Implementing recommendations is critical to restoring the health system
4 June 2010
On Monday 31 May Business Day reported that because of the deepening financial crisis facing health services in the provinces the Minister of Health is discussing a “bail-out” of provincial departments of health by the Treasury. Treasury intervention is now vital to prevent the collapse of health services. But equally important is the resolution of the crisis facing financial management systems that led to the massive debt in the first place.
In this context, the Treatment Action Campaign (TAC) and SECTION27 incorporating the AIDS Law Project welcome Minister Motsoaledi's release of the Consolidated Report of the Integrated Support Team's (IST) review of the public health system. This report is the product of the ISTs that were commissioned by former Minister of Health, Barbara Hogan, in February 2009. The investigation was largely in response to TAC’s protest over the deadly five month moratorium on ARV initiation in the Free State.
Since 2009 TAC and SECTION27 have called repeatedly on the Department of Health to make public these reports so that we can assist the government to implement a public health service that is more accountable and better serves poor people. Until now only leaked copies of the Free State and Limpopo provincial reports have been made public.
The release of this report is a positive sign that the Minister wishes to work with civil society.
Unfortunately but not unexpectedly the Report offers an honest and grim assessment of failing financial, management, human resource and monitoring and evaluation systems. It also describes failures of leadership from the National Department of Health (NDoH) during the administration of former DG Mseleku who failed in his duty to intervene and resolve these problems.
The report reveals failures by the provincial departments of health and finance, the NDoH and the National Treasury to take appropriate action as provincial departments of health accumulated debts beginning in the 2006/2007 financial year. The accumulated debt was-estimated to have been R7.5 billion by 1 April 2009. The financial management of all these departments has been characterised by a lack of transparency. We believe those responsible for corrupt, wasteful and inefficient expenditure at all levels must still be held accountable and barred from working in the public service. Allegations of corruption against MECs and Heads of Health should be investigated and prosecuted.
We believe that resolving the failures identified in the IST reports requires urgent prioritisation before service delivery further threatened. Already there are reports of chaos in the delivery of essential medicines in the Eastern Cape.
However, the IST report also offers a set of recommendations that constitute a blueprint for rectifying the health system. Some of its recommendations include:
• The need to accurately determine the exact amount of the financial backlogs in each province with the NDOH CFO taking the lead.
• Before public policy announcements are made about implementation of new health programmes there must be accurate costing, guaranteed funding from a properly determined baseline budget.
• The Minister of Health should drive the development of one national health vision and strategy. This should be done with the involvement and participation of the provincial health MECs and health departments and other stakeholders.
• There should be alignment between the national vision and strategy, programme strategic plans and annual national health plan, as well as between targets and interventions within the NDOH. All plans should pay more attention to implementation, should be aligned with each other and should contain a clear M&E framework with performance targets.
• Proposed new structures should be carefully reviewed and restructuring, with a view to establishing minimum staffing levels and optimal management and administrative positions, should be undertaken based on objectively agreed benchmarks, optimal application of scarce skills, the public health sector’s strategic and service delivery priorities and resource availability.
• A moratorium on the establishment of additional provincial head office positions should be considered until the review is concluded.
TAC and SECTION27 believe the recommendations of the Consolidated and Provincial IST Reports should be studied by members of the Health Portfolio committee in the National Assembly and Provincial legislatures. Implementation of their recommendations must be monitored and there should be regular reports of progress made in implementing the recommendations.
Sustaining the ARV programme
The report repeatedly states that the current model for the scale up of antiretroviral therapy is unsustainable from a health system perspective and unaffordable from a budgetary perspective. It recommends that financing for HIV/AIDS must be ring fenced.
It also states that there should be a fundamental review and adjustment of the current delivery model of providing ARV treatment. Unfortunately the report does not go further than this. In our view, this finding highlights the importance of these additional interventions:
1. Task shifting: There are not enough doctors to prescribe and initiate ARV treatment. Nor are there enough nurses to counsel and test patients for HIV. Therefore nurses need to be allowed to prescribe and initiate treatment. In this regard, we welcome new National Health Act regulations – effective from 17 May 2010 - that allow counsellors to do finger prick tests.
2. TB and HIV integration: By ensuring people with HIV are screened for TB and that people with TB are tested for HIV, and if co-infected that they are managed by the same health workers for both diseases, much time can be saved and patients will be better managed.
3. Prevention: Scaling up and improving proven prevention interventions including mother-to-child transmission prevention, voluntary male medical circumcision, earlier HIV treatment, sustained male and female condom distribution and public messaging, will reduce the number of people who become infected with HIV and need treatment in the future.
4. Private sector: Business has to take greater responsibility for treating employees with HIV and their families. This applies particularly to industries whose employees are at higher risk of HIV infection, such as the mining and transport sectors. But it also applies to medical schemes who collectively cater for less than 20% of the population. Medical scheme members have lower prevalence than the rest of the population. Mechanisms need to be implemented to reduce the burden of HIV on the state by getting medical schemes to absorb more patients at risk of HIV infection.
5. Drug prices: South Africa needs to relentlessly pursue the lowest price ARV and opportunistic infection medicines available globally, even if this means issuing compulsory licenses. But it is also critical to ensure the new ARV tender is effectively implemented and that the Medicines Control Council speeds up the registration process for antiretroviral formulations.
TAC and SECTION27 state our continued support for Minister Motsolaedi in his efforts to resolve the health crisis and bring dignity, honesty and efficiency back into the delivery of health care. Acting on the IST reports is a necessary step towards all the key objectives set by Motsoaledi and the ANC in their 10 point plan for health, including the introduction of a National Health Insurance System.
Finally we continue to urge the Minister of Health to release the provincial IST reports and the IST report evaluating the NDoH.
The Consolidated IST report can be downloaded here: