Hospice care are all critical for the support of these patients so that they maintain their privacy and dignity to the end. Community Health Workers of the Department support the Home-Based Care initiative and are providing invaluable services.

The fifth leg is surveillance, research and human rights. The Human and Legal rights of HIV positive people must be protected. The surveillance provides an awareness of the size of the epidemic and how the measures and strategy to combat the epidemic are working while the research is looking for answers for further prevention and/or treatment for HIV positive people. The HIV vaccine initiative, when successful in producing an effective HIV vaccine will not benefit those that are already infected with the virus but will protect those that are not yet infected and prevent further extension of the epidemic.

This year we have targeted all hospitals and primary health care clinics to provide Voluntary Counseling & Testing (VCT) and at least 5 other non-medical sites to be established in all Districts. We aim to decrease the incidence of STI's in the province by 10%, to increase the combined TB/H HIV/AIDS management strategy from two sites to at least 11 sites, one site in each District.

We shall implement targeted youth life skills campaigns in all Districts using NAFCI initiative, which has been successfully piloted in the Province in partnership with Love Life. This will offer an opportunity for mass mobilization under the concept of moral regeneration.

We further aim to improve the quality of life of those infected through the provision of a quality accessible home-based care. Teams will be increased from the current 48 to 88, that is, 8 home-based care teams in each of the 11 Districts linked in a continuum of care with the hospitals and clinics.

The Provincial Aids Action Unit will complete the training of all community leaders (Councilors, MPL's and Traditional Leaders). Our target is to have an HIV/AIDS structure in every district and ward by the end of 2003 and 2004 respectively. All Religious Leaders in all communities have been targeted for training in HIV/AIDS peer education and through a co-ordinating committee, Provincial Religious Leaders Coordinating Committee (PARECO). At least 90 in each of the 11 Districts will be targeted for next few months. Our target is that in 3 years all wards have a programme based on churches.

All traditional birth attendants are to be adequately trained with regard to the management of labour and the newborn in the light of the epidemic.

The Unit shall also ensure that all Government Departments have an HIV/AIDS plan of action and to forge relationships and partnerships with the private sector, NGO's, CBO's and FBO's, to engender community ownership in support of HIV /AIDS strategies of the Unit.

A high profile communication strategy will be conducted that leads to a positive and sustained behavioural change by utilizing all major commercial radio stations, newspapers as well as massive outdoor communication including billboards, taxis and sports events.

The Global Fund has accepted the project proposal submitted jointly by the Department of Health of the Province, the Nelson R Mandela School of Medicine, the Durban Chamber of Commerce and Industry and the NGO's after being submitted by SANAC. Notwithstanding the media speculation to the contrary, the funds will be made available to the Province. The Province has lost no money, in fact the country has not received any funds and this includes the National project. This Global Fund allocation is an add-on and does not form part of the budget. It will enable the Department to conduct the additional programmes necessary to combat HIV/AIDS and Tuberculosis. Professor R. Feacham, the Executive Director of the Global Fund for HIV/AIDS, Tuberculosis and Malaria, will be visiting South Africa this month and will be hosted by KwaZulu-Natal on the 9th of April 2003. We are confident that his visit will put an end to all the negative speculations on this matter.

Reduce the burden of disease throuch decreasing morbidity and mortality


It is absolutely mandatory for the Department of Health to strengthen surveillance of disease patterns and profiles, clinical audit, clinical protocols for all diseases, in order to improve the quality of care and reduce morbidity and mortality. The advancement of the accessibility of the basic health care to our people will be further improved this year. There are currently 41 clinics providing a 24-hour service. The target is to increase this number this year by 22 that is 2 additional clinics in each District. There are 142 mobile clinics in the Province and the target is to increase this to 1 70 this year. This will entail additional costs for staff serving these facilities, which will be accommodated within the District Health System budget. Most of these will benefit people in rural areas.


The catchment areas and the demographics of these catchment areas for all institutions and districts will be reviewed once the October 2001 population census becomes available. Networking and the forward and reverse referrals will be tidied up when this is done. The Department is now ready to finalise this as it has finalized the central and tertiary hospitals in the Province.

The priority to combat HIV/AIDS has been extended by the Department to include addressing the impact of emerging and re-emerging diseases including Tuberculosis, Malaria, Cholera and the chronic non-communicable diseases such as Cardio-Vascular Diseases, Diabetes and Disability.

Tuberculosis has re-emerged in the developing world because of poverty, poor housing, poor nutrition and HIV/AIDS. This is evident in the Department and is reflected as one of the major causes of death. The Department has taken up the challenge by increasing the resources including an additional financial allocation. Staff have been appointed at the Head Office and in the Districts. They are now all in place. The laboratories are providing good back-up for the diagnosis of TB and collecting specimens from Clinics and Hospitals and providing the results. The target for specimen collection and the provision of results in all districts in the rural areas is three times a week and in the urban areas is daily. Significant advance has been made by the Department with the management of TB, the systems are running well but Multiple Drug Resistance Tuberculosis (MDR) is becoming an increasing problem, which the Department is addressing. An amount of R7 million has been allocated specifically for MDR. A second centre to complement King George V, for the treatment of MDR patients is being explored and together with the National Department of Health the protocol for the management of MDR patients is being reviewed.

The number of cases of TB being diagnosed in the Province is increasing. In 1 999, 29 645 cases were diagnosed and there were 1 859 deaths, that is 6% while for the 6 month period from January to June 2002 there were 27 761 cases diagnosed and 474 deaths, that is, 2%. The Community Health Workers and the rapid diagnosis by the laboratories are supporting the DOTS protocol for TB management. Sick TB patients who are also HIV positive are occupying an increasing number of hospital beds, thus increasing the burden on hospital bed occupancy and resources. The target for this and subsequent financial years is to:

4:. Increase the detection rate from the current 30% to 70% by 2005,
C:. Increase the cure rate from the current 29% to 85% by 2005,
4:. Decrease the treatment interruption rate from 16% to 5% by 2005,
4:. Reduce TB by 50% by 2010 and achieve complete eradication by 2020.

An intensive anti TB campaign by the department, involving the community, Community Health Workers, and DOTS supporters, with good patient follow up, will lay the foundation for success in the widespread use of anti-retroviral treatment. Without this base, the comprehensive management of HIV/AIDS will be almost impossible.
The control of the common childhood illnesses by the Expanded Programme of Immunization (EPI) will ensure that children do not become afflicted by the childhood illresses such as Measles, Diphtheria, Polio as well as Tetanus and Haemophilus Influenza B, (that is HIB). The protection from Tuberculosis is being provided by BCG coverage. Our Province is robustly supporting the Government's efforts to have South Africa declared a Polio free country by the year 2005 which is the deadline provided by the World Health Organisation.

The Cholera epidemic has abated but has not been controlled as cases are still being diagnosed on a weekly basis. Cholera will only be finally eradicated when all our people of the Province have access to safe water and sanitation. According to the World Health
Organisation, a Cholera epidemic is only controlled when no new cases are reported for a period of at least seven to ten days. The World Health Organisation has commended the Department for the best control of a Cholera epidemic globally, ever. To date there have been 121 054 cases reported with 290 deaths reported, giving a death rate of 0,24%. The cost to the Department was significant but it met the challenge.

There were 2 345 cases of Malaria recorded in the year 2002 and 16 deaths. This is a significant drop from the number of cases in previous years as in the year 2000 there were 42 284 cases and 342 deaths while in 2001 there were 9 506 cases and 47 deaths. This dramatic drop in the number of cases of Malaria recorded and drop in death rate is due to the robust Malaria Control Programme initiated by the Department and for which the Department has been complimented by the World Health Organisation and received the shield for the best Malaria Control Programme in the Southern Hemisphere. In the year 2002, 218 719 homesteads were sprayed which covered a population of 1 409 527 and 10845 bed nets were distributed. The total number of spray personnel utilized is 137. The DDT spraying has made a marked difference in the reduction and control of mosquitoes. A challenge to be met by the Department is the control of mosquitoes across the border in Mozambique and Swaziland. The introduction of Co-artem (Artemether and Lurnafanthrine) for the treatment of the Malaria has made a significant improvement as the Malaria parasites in Kwazulu-Natal have become resistant to Chloroquine. The Department is making preparations to respond to the target announced by the President to eliminate malaria by the year 2007. The target for this financial year is to effect a 30 % reduction in the number of Malaria cases with further reductions leading to elimination of Malaria by the year 2007. This will only be achieved with regional co-operation. As part of this effort, a SADC Rally Against Malaria will be launched on 10~~ April 2003 in Ndumu and will be attended by National & SADC Leaders. This rally will move through Mpumalanga, Limpopo, SADC countries and will end in Tanzania on the 25th April 2003.

