By Theo Smart
Blunt acknowledgement of South Africa’s past failure to confront its TB and HIV epidemics was served up by several of the key speakers — including the country’s current Minister of Health, Dr Aaron Motsoaledi — at the 2nd South African TB Conference held last week in Durban.
But as the country embarks on what could be the world’s largest HIV testing — and TB screening — campaign, many presenters called for moving beyond South Africa’s endless debates about what’s gone wrong and who is responsible, to mobilisation and delivery of integrated services that are more convenient for the patient and more efficient for the health system.
“The size of the TB and HIV burden is too great for any one role player to tackle alone,” said conference chair Professor Harry Hausler at the conference opening. “But we also need to integrate TB and HIV services so that patients receive both TB and HIV care from the same health worker at facility level and the same care worker at community level. As the Minister of Health said on World AIDS Day, 2009, TB and HIV should be treated under one roof in SA and this will require nurse-initiated and managed ART.”
This sentiment was echoed by several speakers.
Dr Nono Simelela, SANAC
“We all know we have a huge problem, it’s not rocket science,” said Dr Nono Simelela, CEO of the South African National AIDS Council (SANAC) at the start of her keynote address. She recounted depressing data on the country’s unmatched TB and HIV epidemics — which she noted would not get any better this year — and other health outcomes that are declining in South Africa relative to other nations.
“South Africa has only 0.7% of the world’s population, but contains 28% of the world’s population with dual HIV and TB infection. Even though we are not considered to be an under-developed country — we have the resources — we are not really responding in a way that is commensurate with what we’ve got at hand. We are one of the only nations that is demonstrating an increase in terms of maternal mortality,” she said.
Dr Simelela, who previously held what must have been a difficult post as the head of the National HIV/AIDS/TB programme from 1998-2004 under the former Minister of Health, Dr Manto Tshabalala-Msimang, said that it was easy but less than helpful to place all the blame the political leadership and the health system:
“With political leadership, we always have the good, the bad and the ugly, the committed, the non-committed. Political leadership is a changing phenomenon… and we are constantly belaboured by problems with the health system. ‘The hospitals are falling apart; the clinics are not working efficiently; we don’t have enough resources’ — that is going to stay with us for a long time. So for how long are we going to cry about these problems and what is it that we are going to do to change these things? There is a lot that we need to fix. But what are the things that we can do differently today when we leave this conference to make a difference — since we are not going to get more nurses, more doctors, more anything, more everything?”
Dr Simelala assigned responsibility to everyone in the audience: “we are not working together, collaboratively and in a consistent way to ensure access. [We] blame patients for poor adherence, but we fail to appreciate the full patient; we see that person as a single disease; we never consider everything outside of that aspect of clinical practice. That undermines our interventions. By continuing to approach these issues in a vertical manner we undermine our response. We are denying our patients, our fellow citizens, the best benefit out of our collective knowledge. We make our patients move from pillar to post looking for this expert on a particular disease.”
She pointed out that, so far, the country had only mobilised around HIV — none of the issues around TB have been raised in such a comprehensive and sustained way. Of note, during a review of South Africa’s TB programme last year, one of the recommendations was that SANAC should be responsible for the multi-sectoral response to TB as well, which the council has now taken on board.
“The divisions between our HIV/TB responses are not even justifiable clinically,” said Dr Simelala. “We are disorganising the response to a co-mingled and indivisible problem. WE are the immediate problem, not TB HIV, and this is a problem WE can solve if we want.”
What a difference a Minister can make
When Dr Simelala spoke about political leadership, she said something quite interesting (especially given her own experience in government): “When you have a window of opportunity, when you have what I call “conscious leadership”, you seize the moment by pushing the agenda on the issues that you feel are being ignored.”
Now appears to be that moment. The current Minister of Health does not appear to suffer from denialism in the least, but owns the problems, even acknowledging that the migrant work system in South Africa was exporting TB and HIV to the rest of the region.
