National Department Of Health Negotiated Service Delivery Agreement

1. Introduction
In the course of 2010, Government adopted an outcome-based approach to service delivery and performance management, and adopted 12 key outcomes to be achieved during this term of office.
The health sector is leading and harnessing the efforts to achieve Outcome 2: “A long and healthy life for all South Africans”.
Four key outputs must be produced namely:

• increasing life expectancy;
• reducing maternal and child mortality rates
• combating HIV and AIDS and Tuberculosis
• strengthening the effectiveness of the health system

Specific interventions of the health sector to achieve these outputs are elaborated in detail in the Negotiated Service Delivery Agreement (NSDA) 2010-2014. This report presents an update of progress made and challenges encountered.
2. Background
Government’s four outputs are premised on the fact that South Africa faces a quadruple burden of diseases consisting of:

• HIV and AIDS and tuberculosis (TB)
• high maternal and child mortality;
• non-communicable diseasesand;
• violence and injuries.

The four outputs outlined in the NSDA 2010-2014 have been considered an integrated response to the quadruple burden of diseases. Interventions to tackle this burden of disease dovetail with efforts to accelerate progress towards the health related Millennium Development Goals (MDGs).
A need exists to also address social determinants of ill-health, which lie outside the health sector, such as poverty; lack of potable water; lack of proper sanitation and child neglect.
 
3. Combating HIV AND AIDS
We won’t tire reminding South Africans that our country constitute only 0,7% of the World population but we carry 17% of HIV positive people of the world.
On World AIDS Day two years ago, on 1 December 2009, the President of South Africa announced new policies and interventions to strengthen efforts to combat HIV and AIDS. These included the provisions that: Antiretroviral Therapy (ART) would be provided to all pregnant women at a CD-4 count of 350 or less to enhance maternal survival; ART would also be provided to TB-HIV co-infected patients at a CD-4 count of 350 or less; all children less one year of age would be placed on treatment irrespective of CD-4 count and that pregnant women who do not qualify for full HAART would receive dual therapy for PMTCT from 14 weeks of pregnancy, until post delivery.
In April 2010, the President launched the HIV Counseling and Testing (HCT) campaign, which has as its primary objective to encourage 15 million South Africans to undergo testing, not only for HIV, but also for tuberculosis and non-communicable diseases such as hypertension and diabetes. The essence of this campaign is to move away from waiting for people to come for testing, but rather to take testing to the people.
3.1 HIV prevention
While the President launched the HCT Campaign, it is by all means not the only prevention intervention we have adopted. There are eight others which we are implementing simultaneously.
These are:

• Widespread Condom Distribution, whereby we are even increasing distribution of female condoms six-fold.
• Male medical circumcision
• Early treatment of Sexually Transmitted Infections (STIs).
• Post-exposure prophylaxis (PEP) for survivors of sexual assault, whereby loop management has been introduced to treat sexual assault without having to ask for them.
• Safe blood transfusion, which we believe we have won.
• Prevention-of-Mother-to-Child-Transmission (PMTCT).
• Promoting behavior change through Information, Education and Communication (IEC).
• Imparting of skills to be able to cope with the disease.