Cardio-Vascular disease remains a major cause of death in adults. This is associated with Hypertension, Diabetes, Hypercholesterolaemia and associated lifestyles particularly overweight, lack of exercise and smoking. Clinical protocols have been developed for Primary Health Care and for hospitals based on the EDL protocols of the National Department of Health as reference. The Department has adopted a clinical audit approach and is asking the clinicians and hospital management to monitor morbidity and mortality rates and to ensure improved patient care and quality of life. Trauma, due to road traffic accidents and interpersonal violence remain a significant cost driver, which can only be reduced in concerted moral regeneration programmes focusing on road safety, and crime reduction involving the whole community.

The provision of care for disabled people is one of the priorities of the Department. Prostheses, walking aids, wheelchairs and spectacles are provided. The Department's target is to address the needs of 50 % of the people requiring rehabilitation and assistive devices this year and to address 100 % by the year 2007.

The Department is diligently pursuing the cataract programme. 5 11 6 cases of cataract surgery were undertaken in the year 2002 which means all these people now have vision. The target is to have cleared all backlog on cataracts by the year 2020.

The flying doctor service is well established and is providing an excellent outreach programme for health worker and specialist services to the hospitals in the rural and/or disadvantaged areas. There have been 5 000 health care workers in all professional groups that have participated in the programme since the inception of the programme in June 1998. 30 different hospitals are visited every month. There have been 515 hospital visits last year and 20 995 patients were seen. Again, this support goes to our people in rural areas.


Chief Specialists have been appointed in Pietermaritzburg who will also have the responsibility of monitoring health care, the use of protocols and the application of clinical audit in the Western half of the Province. The Durban Chief Specialists are responsible for the Eastern Seaboard half of the Province. Posts will be created at Chief Specialist Sevel for Ngwelezane/Umfolozi Regional Hospital Complex. The Chief Specialists in this complex will be responsible for the East-North part of the Province. Consideration will then be given to a similar situation in Madadeni/Newcastle Regional Hospital Complex who will then be responsible for the North-Western part of the Province. This will create four strong legs in the Department at regional level to care for the communities and will ensure that we move closer to equity. Thus specialist health care will now become accessible to people in rural areas without them needing to travel to the metropoles. Our focus is "HEALTH FOR ALL" by the year 2020.


Targets for the Institutional Support Services component of our Department is to have all hospitals participating in the COHSASA accreditation programme this year with all of them being accredited by the end of 2004, to have Batho Pele sustained programmes in all hospitals, to implement service level agreements and performance agreements for all hospitals and hospital managers respectively, to have appropriate levels of care for at least 50% of patients in provincial hospitals and to have clinical audit and clinical protocols in all hospitals.


Providing Social Security nets for the poor


Our Department recognizes the plight of the poor and the significance of poverty's contribution to poor health. Our Nutrition Programme is providing food supplementation and programmes for the poor inclusive of school children in Primary School, patients with Tuberculosis and advanced HIV/AIDS, particularly those requiring home based care. Biomax and other nutrition supplements are being piloted with the intention of a roll-out if it proves successful. Our Department will be involved with the Department of Welfare in the provision of food parcels to those identified as needy and will at the same time assist to develop independence by the Integrated Nutrition Programme providing gardens at clinics7 community health centres and district hospitals so that they can act as seed projects for communities.