governance, citizens and HIV/AIDS
news diaries from Sub-Saharan AfricaArchive for South Africa
What does the health budget mean? A view from the coal-face
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
Mentor mothers
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.
http://www.health-e.org.za/news/easy_print.php?uid=20032596
Story ideas:
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.
Excluded from HIV Response
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.
Stigma and Discrimination – no sign of diminishing
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.
Condom message misinterpreted
The number of women presenting with unplanned pregnancies who have switched from pills or injections to condoms in response to messages promoting condoms for HIV prevention is very worrying, Dr Margaret Moss, who heads the Contraceptive and Sexual Health Services at Groote Schuur Hospital in Cape Town, South Africa, writes in the October edition of Continuing Medical Education. “Some HIV-infected women said lay counsellors actively discouraged use of other contraceptives,” she says.
“Whether this is the true counselling message, or merely the client’s interpretation, is open to question. Whatever the case, it is an extremely worrying situation.” Advice should be to use “highly effective contraception, of the client’s choice, to prevent pregnancy, in addition to correct and consistent use of male or female condoms to protect against STI/HIV infection or reinfection,” she says.
Story ideas:
See if you can find out whether this counselling – or misinterpretation – problem in Cape Town exists in your area too. You could get accurate facts from medical authorities, making sure they are in language easy understood by the layperson, and use them in a sidebar to a story about HIV.
Prevalence still far too high
The latest HIV/AIDS statistics for South Africa show that prevalence is still far too high – 40% among women in their 30s, , with Health Minister Dr Aaron Motsoaledi saying that national prevention campaigns are not making a significant impact.
These new figures show that prevention strategies are not protecting young women – new infections among teens rose from 13% in 2007 to 14% in 2008.
Professor Helen Rees, director of the Wits RHRU Unit, called for new prevention strategies at an HIV Clinicians RHRU is currently conducting research on keeping teenage girls in school since three studies have shown that keeping adolescents in school protects them against HIV. Rees also suggested integrated male circumcision programmes as a prevention strategy for boys.
http://blogs.timeslive.co.za/hiv/2009/10/06/40-hiv-among-pregnant-women-too-high/
Story ideas:
What efforts are being made to stop girls having to leave school early in your area? Interview teachers, principals, parents and adolescents to gage awareness of the potential harm of teens not being in school.
If you’re not in South Africa, does your country have similar alarming figures for young women’s infection rate? If not, try to find out what your country is doing right where South Africa is failing. Look into the situation at schools – ask girls how they see their futures and the importance of finishing school to realising their hopes.
Relaunching AIDS Charter
After South Africa’s AIDS Consortium conducted research among citizens and found the results “disturbing”, it decided to lead the re-launch of the AIDS Charter, which was first launched 17 years ago. The AIDS Charter is aimed at legally protecting the rights of people living with HIV and AIDS and to ensure that they are not discriminated against. Health-e reports that Denise Hunt, executive director of the consortium, a support structure for a network of AIDS support organisations in South Africa, said: “It would appear that young people in particular still see HIV as a condition that is worthy of blame. A lot of fault-finding and a lot of blame was actually raised. In fact I would say, most of the people that we chatted to spoke about ‘whether a person has rights would probably be dependent upon the source of their infection’. In other words, if it was rape or if a child was born with HIV, then, yes, perhaps they qualified or were eligible for treatment and for access to various services. However, there was a quite strong view that if the HIV was contracted through unprotected sex, which, of course, it primarily is in our country, then there was an element of blame involved and perhaps that would then limit the person’s rights. Now, on the backburner of the fact that most HIV-positive South Africans don’t know their status that really shows that there is a lot of work to be done”.
http://www.health-e.org.za/news/easy_print.php?uid=20032451
Story ideas
You could do your own research of citizen’s views in your area and report the findings. If you’re in South Africa you could investigate how aware citizens are of the AIDS Charter. If you find that few people know what it’s about, you could run an awareness campaign in your newspaper or radio station, featuring the charter’s clauses and inviting views on their implications and how best they can be implemented.