 
The HCT Campaign
Through the HIV Counseling and Testing (HCT) campaign launched in April 2010, government succeeded in reaching 6,208,157 South Africans by December 2010, who were counseled for HIV.
A total of six million people were tested for HIV, and around one million tested positive. This constitute 18% prevalence rate. It is consistent with the issues we already know. Without this campaign, six million people would not have known their HIV status.
HCT campaign will be accelerated and extended to all sectors of society in 2011. It will be extended to universities as we did yesterday, to schools as are planning to do, to farms, villages, major factories and industries like the mining etc.
Male medical circumcision
Male medical circumcision is one of effective interventions to combat the spread of HIV. In 2010, all nine provinces vigorously promoted and conducted male medical circumcision, with KwaZulu-Natal taking the lead, under the stewardship of the King himself. Since the launch in April last year, they have conducted 17 000 circumcisions.
The beautiful thing about this circumcision campaign is that a lot of counseling of the young men takes place there, with traditional advice imparted to the young people together with technical aspect of HIV and AIDS on male and female sexuality.
Condom distribution
The Department of Health is aggressively increasing access to condoms for all South Africans. By the end of December 2010, a total of 403, 839,400 male condoms and 4,367,185 female condoms had been distributed.This serves as protection against HIV infection, STIs, and unwanted pregnancies.
Management of STIs
All health facilities in South Africa are implementing the syndromic management of STI. Partner notification and partner treatment are encouraged. All people who present with STIs are requested to bring their partners for treatment.
Post-exposure prophylaxis (PEP) for survivors of sexual assault
PEP is being provided in heath facilities across the country. Survivors of sexual assault are now encouraged to seek health care first. Health institutions are encouraged to help them first without insisting on police case files first before treatment.
Safe blood transfusion
Of all the prevention HIV prevention strategies, the issue of safe blood transfusion is something South Africa has won with flying colours. It will be one in a million for any South African to get HIV from our South African transfusion services.
Prevention-of-Mother-to-Child-Transmission (PMTCT)
If we are to dramatically reverse the 70 000 children who are born HIV positive each year, it will be imperative for every single pregnant woman to know their status and if positive, to start PMTCT of 14 weeks as announce in 2009 at the World AIDS Day by the President.
3.2 Increasing Access to ART
Access to ART has also increased, with a total of 1,3 million people being on treatment by the end of December 2010. This was made possible, amongst other, by the health sector’s decision to train and authorise professional nurses to initiate ART. The number of nurses trained in the Nurse Initiated and Managed ART (NIMART) programme increased from 290 at the beginning of 2010 to 2 000 by the end of the same year. In the same period, the number of health institutions who are able to provide ART increased from 490 to 1 500.
In 2011, the National DoH awarded a tender for the supply of Antiretroviral medicines to the value of R4,2 billion over two year. This has resulted in savings of R4,7 billion (53%),which will enable the health sector to place more people on ART. Access to Antiretroviral treatment will be expanded by half a million people each financial year for the MTEF period.
 
3. Combating tuberculosis (TB)
There are 22 countries in the World which are regarded as high burden countries for TB. They carry between them 80% of the TB of the World. In terms of infection per unit population, South Africa is number one in the World.
Our TB-HIV co-infection rate is also the highest in the World at 73%. A total of 80% of all HIV infected people in South Africa are killed by TB.
For these reasons, our fight against TB needs to be intensified more than ever before.
Just like the President did with HIV and AIDS on World AIDS Day on 1 December 2009, we are intending to unveil our concerted strategies to combat TB on World AIDS Day on 24 March this year.
 
4. Reducing maternal mortality rates and child mortality rates
South Africa’s maternal mortality rates and child mortality rates are unacceptably high.
Diverse interventions have been implemented to improve the health of South African women, mothers and children. Interventions to protect South African children against vaccine preventable diseases are reflecting the desired results. Of the 15 million children aged between 6 to 59 months targeted for measles immunisation, we have covered 98% of them. Of the group between 60-179 months, we have covered 89%. For polio, we have covered 101% of the children targeted, which was five million.
A system of perinatal reviews was set up to monitor and evaluate causes of perinatal deaths and illness at 92% of maternity facilities country wide.
42% of new mothers and babies were reviewed within six days postnatally (after discharge from health facilities).
 
5. Strengthening the effectiveness of the health system
5.1 Revitalising Primary Health Care
The health system will be reinvigorated in 2011 based on the Primary Health Care (PHC) approach. Primary Health Care is defined as ‘essential health care, based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development’.
The newly developed model places greater emphasis on the family, rather than the individual; focuses promotion and prevention, rehabilitative and referral services, rather than exclusively on curative services; avoids fragmentation that results in multiple health care providers visiting families, and ensures that a single integrated team establishes relations with families in the catchment area; and accentuates strong community participation as well as multi-sectoral collaboration.
During 2011, we will see the deployment of PHC outreach teams, consisting of Professional Nurses; Enrolled Nurses and Community Health Workers in different wards across the country. The focus will be on health promotion, disease prevention and referral for curative care, to improve health outcomes. Details of this massive primary health care approach will be outlined during the course of the year.
PHC Teams will be supported by technical teams consisting of medical specialists, with expertise in maternal and child health.This will significantly contribute to enhancing health outcomes in our country.
 
6. Introducing national health insurance
Introduction of NHI is part of the 10 Point Plan of the Health Sector for 2009-2014.
A solid foundation for the introduction of Insurance (NHI) has been laid. The Inter-Ministerial Committee (IMC) on the NHI has approved the proposed NHI policy. A policy document, the White Paper on NHI, will be published for public comment.