“At the beginning of the year, I was in Vietnam attending the International Coordinating Board of the Stop TB Campaign, and what I saw while I was seated there [concerning South Africa’s HIV and TB burden] would have made any normal South African not want to be South African, just for that time… Looked at from whatever angle, we are living in a country that finds itself in a position that nobody envies, a position in which everybody’s asking the question, ‘How did you arrive in this situation?’ I’m not sure that South Africa has an answer to that,” said Minister Motsoaledi. But he stressed that even though “the problem is intimidating, it is not insurmountable. But the size of the TB/HIV epidemic is too enormous for the Department of Health or government to be able to tackle alone.”
The Minister presented his response to a memorandum from an alliance of NGOs who committed themselves in the fight against TB and HIV and called on the ministry to respond with concrete plans. Although he didn’t read all the following points, the official transcript of his speech included several major departures from former policy.
Involving the NGOs in planning meetings at a national level. “The Chief Directorate for TB in the Department of Health holds quarterly meetings with provincial coordinators to develop and review strategies and plans. NGOs involved in TB and HIV services participate in these meetings going forward. These NGOs have also been included and have a vital role to play in the TB/HIV Technical Task Team of SANAC,” said Minister Motsoaledi.
Integrating TB and HIV at the primary care level — which will require nurses initiating ART. “The Department of Health strongly supports the move to provide integrated TB/HIV services and is committed to making nurse-initiated and managed antiretroviral treatment available at all primary care facilities that provide TB treatment.”
Making TB screening and isoniazid preventive therapy a part of the basic package of care. “The Department of Health is committed to providing IPT in all primary care facilities to be offered as part of a package of HIV care by World TB Day 2011.” The department has set a goal within the HCT campaign that 450,000 people should be started on IPT by March 2011 and 600,000 by June 2011. “There is no excuse for health workers to withhold this inexpensive and effective intervention to prevent TB. I strongly urge you to download the guidelines from the Department’s web site and work with your districts to start implementing as soon as you return to your health facilities.”
The decentralisation of MDR-TB services linked with strengthened infection control measures at facility and community levels. “We do not have an adequate number of hospital beds and welcome the opportunity to work with other partners to provide decentralised MDR-TB services.” [Many of the sessions at the conference addressed the management of drug resistant TB, and will be the focus of a future issue of HATIP]
Standardised stipends for community health workers (whether HIV or TB). “The Department of Health is finalising a Community Care Giver Policy Framework that supports the development of multi-skilled comprehensive community care givers with fixed stipends.”
Allowing NGO’s who are supporting TB/HIV at a facility to access facility-based registers so that they can monitor and evaluate their programmes “so that they can be accountable for the work they do.” DOH will also explore the idea of creating a community team leader post or function at health facilities to coordinate all community care givers in the catchment population of the health facility
The Minister went off his script several times to emphasise the need to move towards a more integrated approach both in planning, training and service delivery at the primary healthcare level.
“Over time, South Africa has become over-reliant on an over-verticalised hospital-based approach to care. Now we are engaged in a very high, expensive, non-workable curative healthcare system. But I was taught even before going to school that prevention is better than cure,” he said.
Addressing the need to move towards community-based care for drug resistant TB, he said, “the whole healthcare system needs to be 'over-hauled' to be community orientated. But more than anything else, we need to put primary healthcare at the centre of the problem. You can build a million more hospitals and recruit and train a million more doctors and put them in our hospitals – but that is too late! That is too late.”
The minister noted that there were a number of ways the system could be made more efficient. For instance, he said that nurses had complained to him about spending much of their time in meetings with different trainers, coordinators and supervisors from different health departments — when what they really need is integrated training and supervision. Likewise, other nurses anxious to prescribe ART complained of being ‘workshopped’ to death. “They tell us ‘We want treatment now, we know who is sick. Why do you still want to workshop us? We understand, we are not that dumb. What we want is action now, please come and act! Do something - the teaching, the talking is over!’” he said.
