The African National Congress (ANC) came out in defence of embattled Minister of Health Manto Tshabalala-Msimang this week, reiterating its confidence in her ability to ”implement the policies of the ANC-led government in working to achieve better health for all”.
Tshabalala-Msimang was appointed to her Cabinet post in June 1999. In the past eight years the track record of the department of health has not been encouraging, with poor financial management accompanied by failure on healthcare delivery.
Financial management
Derek Luyt of the Public Service Accountability Monitor (PSAM) says an examination of the Auditor General’s and provincial annual reports would provide ample evidence for President Thabo Mbeki to remove the health minister on the grounds of performance failure.
For the past three years, the Auditor General has issued qualified audit opinions for the national Department of Health, indicating that there are financial management problems. One analyst describes financial management problems in the department as ”very severe” and says it is difficult even to find a publicly available routine expenditure review.
For the 2005/06 financial year, the Auditor General described internal audit function at the department as ”ineffective”, with most planned audits being postponed to the next financial year. The audit committee was not operational and held only one meeting — at which there was no quorum. This was a repeat of the committee’s performance in the previous financial year. So, for two years the department has been unable to set up something as fundamental as an audit committee. In 2005/06, only 8% of cases reported to the fraud hotline were investigated.
The national Department of Health gives about 90% of its budget to the provinces, but is required to oversee the provincial departments. The latest Auditor General’s report gives a list of failures in this regard, including missing monthly and quarterly reports and failure to visit the provinces on a quarterly basis.
Qualified audit opinions indicate failure to monitor expenditure. One of the results can be overspending, or underspending and a compensatory spending spree at the end of the financial year as departments try to avoid having unspent money reclaimed by the national Treasury.
More troubling are audit disclaimers, which effectively indicate a financial black hole with an insufficient paper trail for the Auditor General to follow. The Eastern Cape, which some analysts regard as the most inept provincial health department in the country, has received audit disclaimers in nine out of the past 10 years for amounts totalling about R25-billion in state expenditure. (Information based on research from PSAM.)
Antiretroviral programme
Despite South Africa having the world’s largest antiretroviral (ARV) programme, it has been calculated that only about 44% of people in need of ARVs are receiving them. Professor Nicoli Nattrass of the University of Cape Town estimates that of the 889Â 293 people who needed ARVs this year, 351Â 479 were receiving them through all public, private and NGO facilities.
The slow expansion of the ARV programme has been attributed to lack of political will, lack of human and infrastructural resources and uncertainty caused by public statements about the respective dangers and merits of ARVs and traditional and complementary medicines.
Nattrass says government prevention and treatment programmes have probably saved about 369Â 000 lives. However, if the national government had rolled out its programmes at the same speed as the Western Cape, another 343Â 000 deaths and 171Â 000 new HIV infections would have been averted.
Researchers are calling increasingly for nurses to be allowed to monitor patients on routine ARV treatment to relieve the pressure on doctors and to allow patients more flexible access to the programme. There is a growing demand for government to amend guidelines to recommend the use of tenofovir, an anti-HIV drug that is safer and has a better barrier to drug resistance. Medical personnel are growing frustrated at the lack of progress on this issue and at slow negotiations to bring down the costs of the drug.
Prevention of mother-to-child transmission of HIV
About 80% of relevant healthcare facilities offer prevention of mother-to-child transmission (PMTCT) programmes to pregnant women. Yet the take-up rate is estimated to be less than 30%, something researchers attribute to patient fears and ignorance and failure by the health system.
Another deficiency is that most of the country offers a single-drug form of PMTCT, where mother and child are both given nevirapine. The minimum required intervention suggested by the World Health Organisation is a two-drug regime, which is better at protecting the child and preventing drug resistance. The Western Cape has successfully managed to provide this programme to its pregnant women.
Recently the Treatment Action Campaign threatened to take the health minister to court over her department’s failure to implement the WHO guidelines. The TAC says at least two provinces, in addition to the Western Cape, are capable of providing the better programme, but that both are reluctant to do so without the minister’s approval. Aids-related complications are the biggest killers of pregnant women and the maternal death rate almost doubled between 1997 and 2004.
Tuberculosis
The TB crisis became highly public with the identification of cases of extensively drug-resistant TB (XDR-TB), which results from failed treatment of drug-susceptible TB infection.
Health experts say the arrival of XDR-TB highlights ongoing failures in TB treatment and prevention in South Africa, which has one of the highest TB rates in the world. In 2004, TB cure rates ranged from about 70% in the Western Cape to less than 50% in Mpumalanga. TB is the single-biggest killer of HIV-positive people.
In some of South Africa’s known drug-resistant TB outbreaks the bacillus appears to have been transmitted within the healthcare facilities, indicating a failure of infection control. This week has seen reports of patients with drug-resistant TB being kept in general wards without special precautions — a situation likely to lead to infection of other patients, visitors and healthcare workers.
Infant and child mortality
A report recently released by the Medicines Control Council has highlighted the number of preventable deaths among newborns. The report, by the Perinatal Problem Identification Programme, found that about one in five of the 23Â 000 annual infant deaths could be prevented.
Among the factors it listed were lack of access to antenatal care for pregnant women, lack of education of parents and healthcare workers, failures of healthcare workers and the lack of trained personnel and facilities. South Africa’s infant mortality has stayed almost unchanged in the past seven years. Four out of five deaths among children under the age of five are attributable to HIV-related factors.
Human resources
Capacity within the Health Department is at crisis point. By the end of March this year, one-third of skilled healthcare vacancies were unfilled, up from 27,2% in 2005. Retention and recruitment of staff is a growing problem as healthcare workers head for the private sector or overseas. Changes next year to the training of doctors will result in a year-long shortage of up to 1Â 000 community service doctors, who are often the mainstay of rural health facilities.
In a submission to the Human Rights Commission this year, the Aids Law Project says the number of nurses has dropped from 120 per 100Â 000 public sector users in 2000 to 109 in 2005.
The Auditor General has blamed lack of capacity in the department for some of the failings in financial management.