If you’re in another country, you could do the same with a similar local charter, and if there isn’t one, ask people if they think a charter is needed and what they hope it would achieve.
The Difficulty of Being Objective
This is an extract from an interview with award-winning author Jonny Steinberg about his book on HIV/AIDS, based in Lusikisiki:
Were there times you found it difficult to be objective?
“Almost all the time. The book is full of my subjective responses to things, particularly my responses to dying people. I saw a very ugly side of myself. When I met a person at death’s door, a visceral feeling of victory came over me: I am alive, soon you won’t be; I no longer have time for you. I suspect that this subjective response taught me more about AIDS than anything else.”
http://www.thetimes.co.za/PrintEdition/Lifestyle/Article.aspx?id=1030605
Story ideas:
Almost all print media and radio features that deal with stigma and discrimination surrounding HIV/AIDS either focus on those who have suffered through it or on people and institutions “unlike us” who discriminate against others and stigmatise them.
If you are HIV-negative or don’t know your status, perhaps use Steinberg’s brutally honest admission as a starting point in examining your own reactions to those infected with HIV. You could write a column that reveals your initial feelings, what they were influenced by, and how they have developed over time. If you are HIV-positive, you could write an honest reflection on your feelings and fears before and after diagnosis. You could invite others to join in the reflection in the hope that progress to true acceptance of each other starts with honesty. Just be careful not to allow bigots to use the space as a platform for their hatred.
HIV Prevalence in SA
In South Africa, a survey by the Human Sciences Research Council (HSRC) has revealed that the country’s HIV/AIDS epidemic has stabilised and there are signs of a declining prevalence among children and teenagers. According to the National HIV Prevalence, Incidence and Communication Survey, conducted in 2008, the HIV prevalence has levelled off at 10.9 percent for people aged two and older.
The study also showed that South Africa has seen a decline in new HIV infections among teenagers aged between 15 and 19 as well as a lowered prevalence of 10.9 percent among children aged between 2 and 14, from 5.6 percent in 2002 to 2.5 percent in 2008. http://www.buanews.gov.za/rss/09/09061012051001
Story ideas:
Could this survey’s results be attributed to the success of prevention programmes? Ask people who work in the field for their interpretations.
If you are in another country, you could seek out data on prevalence among children and teenagers at home and talk to people about which programmes seem to be working well and which could be improved / change focus. If prevalence among different age groups is not being noted, find out why (researchers in this study said it was useful to find out which age groups HIV/AIDS programmes are reaching).
Encouraging people to test
More South Africans are testing to find out their HIV status according to the 2008 National HIV prevalence survey, Health-e reports. But more creative ways to test for HIV are needed to encourage even more people to test, says the Southern African HIV/AIDS Clinicians’ Society President, Dr Francois Venter. One of the biggest failures of HIV testing in South Africa “is the fact that we test people when they are sick”, Dr Venter said, adding that: “I think that we need to do some harsh self-reflection in the HIV-testing world to say, ‘how can we provide care that is suitable to the people, that respects human rights wherever we can, respects privacy wherever we can, that, at least, expands the debate to make sure that the testing is actually valuable to the country, to the programmes that are engaged and to the people that are accessing them’?”.
http://www.health-e.org.za/news/article.php?uid=20032352
Story ideas:
Testing people for HIV only when they are sick is noted here as a major failure. Is that the case in your country? Look for local places where wellness is the focus, such as the much-lauded Anglo American model, and ask how their testing works and how they get people motivated to test when they feel well. Interview staff in HIV/AIDS programmes as well as citizens on creative ways to get more people to test.
Stigma would seem to be the biggest barrier to testing, but what are others? What are people’s experiences of stigma – being seen to be tested – and do people think that leaders being tested publicly would help change attitudes to testing?
governance, citizens and HIV/AIDS 