“We all know what must be done. The question is why is it not being done in this country? Debate rather than action is what is killing us…,” said the minister, who concluded. “But we are not deliberating… we are committed to work with you.”
Enough talk, time for action
Several ideas about how to put integration in action were presented by Dr Vincent Tihon, DOH’s advisor on TB-HIV on the previous day.
“We’ve been talking a lot about it, I’m not to sure whether we should keep talking about it and just do it,” he said.
But in order to integrate these services, programmes and facilities, he said that facilities do need to think through the channels and the patient flow that clinics are organized.
“If we have a patient coming today to the reception of any facility, what is the path of that patient from one room to another in the clinic? How long will it take, how many people will they have to see before receiving comprehensive care? We talk about integrating family planning, we talk about integrating reproductive health, antenatal, sexually transmitted infections, TB, and also for HIV to be integrated into primary healthcare. But I think the bottom line is really to bring back all concepts of primary healthcare and to have all of the vertical programmes really articulated around the patient who enters all services in primary healthcare. Otherwise we have many doors for the patients to knock on; many faces that the patient will meet and many queues and many different messages and many infectious germs being happily transmitted, and many patients being lost in the process,” he said.
First, Dr Tihon said that better collaboration is needed between the programmes when it comes to planning and training:
- How [are] we coordinating our programmes?
- How do we plan activities together?
- How do we avoid a plethora of workshops that are not coordinated?
- How do we achieve comprehensive surveillance?
- How do we standardise Monitoring and Evaluation?
Integration of services happens at the facility level, and may be easier to implement at primary care facilities than in hospitals.
“The whole process of responsibilities and roles within the clinics has been redefined,” he said, pointing out that it is time that the TB hospitals be accredited to provide ART when patients are eligible for it. “And we need to promote a more nurse-led and doctor-supported programme.”
“In a consulting room, we will now address four general conditions — STI screening and management, TB screening and management, HIV Screening and management, maternal and child health — which will then require equipping all healthcare workers with a more comprehensive approach of how to deal with the client, the patient in front of us,” he said.
This will require standardised comprehensive training, standardised registers and standardised supervision.
To get this all rolling will require leadership at the provincial and district levels, according to Dr Tihon.
“It’s really the district managers, the facility managers [who need] to think differently… to redraw the rules of the clinic. So practically it means for the district to identify which are the facilities that are the most ready to change this mindset,” he said.
Advocacy and the community
The Minister’s words about the need to move on from debate also appeared to strike a chord with Paula Akugibizwe, of the AIDS Rights Alliance of Southern Africa, who gave one of the closing addresses at the meeting. After quoting the minister on the need for less talk and more action, she told the audience:“There are 208 deaths from TB per hour, 52 deaths per 15 minute conference presentations, 6,240 lives were lost to TB during the time we spent in SA TB conference… How many were saved? We need a little less conversation, a little more action,” she said.
Akugibizwe supports the move to decentralise care to the primary health care level, but pointed out that this will require an expanded community role in service delivery. "Conscious leadership does present a window of opportunity – but we need much more than strategic partnerships to capitalise on this. We need advocacy to break out of the comfort zone to generate truly vigorous response."
Advocacy must tackle what Akugibizwe calls the TB factories, including the mines in South Africa, and the health facilities that have been implicated in spreading TB and drug-resistant TB due to poor infection control. Advocates need to push for a massive injection of funding
“Without replenishment of the Global Fund with at least US$20 billion in October 2010, sustained progress in the fight against TB is unlikely,” said Akugibizwe who pointed out the new football stadium in Durban cost 1.6 times the global budget for control of drug-resistant TB.
Akugibizwe closed emphasising the need for a human rights approach to demanding action on TB/HIV with a quote from Marcos Espinal, on World TB Day this year. “TB is not a medical problem. It is a development issue. It is an economic problem. It's a human rights situation.”