Together we can kick TB out of Khayelitsha – an important story about the potential of collaborative governance
OPINION: The response to the announced increase in spending on health (from R84bn to R102bn approximately a 25% increase) by Pravin Gordhan has received mixed responses, from praise to queries regarding whether the budget brings us closer to the proposed National Health Insurance. By Bernhard Gaede
The response has been similar to previous years with vague but general consensus that spending in health needs to increase. There has been little debate, though, what an adequate increase should be to adequately address the some fundamental issues in the current collapsing health care system.
The reality on the ground is that most of the provincial departments of health have massive budget deficits (many of a R2-3bn!) over many years. With massive vacancy rates particularly in rural areas (in some instances 80% of available posts on the establishment of some categories of professional staff) it seems that the scale of over-expenditure is more due to inadequate budgeting than inefficiency, incompetence and or at times corruption. In order to cope with staying within the budget, provincial departments of health have introduced measures over the years, such as freezing posts or centralising appointment processes (leading to inefficient micromanagement of local needs by the Head of Department or the MEC) (in KZN, Limpopo, Mpumalanga, NorthWest Province). Other provinces have run into other troubles, such as medicine stock outs (as in the Freestate and the Eastern Cape) defaulting on paying for services (Gauteng, Mpumalanga and Limpopo) etc. Many of these situati! ons have not been due to wasteful expenditure or corruption, but budgets running out at times as soon as half way through the financial year.
In this light how do we assess the adequacy of the budget? Is the budget adequate to deal with the over-expenditure of the provinces? As long as there is a deficit, the posts will continue to remain vacant and medicines will continue to run out and the current status quo of inequitable allocation will continue. In the same vein, does the current budgetary allocation adequately take inflation in health care into consideration (which is considerably higher than consumer inflation)? And does the budget cover the expansion of services, not only ARVs but issues such as that a greater percentage of the population is dependent on the public sector for their health care? Just answering these 3 question, it may well seem that the current budget merely maintains the status quo of a dysfunctional health care system.
More fundamental issues are maintaining the poor state and the profound inequities that characterize the health care system.3 inequities have been identified that characterize the health care sector the inequity between private health and public health, between tertiary care and primary / community care and between urban and rural health care. In order to be able to assess whether the budget meets the promises made by politicians and the rights enshrined in the constitution in an equitable manner and addresses these 3 inequities mentioned – the budgeting process needs to focus at a minimum on the following:
1) Norms and standards of care National norms and standards for different levels of care, specifically at PHC clinic, Community Health Centres and District Hospitals, have been available for many years but have not been costed or implemented. The norms and standards have not been used to drive service delivery development in a consistent manner, mostly due to the perpetual crisis the health care system has been in, and thus there is considerable variation of service delivery between provinces, but at times even within a single district.
2) Human resource norms The HR norms are central in the 2004 Strategic Human Resource Plan and the development of the norms was to be fast-tracked. However, to date little work has been done on this and the historic inequities of staffing differences have been maintained.
3) Implementation of programmatic interventions Many programs have remained unfunded meaning that already overstretched services need to stretch a bit further to meet the often politically motivated promises of what the population can expect from the health care system. Furthermore, programs that do not have a high profile such as mental health, eye care or disability fall off the table and often the most vulnerable in the health care system receive the worst care.
Not taking the above issues into account implies that the current budget is a thumb-suck, and maintains historic inequities. Incidentally, all of the issues mentioned above need to be in place before any serious discussion regarding the NHI can take place.
Meanwhile, working in a rural hospital, desperately trying to recruit staff and ensuring that the local systems and processes are functioning, is bleak business: the larger system is crumbling and not able to support the work that is being done on the ground. There is no budget to appoint anyone. There are hospitals where the doctors are only able to do a ward round every 3 days, due to the work load they face. There are wards that run without a professional nurse, many hospitals are without pharmacists.
The turn-around strategy mentioned by Dr Motswaldi needs to urgently address the issues mentioned above. However, it also needs to take care of the current crisis on the ground. In order to move forward immediate administrative measures need to put in place to be able to fill posts and the budget needs to be available to do so. The current budget by Gordhan does not seem to be able to do either of these.
This article first appeared in The Business Day on 5 March 2010.
News article from the Health-e web site
Health-e news reported on the success of the mothers2mothers (m2m) programme, which started in Cape Town in 2001 and is rapidly expanding across Africa, calling it simple in its design and methodology, yet massive in its impact. m2m has ballooned
to 588 sites in seven countries, employing over 1 500 women living with HIV who have in turn enrolled over 300 000 pregnant women onto the m2m programme. Mothers2mothers offers an effective, sustainable model of care that provides education and support for pregnant women and new mothers living with HIV and AIDS. “We take mothers who are living with HIV and have been through the prevention of mother to child transmission programme, we employ, train and educate them to in turn offer education and support for the mothers living with HIV and who come into contact with the health system,” said founder Dr Mitch Besser, who believes that programmes such as m2m could change the world’s perceptions of women in Africa. “Women are an extraordinary resource and they are undervalued,” he said. The programme has expanded from South Africa to Kenya, Rwanda, Zambia, Malawi, Lesotho and Swaziland and in 2010 will add Uganda, Tanzania, Namibia and Mozambique.
If Mothers2mothers is in your area, visit people involved and do a feature on how it works and the impact it has had on the community. If no one has heard of it, find out how HIV programmes in anteclinics in your area are faring. Is the positive
energy this programme seems to foster evident there and if so, is role modeling such as this happening?
