In the state of the nation address the President highlighted a number of challenges for us. I wish to deal with some of these and indicate both progress as well as the immediate challenges ahead.
HIV/AIDS Quite clearly HIV/AIDS continues to be the major challenge facing us. Also important in our perspective is for us to remember the point made by the President that where Poverty & disease is rife HIV/AIDS thrives with even greater brutality. So our approaches to be comprehensive must grasp this reality. HIV/AIDS is a major developmental challenge both in terms of its contribution to economic under performance as well as its viciousness in areas characterised by under development. What then have we tried to do:
1. Following a major review of our HIV/AIDS campaign in 1997 we concluded that key ingredients for success were visible and sustained political leadership and mobilisation of different formations in our society.
2. The Interministerial Committee on AIDS (IMC) committee was thus formed chaired by then Deputy President Mbeki - a practice that continued in this present administration under the guidance of Deputy President Zuma.
As you are all aware, Cabinet recently undertook a restructuring of the way it does business. This also included a review of all the cabinet committees including the IMC. This however will not in anyway reduce the attention that cabinet will dedicate to this important subject.
3. In October 1998, we also launched the partnership against HIV/AIDS as a challenge for all of us to act in unity in the different sectors to which we belong.
4. We have taken this further with the launch/establishment of the South African AIDS Council (SANAC) in January 2000 - under the chairmanship of the Deputy President.
5. The SANAC consists of representatives from different sectors. Government is approaching this initiative with an open mind. We do not have experience in this country on this and the lessons from countries such as Uganda are that the form and nature of such institutions evolves over time responding as they should to changing and evolving situations.
6. Government therefore holds the view that during its 2 year span, this council will learn and subsequently inform the composition and the functioning of its successor.
7. It was also important for us, that we make a start as a matter of urgency without bogging ourselves on prolonged discussions on such matters as legal status in particular. These will be addressed as we deal with our primary task - viz. the containment of this epidemic.
8. As many of you know, the SANAC had its first meeting on Tuesday February 1 2000. I have been encouraged by the seriousness with which all the members tackled their task. The meeting was vibrant and I am certain that by establishing sectoral task teams the representatives of the sectors will root the work of SANAC throughout our country. This also includes to responsibility of the government Ministers sitting in the Council to ensure that all government departments act in a co-ordinated manner.
A key decision of that meeting was the agreement on the establishment of 5 technical task teams. These are:
i) Prevention
ii) Care, treatment and support
iii) Research
iv) Human Rights and legal issues
v) Social mobilisation
These technical task teams will be constituted soon. In addition to these, each sector is to establish sectoral task teams that will cover all the identified areas. Each sectoral team will then report progress to the SANAC through the sectoral representative in the Council. Through this mechanism we believe there will be greater involvement of the sectors in the work of the Council.
The next meeting of SANAC is scheduled for February 26 2000.
The success of this initiative is key to a sustained social mobilisation against
HIVIAIDS.
In addition to this above initiative, in our MINMEC of the 3rd February 2000, my colleagues the nine provincial MECs for Health and myself agreed on a number of key decisions.
9. We agreed to roll out a programme of Voluntary Counselling and Testing. This decision was preceded by an investigation on the availability currently of testing sites as well as Counselling Services. We need of course to do a lot to consolidate what exists but we believe we are ready to make a start.
10. We have also concluded that to sustain a programme of counselling, use has to be made also of lay counsellors. In this regard we deliberated and endorsed a proposal detailing minimum standards to be adhered to in any training of these counsellors. We shall be proceeding with the training and in certain instances retraining of existing counsellors.
11. We also reflected and endorsed a recent initiative on the greater use of Rapid HIV testing in the health sector. This would enable pre test Counselling, obtaining results and post test Counselling to be done in one visit thereby reducing default rates and the anxiety associated with long periods of waiting for results.
12. We caution however in relation to these rapid tests against individual use outside the context of available counselling services.
13. We also believe that various sectors of our society like NGOs and Churches have and important role to play to ensure a successful VCT initiative.
14. It is our view that knowledge of one's HIV status is important to facilitate appropriate behaviour.
15. Another key decision taken in our recent MINMEC was the approval of Guidelines for the adequate treatment of opportunistic infections. We believe this will contribute significantly to improving the quality of life of those infected. We need to all remember that proper treatment of these infections leads to productive lives in the interests of the individuals, families and communities.
16. You will recall that in his address to the NCOP, the President instructed us to investigate concerns around the toxicity of the antiretrovirals. We have commenced with this task. We asked the Medicines Control Council (MCC) to make available to us information that would assist in determining the risk benefit assessments of the use of the antiretrovirals for different indications. The initial reports we got were not to our satisfaction. I have now recently received the latest report from the MCC which I am studying.
17. Another challenge we face in the months and years ahead is the extent to which we shall be able to deal with the many children orphaned due to AIDS as well as provision of care and support. In this regard, last week I had the opportunity to listen to some presentations from a group of NGOs who have been doing some work for the department on alternative settings for care of those with AIDS.
We shall be dedicating a significant part of our discussions in our next MINMEC in March to this topic. So too shall we be working with other government departments particularly Welfare.
QUALITY OF CARE
During his state of the Nation address, the President also reaffirmed our common
commitment to a caring and a humane society. Over the past few years, we have done a lot to improve access to hither to marginalised communities. In my previous briefings I detailed these achievements to you. Needless to say, we are proud of these achievements and we believe they form a solid foundation and a launching pad for our further advance. But we are not saying the job is complete. Far from it. But we believe in addition to continuing to improve access, time has come for us to deal with the problems of quality throughout the health system.
This will be a comprehensive attack on all the dimensions of quality and include such interventions as:
vi) Peer review systems and clinical Audits
vii) Establishment of complaints mechanisms
viii) Continuing Professional development and rectification
This work will constitute our strategic focus over the next few years. That is why in November 1999 we launched the Patients Rights Charter as an intervention to highlight this focus. Together with the Batho Pele initiative, we believe this will contribute to the restoration of the humanity of all South Africans especially the most vulnerable, the poor, women and the rural.
We need a restoration of the caring and compassionate ethos that has characterised our health professions. We need to emulate those health workers who work under extremely difficult conditions at times in service of their country and people.
But to succeed in these initiatives, we need all our people to reclaim their right to dignity and own our institutions which are afterall their own.
BRIEFING
The Annual HIV antenatal Survey Once a year the Department of health co-ordinates the annual antenatal survey. This survey is an unlinked and anonymous voluntary survey which forms the cornerstone for determining HIV prevalence rates and progression of the HIV epidemic for the country. Three hundred clinics are selected on a random basis resulting in at least 15,000 women participating.
At each clinic women attending for the first time in the current pregnancy are eligible over the one month (October) study period for inclusion. In accordance with ethical principles and guidelines followed by the survey the women are given a full briefing where participating women are informed that the survey in unlinked, anonymous and confidential i.e. it is not possible to link any blood specimen to an individual by name or any other identifier. They are given the option to agree or decline participation in the survey i.e. Volunteer.
Women who meet the eligibility criteria are asked for their consent although the testing is absolutely anonymous and unlinked. They are offered three choices:
1) consent to participate in the study and not know their HIV status;
2) consent to participate in the study and know their HIV status.
3) refuse to participate in the study;
When women present at the antenatal clinic routine blood specimens are taken to test and if necessary treat the woman for syphilis. 5ml of blood are drawn into a tube which is labelled with the womans' name, age and the name of health facility.
If a woman chooses to participate without knowing her HIV status another blood specimen is taken. Instead of being labelled with her name, age and facility the tube is only labelled with a randomly allocated bar code with facility and woman’s age. The bar coded specimens are sent to one of the 7 study laboratories.
If a woman chooses to participate and wants to know her HIV status this is not possible through the antenatal survey procedure because of the built in confidentiality. However the participant is encouraged to use the voluntary, testing and counselling facilities offered as a separate service by clinics.
If a woman chooses not to participate in the antenatal survey, a blood specimen is only taken for syphilis testing as per routine care service. However blood for the antenatal survey HP' test is not taken and the woman is not included in the study.
General Reliability ofHIV antenatal survey data. Although South Africa is believed to have one of the most reliable antenatal surveys in developing countries, in the last two years there has been a review of the methodology of the survey to make further improvements on methodology. The review was a joint and combined effort of the Department of Health, Medical Research Council, South African Institutes of Medical Research, University of Natal Medical School (Virology Department) the National Institute of Virology, the South African Blood Transfusion Services and Medical University of Southern Africa.
A standard national protocol was developed and introduced. The key areas of improvement that were introduced were on Sampling - to ensure more reliable and proper random sampling of clinics for each province, Laboratory quality controls - to ensure that errors in laboratory analysis and interpretation do not occur, data capture - double data entering and independent data checks are conducted to ensure that no errors occur during this task.
The World Health Organisation with the Centers for Disease Control are now developing manuals based on the South African and other protocols for countries in the region to consider using in devel9 ping improved HIV antenatal surveillance in Africa.
Scientific assumption behind the survey It is international practice to base the survey on those women attending antenatal clinics as a reference population for sentinel surveillance to track HIV. In so doing several assumptions are made; a) that pregnant women are sexually active b) they represent normal healthy adults from the general population. In addition these women are a) already attending health institutions and are therefore easy to reach and b) blood is already taken as a routine procedure for syphilis and other pregnancy tests. There are clearly a few limitations - selection bias in this methodology namely; Women attending public health facilities may differ from those in private facilities, Research has shown that HIV reduces fertility progressively over time. Thus possibly resulting in underestimates, HIV is associated with other STDs known to cause infertility. Other limitations are that the data are limited to women to the exclusion of healthy men, and infants. Despite these methodological limitations, antenatal survey data have been shown to be useful and reasonably accurate for prevalence statistics.
PRESS STATEMENT
HIV/AIDS AND THE TESTING OF CHILDREN AT SCHOOL Tuesday, February 8, 2000
On Saturday 5 February 2000, The Argus Newspaper published a report that the Department of Health would start pilot projects to test pupils for HIVIAIDS at several schools.
This is not correct. A staff member of the Department of Health, Dr Rose Mulumba was interviewed over the telephone in connection with ante-natal statistics on HIV/AIDS. During the course of the conversation, issues regarding young people and HIV/AIDS were also discussed.
The Department has no intention of testing children at schools for HIV/AIDS. What the Department is currently considering is drawing up a Youth Risk Behaviour Survey to be carried out in all schools. The survey will seek to establish baseline information on several modes of behaviour that could place young people at risk of infection. These include sexual behaviour, behaviour relating to the use of alcohol, drugs and other substances, violence and crime amongst young people. This survey is purely behavioural and no testing will be conducted on pupils.
At the same time, through its already established educational programmes on HIV/AIDS the Department will encourage young people, under the guidance of their parents and teachers, to participate in voluntary testing for HIV/AIDS once the necessary counselling has been received. In accordance with established departmental policy, all counselling and testing by the Department will be done in clinics.
The Department has been and will continue to be sensitive to the manner in which it handles testing for HIV/AIDS. Departmental policy has been developed to ensure that testing for HIV/AIDS includes counselling, mental preparation for the test and parental consent in the case of minors. To enable parents to consent, they have to receive and understand information regarding the test itself and its anticipated consequences. The purpose of testing for HIV/AIDS is to enable people to know their HIV status so that they can act appropriately. If they test negative, they can make sure that they behave in such a way that they remain negative. If they test positive, they can take steps to change their life styles so that they remain healthy, and learn how to manage any opportunistic infections that they may get.
The Department is aware that a report such as the one that appeared in the Argus on Saturday could cause people alarm. We wish to reassure people that HIVIAIDS testing will not be taking place in schools, and the Department deeply regrets any confusion that the report, as it appeared, has caused.
Prepared by: Nothemba Dlali
082 775 4791
Enquiries: Nothemba Dlali
Input for the Minister's Press Conference scheduled for the 8th February 2000:
Youth Risk Behaviour Surveys (YRBS).
Youth Risk Behaviour Surveys are carried out world-wide. They are designed to measure the extent to which certain types of behaviour prevail among children of school going age. The findings of YRBS surveys are used to guide and monitor intervention programmes around sexual and reproductive health tobacco, alcohol and drug use as well as violence and crime among teenagers These are purely behavioural studies with no HTV testing component.
A proposal to conduct a similar type of survey in South Africa is being co-ordinated by the Health Promotion Directorate since last year A working group (comprising the National Health Department - Health Promotion Directorate, National AIDS Programme, Health Systems Research and Epidemiology Directorate and Maternal, Child and Woman's Health Directorate -the Department of Education, the Youth Commission, the Medical Research Council, the Human Sciences Research Council and the Centres for Disease Control and Prevention) has been constituted to look at operational and methodological issues around implementing such a survey in South Africa. An interviewer or self-administered questionnaires will be used to collect quantitative data from the participants, no blood will be drawn. Approximately 6000 participants will be used in the study.
The working group met on 31st May 1999 to divide responsibilities around protocol development. On going consultation has taken place since then to further review the study proposal and protocol. Once finalised these shall formally be presented to DOH management for consideration.
RESPONSE TO THE STATE OF THE NATION ADDRESS
BY THE MINSITER OF HEALTH - DR ME TSHABALALA-MSIMANG
During the state of the nation address, the President reaffirmed our common commitment to a caring and humane society. Such a society will not drop on us like the biblical "manna from heaven" but will come about as a consequence of our own actions. Such actions in turn can only be inspired by an unequivocal acceptance of our common humanity.
Consistent with this approach, the ANC led government has over the past 5 years invested significant resources in improving access to health care for previously marginalised communities. This has involved:
i)Putting physical infrastructure through the clinic building programme
ii) Redeployment of health personnel including the commencement of a system of community service. This has also included the structuring of government to government agreements with countries like Cuba.
iii) Improving the reliable distribution of our pharmaceutical supplies through public private partnerships.
iv) Removal of the financial barrier to access through our policy of free Primary Health Care and Free Health Care for pregnant mothers and children under six.
v) The reprioritisation of public health spending to advance equity and support interventions that contribute to alleviation of Poverty.
Mr President, we have reflected carefully on the impact of these interventions. We are convinced that they have advanced the best interests of those on whose behalf we are gathered here as public representatives. Equally, we are convinced that this has contributed to the hope that has replaced despair of which you have spoken.
Mr President, these successes have also brought to our attention two interrelated factors.
First - They have further strengthened our confidence in the ability of South Africans to rise to the challenges of our times. How else can we explain the positive sentiment that is expressed by hundreds of our young graduates across the colour divide who have embraced our call for Community Service. Yes, some of them were negative at the beginning influenced in certain instances, regrettably, by some present here. Yet once they experienced the positive feeling of making a contribution to the reconstruction of our nation many have openly come to express their gratitude for the opportunity.
As we speak, preparations are afoot to extend this initiative to dentists in July 2000 and pharmacists in January 2001. Mr President I raise this on this occasion because this is a solid pointer to the preparedness of our youth to embrace the spirit of the "new Patriotism" of which we have spoken.
Secondly Mr President our successes have thrown up new challenges. We stand ready to tackle these. Central amongst them is the need to address the quality of care throughout our health care delivery system. (This refers to all the dimensions of quality but more importantly the restoration of a caring and compassionate ethos amongst our health workers). This constitutes the strategic focus of our work over the next 4 years. That is why in November 1999 we launched the Patients Rights Charter as a specific intervention to highlight this challenge.
