SOUTH AFRICA PUBLIC HEALTH NOVEMBER 12 ISSUE

1. Summary. Every two weeks, USEmbassy Pretoria publishes a
public health newsletter highlighting South African health
issues based on press reports and studies of South African
researchers. Comments and analysis do not necessarily reflect
the opinion of the U.S. Government. Topics of this week's
newsletter cover: financing of shift to primary health care to
provinces; obesity as a problem in Africa; Cape study shows
most addicts share needles; real health care spending 4.8
percent lower in 2003; increasing welfare grants crowd out
other government expenditures; alcohol-related sexual risk
behavior study released; shortage in health staffing; AIDS
drugs needed for South African HIV-positive children; and South
African insurance companies remove HIV exclusion clauses. End
Summary

Treasury Questions Shift of Primary Health Care to Provinces


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2. Under the National Health Act, expected to begin in the
2005-06 financial year, provincial health departments are to
take over responsibility for primary health care, which they
can then delegate to local authorities. The act's intention is
to consolidate fragmented primary health-care services under a
single level of government, and will leave local government
responsible only for environmental health services. The act
will also mean that the national treasury will replace local
government as the funder of primary health-care services, via
increases to the equitable share form of grant funding given to
provinces. But a senior treasury official said that the health
department was being urged to discuss alternative arrangements
with the metropolitan areas. The six metropolitan councils of
Johannesburg, