1. INTRODUCTION

   During the 19^th century, the health profiles of most countries of the world were dominated by infectious diseases. Before the outbreak of the HIV/AIDS pandemic, the 20^th century had been known for its "conquest" of many of these diseases and the associated epidemics. Smallpox, polio, measles and syphilis are notable examples. The pattern of disease shifted to chronic problems such as diabetes, hypertension (high blood pressure) and cancers.

   Unfortunately, in almost all countries, both rich and poor, infectious and nutritional disorders continue to afflict mostly the poorest members of society such as the case in South Africa, and especially in Eastern Cape, where unemployment and poverty afflict over half of our people. In addition, the emergence of the HIV/AIDS pandemic and its associated opportunistic infections, particularly TB affects disproportionately the poor. The primary focus of the Department of Health shall be the disadvantaged segment of our population, which is still afflicted by infectious diseases and malnutrition. Some key indicators of the health status in our province are summarized in the accompanying pamphlet.

   Many of the diseases from which people suffer today, including HIV/AIDS, are long-term, chronic and degenerative in nature. Most are incurable (this is a sad statement – many cancers can be cured if managed properly). Health professionals, therefore, must become more concerned with the management of the disease and the psycho- social needs of the patients, rather than simply with the cure. The relationship between patient and a health provider becomes particularly important.

   Today, we recognize that many diseases are caused by a multiplicity of factors, including but not limited to the infectious agents and the complex interrelationships among them. This recognition suggests a multifaceted and intersectoral approach.

   In line with this realization, this department has to gradually affect a paradigm shift towards ‘health maintenance’ rather than ‘disease treatment’. Health promotion, environmental maintenance and community participation are becoming increasingly important.

2. CORE BUSINESS OF THE DEPARTMENT OF HEALTH
   

   The core business of the Department is the delivery of health services. These services are organized at various levels depending on the degree of specialization required. Primary health care constitutes the foundation and is provided by nurses working at clinics and district hospital outpatient departments. District hospitals provide general inpatient care to patients referred from clinics, community health centres and outpatient departments. These are all "level one" services. Any patient requiring a higher-level care is referred to either a regional, provincial or specialized hospital. These hospitals provide "level two" and "level three" care to refer patients. Level three services are only provided by the hospital complexes in Port Elizabeth, East London and Umtata.

   The Head Office here is supported by two distinct levels of management. The provincial level is overseen by the Provincial Health Authority and is responsible for policy evolution, strategy formulation, resource allocation, monitoring and evaluation of service delivery in accordance with the aforementioned policies and strategies. At the district level a District Health Authority oversees the management and execution of primary health care services through the network of clinics in their respective areas.

   1. Primary Health Care

   It is our vision to develop and build a municipality-based District Health System (DHS) within which primary health care (PHC) services will be provided. This is based on our policy framework, the Constitution, the White Paper on Transformation of Health Services and the White Paper on Local Government.

   The Department of Health set the scene in February 2002, when we launched the Provincial Health Authority (PHA). All the District Municipalities and the Metro are urged to establish District Health Authorities (DHA’s) by June 2002 (The Cacadu District Municipality launched its DHA on 4 April 2002). It is our intention to implement the devolution of PHC services in the Eastern Cape in a phased approach, beginning with functional integration by June 2002, when our structures and systems will be integrated with those of the municipalities.

   The devolution of Primary Health Care as commencing now shall be completed by July 2003. The Emergency Medical and Rescue Services are due to be implemented within the next six months to Nelson Mandela Metropolitan Municipality and Cacadu District Municipality. In other District Municipalities the process of devolution will take place in line with their capacities. If on the basis of their evaluation to deliver it is established that the required capacity does not exist, it is the responsibility of the Department of Health to ensure that capacity exists. We hope that by July 2004 the process of devolution would have been completed.

   All the resources (staff, equipment and finance) that are associated with the provision of PHC services will be transferred to the municipalities. Chapter five of the National Health Bill is being reviewed and finalized to empower us to deal with these matters in an organized, well-thought-through and structured way.

   Honourable Speaker, as stated earlier, our people are faced with challenges of communicable and non-communicable diseases as reflected in the booklet on health profile of this province.. It is critical and crucial to realize that the best way of dealing with communicable disease is prevention. (Please see the accompanying copy of the National AIDS Programme.) There shall be a remarkable and noticeable reduction in new HIV/AIDS cases, when condoms and other femidoms preventive measures are adopted to by everyone in our society.