Our commitment to a caring and humane society obliges us to confront this challenge with the same determination to succeed that has characterised our government. We call on all South Africans to join in this offensive.
As a further challenge specifically addressed to our nursing profession, I am happy to announce that this year we shall launch the Celicia Makiwane Nursing award in recognition of that outstanding pioneer. We hope this will challenge our nursing profession to emulate this exemplary daughter of our soil.
A central theme of your Presidency, Mr President is the need for the different arms of government and society as a whole to confront our developmental challenges in an integrated manner. May I dare say, that this is the essence of the Primary Health Care approach which our government espouses. Many of the determinants of good health lie outside the formal health sector. They are the availability of water and sanitation; adequate housing and a direct attack on poverty to mention but a few.
Recently my department released the first ever demographic and Health Survey in the history of South Africa. This baseline survey shows the strong correlation that still exists between ruralness, poverty and disease.
The integrated and sustainable rural development strategy would thus be an invaluable instrument to tackle some of our health problems. So too, would the interventions aimed at the alleviation and eradication of poverty.
Mr President,the poor of our land feel the full impact of the debilitating diseases that cause so much pain and suffering in our country and our continent. Malaria, TB, STDs and HIV/AIDS have the worst impact in these communities. These diseases in turn exarcebate the problems of poverty and malnutrition. We are therefore at one with you that in addition to the initiatives currently underway largely around the sexual behaviour of our people, the challenges of Poverty, Malnutrition and adequate treatment of these common disease are critical to a successful sustainable campaign against AIDS.
Recently, (last week) Our MINMEC accepted guidelines for effective treatment of opportunistic infections throughout the public health system. We have taken this view driven by the need to send a clear unequivocal message viz. Adequate treatment of attendant disease improves the quality of life of those wit HIV infection and AIDS. Once treated they too can live fully productive lives. The simple approach of HIV infection and AIDS = DEATH needs to be removed from the South African psyche. Grave as the problems of AIDS are, none of us should parade as prophets of doom.
Consistent with this approach, I have recently received a report of a WHO team that visited South Africa at the end of last year to review our progress in the management of TB. I have been encouraged by their report. It clearly shows significant improvement in the evolution of our strategies to deal with this scourge and clearly shows our commitment to the adequate treatment of TB irrespective of the HIV status of the individual.
In line with our commitment to work closely with our neighbours and the peoples of our continent - we have identified within SADC HIV/AIDS as a major challenge confronting us collectively. Also we are working together to ensure that the international partnership against AIDS truly addresses the needs of Africa rooted as it should in a perspective that puts Africans themselves at the centre of the elaboration of strategies relevant to their own circumstances.
May I Mr President join you in congratulating the members of the South African National AIDS Council. These eminent sons and daughters of our country have a daunting task ahead of them. But judging by their contributions during the first meeting of SANAC on 1/2/2000 I' m sure they' II be equal to the challenge.
May I reaffirm governments approach that this being a new experience, there is a lot of learning to do. We stand ready to learn from each other so that progressively we improve the work of this body. We are sure that by the end of the two years of life of this body we shall be ready to make recommendations on the further improvement of its successor.
Mr President you highlighted the importance of Human Resource Development. We fully share this view. As a major initiative, our department is currently working on a Human Resource Plan for the health Sector. This is due for completion by the end of June this year.
More important is however the need to confront the challenge of deracialising our workforce at all levels. Needless to say, a lot still needs to be done in this regard. We appeal to all South Africans especially our training institutions to reflect carefully on the challenge you posed on the imperative need to speed up true, honest and wholehearted embrace of the essence of the democratic! non racial, non sexist society we want to build. More specifically the imperative need for us to grasp that the movement forward towards the realisation of this ideal is too strong to be stoppable. Those who try to, can only be the victims of their own naivety and stupidity. Let us not everyday deceive even ourselves about our own individual commitment to this task. Sometimes as we try to cheat others with apparently plausible explanations we do irreparable damage by cheating ourselves. But truth and justice has to prevail and will.