If not, if health care workers in your community seem exhausted with their workload, find out if they have tried to introduce this programme or something similar. Use your media outlet to make people in your community aware of m2m’s expansion in Africa, how it works and who to contact if they would like to use it.
What other positive role-modelling programmes are operating in your community? Ghana has a Models of Hope project, see
Models of Hope, if there’s similar work being done in your area, find an interesting, topical angle to report on their work.
IRIN/PlusNews did a feature where they interviewed young Mozambicans with
disabilities about what they know about HIV and AIDS and found that most of their
information came from their own observations. HIV prevention campaigns have ignored
the fact that young disabled people are also at risk of infection – a 2007 study
involving people between 11 and 23 years of age with and without disabilities found
that just 10 percent of the disabled respondents knew the difference between the
virus (HIV) and the disease (AIDS), and only four percent knew the symptoms of AIDS.
The Mozambican Association of Youths With Disabilities (AJUDEMO) has been working
with various partners to include people living with disabilities in AIDS initiatives
and turn them into activists. “The activists are trained and given the task of
identifying other handicapped people in their neighbourhoods, and planning
interventions based on their individual needs and capacities,” said AJUDEMO
president, Sergio Reis. Conversations with the intellectually handicapped are kept simple and direct,
sign language interpreters design programmes for the deaf, and the blind are taught
how to handle condoms. The activists also help disabled people overcome structural
barriers at medical centres so that they can access HIV counselling, testing and
How well-equipped are people with disabilities in your community to avoid getting
infected with HIV and to access treatment and other help if they are?
Find out if there is an organisation doing similar work to AJUDEMO – including
people with disabilities in AIDS initiatives, keeping conversations with
intellectually disabled people simple and direct, using sign language interpreters,
Ask people living with disabilities how they would like to be involved in AIDS
initiatives and learning more about HIV. What barriers are there to their inclusion
and how can these be set aside?
In Zimbabwe, where aid agencies estimate 120 000 children are HIV-positive, school
teachers are finding themselves increasingly in the frontline of the epidemic. In a
recent report, IPS interviewed a grandmother who said her grandchild’s teacher
“believes she is wasting time by coming to school when it is obvious she will die
before she completes her studies”. The United Nations Educational, Scientific and
Cultural Organisation (UNESCO) Harare Cluster office has partnered with the ministry
of higher and tertiary education to develop an HIV/AIDS manual for teachers, which
was incorporated into the curriculum at teacher’s training colleges at the start of
the 2010 academic year. The manual will also be distributed to teachers who are
already practicing. Special courses and workshops will also be held for those
teachers already practicing. Noting that the manual could provide the link that has
been missing between parents or guardians and teachers of children living with HIV,
an analyst said the impact teachers have on their students can make a big difference
in the wider community.
How are teachers in your area kept up to date with HIV/AIDS issues? Talk to teachers
and principals to get a sense of how they see their role in the fight against
HIV/AIDS. Also speak to learners who are HIV-positive and their parents or carers,
asking them if and how they are supported (obviously protecting their privacy if
necessary). Do they think a local manual, such as the Harare UNESCO manual, would be
helpful? Are there any plans to develop one?
More than two-thirds of African countries have laws criminalising homosexual acts and, despite accounting for a significant percentage of new infections in many countries, men who have sex with men tend to be left out of the HIV response, IRIN/PlusNews reports. "[They] are going underground; they are hiding themselves and continuing to fuel the epidemic," UNAIDS executive director Michel Sidibe told IRIN/PlusNews. The news agency compiled a list of rights violations against gay Africans, including cases from Uganda, Tanzania, Malawi and South Africa. http://www.irinnews.org/report.aspx?ReportID=87793 Story ideas: In your country / area, who is working to ensure that gay men and women have the right of access to information about HIV and AIDS as well as care and prevention? Ask them about the difficulties they face in advocating for this vulnerable sector of society. If men who have sex with men are completely left out of the HIV response in your country, find out what the situation is in neighbouring countries and if there are any community initiatives there that could provide valuable lessons.
IPS ran a story quoting experts who said that HIV-related stigma and discrimination remain a key concern in southern Africa, despite many HIV-awareness campaigns launched by government and civil society organisations. A woman from a small village on South Africa's West Coast told the reporter that her life has been lonely and difficult since her community found out about her HIV-positive status. She is not well enough to work and has tried to apply for a disability grant but, being semi-literate, has been struggling to fill out the forms. Recently published research by the Centre for Social Science Research (CSSR) at the University of Cape Town confirms that stigma continues to inhibit people from accessing HIV counselling and testing services, including programmes to prevent mother-to-child-transmission, HIV treatment and care. CSSR researcher Brendan Maughan-Brown, who surveyed 1,074 young Capetonians in 2003 and 2006, found that stigma has increased despite public sector c ampaigns and improved treatment and care services. http://ipsnews.net/news.asp?idnews=49904 Story ideas: If stigma is increasing then HIV-awareness campaigns are not doing their job. Ask people who are infected or affected by HIV in the communities you cover if they think this is the case - do they feel there is more stigma and discrimination, less or much the same in the past five years? What do they think of the awareness campaigns they are exposed to? Have they been involved in any / would they like to be / how do they think campaigns could reduce stigma? See if your newspaper / radio station could work with local government structures and involve the community in an HIV-awareness campaign that brings people together.