   We are, however, also responsible for the current infected or affected people. The Department shall continue to provide treatment of opportunistic infections (including TB), care and support to increasing numbers of communities. The training of doctors, midwives and counselors is proceeding as rapidly as possible in order to implement the programme to prevent mother-to-child transmission with the use of Nevirapine. Already this year over one hundred of these workers have been trained. This programme will be integrated into our routine antenatal services following the results of the evaluation by the ministerial task team capacity of our facilities’ for implementation, which is currently ongoing.

   Addressing the dual epidemic of TB and HIV/AIDS remains our top priority. Our country has been identified as one of the 22 countries that are most burdened by the TB epidemic. TB is presently the main killer disease in this province. The Belgian Government will be assisting us with technical support for the development and implementation of TB Medium Term Plan. TB is a curable disease and the Direct Observation Treatment Strategy (DOTS) will be intensified with the recruitment of more people. Measures to limit and eradicate the Cholera outbreak in and around the King Sabata Dalindyebo Municipality are in place, the effectiveness of this campaign is underpinned by the intersectoral approach undertaken by the South African Military Health Services, Department of Water Affairs and Forestry and the ECDOH.

   Balanced nutrition is a basic prerequisite for the attainment of people’s full intellectual and physical potential. Evaluations have shown that our delivery approach and systems failed to develop women and poor (as intended in the RDP), but instead favoured the rich over the poor.

   Our new approach will have three main objectives. Firstly it will alleviate temporary hunger in our learners. Secondly it will empower unemployed and poor women to deliver the required services. Lastly it will encourage the development of small, micro and medium enterprises (SMME’s) and local economies.

   It is our firm intention that the school feeding scheme be managed by district municipalities and the NMMM as from 01 October 2002.

   Women’s groups & SMME’s will organize themselves at the district level, and the Department will ensure that they are trained in business skills to manage feeding. The department has developed a detailed plan, including a consultation and communication process, to ensure the smooth and successful devolution of this function by October. Our systems will include controls and vetting to exclude unscrupulous elements.

   We recognize that the Eastern Cape has one of the highest rates of child mortality in South Africa. In the previously disadvantaged regions, the number is much higher due to poor nutrition and lack of immunization.. In the Alfred Nzo and Oliver R. Tambo Municipalities 98 out of every 1000 babies born die before the age of five years mostly from diarrhea, respiratory infections and vaccine preventable diseases. Simple and basic services at the clinic level can easily prevent these deaths. Just the simple act of giving a vitamin A capsule to every child can cut the death rate by a quarter.

   Vitamin A supplementation will be given to mothers at delivery and all children under the age of 2 through integration and strengthening of routine child health services.

   For immunization services, the department is ring-fencing R2m to boost immunization coverage. The plan will kick off with the launch by me of the two-week Mop-up Immunization Campaign in the OR Tambo and Alfred Nzo Districts on 29 April 2002. We urge our youth and other volunteers to participate in this campaign.

   As previously indicated, prevention of disease is better, and more cost effective than treatment. In line with the "year of voluntarism", the Department will embark on monthly health campaigns emphasizing those interventions, which should be undertaken by our people.

   2.2 Hospital Services

   For the first time this year, the Department of Health will benefit from the National Tertiary Services Grant. This grant is intended to fund some of the specialized services which, to date, have been provided by other provinces.

   The Department is developing an integrated ten-year hospital plan within a macro financial and resource envelope. The core principles of this plan will be equity of access and resource allocation, affordability and sustainability of the infrastructure and services. The emphasis will not be on capital planning only, but also on the improvement of our services.

   The initial phase of this ten-year plan is the review of hospital services with the intention of reorganizing and restructuring services to promote equity, cost-efficiency and quality of care.

   Communities and staff are being empowered in the design and delivery of appropriate and improved services that meet the needs of the community. This process will result in the development of business plans to guide the implementation and the execution of rationalization of services.

   The ten-year plan will incorporate a series of projects. The first of these projects will be for Frontier Hospital in Queenstown.

   During the current year the Department will continue with the Council for Health Service Accreditation in Southern Africa (COHSASA) initiative in 19 district hospitals and will initiate the process in the three complexes. This is a quality assurance programme, which is conducted in phases, followed by accreditation of the institution when it meets certain performance standards. To earn and maintain accreditation an institution must undergo an on- site survey by a team of health professionals at least every two to three years. Accredited hospitals will become centres of excellence, which will share lessons learnt with other hospitals.
   

   In addition to the foregoing, the Department is working to extend sophisticated services to remote parts of the Province as a priority. We will be accelerating our current initiatives in telemedicine, including telepathology, teleradiology and teledermatology. These outreach services will be supported by the Health Professionals Training and Development Grant. We have also started the development of videoconferencing in order to reduce travel costs.

   During the past year, the department initiated the Budget and Expenditure Analysis and Review process. This year the process will be extended to be a Performance Review and Expenditure Analysis. All hospital management teams will be expected to review their facilities’ outputs and expenditures each month and to make a presentation to provincial authorities at least once per quarter. These reviews will, among other things, identify weak and strong areas of performance and thereby provide management with information on how to improve the efficacy of service delivery.

   Once more, the department will develop service level agreements with our provincially aided and SANTA hospitals. These agreements will be further strengthened by the identification of services to be provided, thereby enabling a tighter link between service production and utilization of state funds.

   We are honoured to house the national forensic psychiatric services at Fort England Hospital. We will be receiving patients from other provinces. The National Tertiary Services Grant has been increased to fund these services.

   During this new-year, the department will transfer as many of our chronic mentally ill patients to community based organizations, which will be equipped to provide better and less expensive care.

   In addition, a facility will be opened to provide short-term acute psychiatric care in the eastern part of the Province, which currently lacks these services.

   Finally with the introduction of the psychosocial model, we came to realize that we have excess physical capacity as well as advanced technology, which we still require. It has become imperative that Public Private Initiatives (PPIs) should be developed at a number of these institutions. These initiatives will commence at the three complexes. It is expected that a final agreement will be negotiated to improve and extend services at the hospital in Humansdorp and Port Alfred

3. CLINICAL AND NON-CLINICAL SUPPORT SERVICES

In order to provide health services, various support functions must be performed. Financial resources must be made available and rigorously managed.

Health workers need to be adequately remunerated, incentivised and that must be in line with upgrading of skills and intellectual capacity. We are placing an over emphasis on rural incentives for all health workers in rural areas. We have set aside funding for this purpose. Deployment of new health workers first and foremost must take in cognizance, the rural nature of our province. This is in line with the policy of deploying health workers in rural areas. Finally, these health workers require buildings, equipment and supplies in order to produce the quality health services our citizens require and have a right to expect.

3.1 Finance

The Department has adopted a policy of zero tolerance towards incidents of fraud and corruption. We have addressed this issue through two approaches.

First, a firm of consultants was appointed to evaluate internal controls and to develop an internal control manual, which is already being implemented at the first institution, following which it will then be applied in all relevant facilities.

Secondly, the department is investigating all cases, which have arisen as a result of our own inspections, and other information received, either internally or through the appointment of forensic investigators. Disciplinary action will be taken against officials involved. To date, the Department has investigated 28 disciplinary cases and 3 are pending. In this process 12 officials have been dismissed, 9 final written warnings have been issued, 3 officials have been demoted, and 1 official was suspended without pay.

In addition and in keeping with provincial policy, the Department implemented a new financial management system called the basic accounting system (BAS). The Department is training its personnel to read and use the new reports. Implementation of the BAS will assist the Department to more easily comply with the requirements of the Public Management Finance Act.

Also in keeping with provincial policy to recover hospital costs, when patients are able to bear all or part of these costs, the Department will initiate implementation of a new fee structure, the uniform patient fee structure. It is proposed that hospitals be permitted to retain any revenue, which is in excess of their target revenue. Revenue retention will provide a motive for hospital managers to increase the collection funds, which they will use to improve services.

In striving to ensure efficiency the Department contemplates the possibility of utilizing alternative service delivery mechanisms for some non-core functions. In preparation for this a tender to conduct option analysis is currently with the Provincial Tender Board.

The Department will increase spending on health professionals training. The Health Professionals Training and Development Grant have been increased. It will assist us in recruiting and retaining specialists by funding incentives for these scarce services. It will also fund the training of registrars. The Department has obtained a commitment from MESAB to fund (approximately R2million) the completion of training for 52 health professionals, the majority of whom are physicians. In addition, underserved areas will benefit from the extension of the community service policy to other health professions; for example, radiographers, clinical psychologists, etc.

The Department is proceeding with the establishment of a single unified nursing college with a single faculty and administrative structure. The existing nursing schools will constitute campuses of this college.

The Department will continue to use the funds provided through the Skills Development Act to develop the skills of all its employees, from general assistants through to managers. Annual workplace skills development plans are developed and implemented at each facility throughout the province. Priority is being given to adult basic education training (ABET), maintenance skills and HIV/AIDS knowledge and management in the workplace.

In accordance with Treasury guidance, the Department is only 80% complete of the GTRS process and will proceed with the filling of critical posts. It will fill not only posts for health professionals, but also those for the senior managers required to facilitate the implementation of the decentralization policy. In filling posts the Department will proceed toward implementing national policies with respect to women and the disabled.

The Department will, after discussion and negotiation with all relevant stakeholders, adjust, adopt and then implement the recommendations of the Hospital Transformation Project. This process will ensure a more equitable distribution of our human resources throughout our Province.

Health services are dependent upon the availability of pharmaceutical and medical supplies. Approximately 40% of our non-personnel expenditure is for these products and I have ring-fenced R 322 million for these items for 2002/03.

The availability of drugs depends, however, on more than funding. We are in the process of strengthening our comprehensive drug management system. We are looking at alternative choices for the management of the medical depots and the distribution of drugs to the hospitals and clinics..

In line with the Department’s policy of ensuring equitable access to health services, capital investment will continue to favour the eastern and northern health districts. Approximately R 60 million will be spent to commission the Nelson Mandela Academic Hospital in Umtata. In addition, the Department will spend approximately R 81 million on the renovation of other hospitals, and will increase expenditure for clinics and hospital maintenance. Dora Nginza Hospital will be commissioned in the next financial year.

To facilitate effectiveness and efficiency the Management of the Department is prioritizing IT infrastructure (computers, software and associated cabling). These investments will assist the Department to comply with the PFMA and will support its decentralization policy.

This year, we will be implementing the National Health Laboratory Services Policy, which entails the nationalization of all laboratory services. Our province will no longer produce laboratory services, but will rather purchase these services from the National Health Laboratory Service, as semi-autonomous institution at national level.

Also this year the Department of Health will be assuming responsibility for medico-legal services, formerly being the responsibility of the Department of Correctional Services. It is assumed that the funds will follow the function.

Honourable Members and colleagues of the Executive Council, I have attempted to describe the work of the Department for you. I would like to briefly summarize our top priorities for 2002/03.

• We will work to ensure the availability of essential drugs at our clinics and hospitals.
• We will implement the strategy to devolve the Primary School Nutrition Programme to district municipalities and the Nelson Mandela Metropolitan Municipality.
• We will accelerate the devolution of PHC services to our communities.
• We will conduct forensic audits of our SANTA hospitals in accordance with the MINMEC resolution of February 2002.
• We will accelerate the rehabilitation, refurbishing and management of our hospitals.

In fulfilling this work the Department requires human and financial resources. At the present time, the Department notes that it must begin the process of replacing professional personnel who have left the service in recent years. (During the past 5 years the Department has lost approximately 7000 professional and non-professional staff.)

Similarly, for the past several years, the Department of Health has received substantial additional funding through the adjustments budget at the end of the year. The Department appreciates these funds, but notes that the same needs will prevail this year. The services required of the Department are continually increasing, in part, because we are attempting to extend services into parts of the Province that have been under-served in the past, but primarily because of the increasing demands resulting from the HIV/AIDS and TB epidemics. In fact we anticipate serious financial difficulties because of (1) the reduction in our global allocation, (2) price increases with which the Honourable Members are no doubt familiar, and (3) the substantial ring fencing of funds for drugs, which I mentioned earlier. The remaining allocations for provisions and other supplies, particularly food for hospitalized patients, as well as for professional and special services, are of particular concern. The expenditure of these allocations will be monitored closely by the Department during the coming months and developments reported to the Department of Finance and the Standing Committee for Health.

Before closing, I would like to extend our gratitude to our donors who have, in a variety of ways, assisted us to attain our goals. The Nelson Mandela Foundation has contributed several clinic buildings. Luxemburg has assisted with renovation and construction at Butterworth Hospital. The United Kingdom, the European Union and Belgium have assisted with capacity building for hospitals, most notably at St. Elizabeth’s Hospital in Lusikisiki. The European Union is also funding support for district development. Meanwhile the United States funds the Equity Project, which has helped strengthen our primary health care services, basic hospital services and management systems at all levels throughout the Province.

Finally, I would like to mention the photograph on the cover of my speech. The Department has launched an innovative programme in Port St Johns. One of our dedicated health workers collects TB sputum samples from remote communities and clinics and delivers to health center by motorcycle. Once the tests have been completed, the results are returned to the clinics via short message systems on special cell-phones. The programme has reduced the average turn around time from several weeks to approximately 48 hours for these tests. This programme was recently selected as the winner of the 2002 Impumelelo silver medal. Impumelelo is a national competition, which recognizes the most innovative programmes serving rural people in South Africa. The silver medal was accompanied by an R 20 000 grant for the continuation of our work. The photograph is that of our nationally recognized, motorcycle-wielding health worker.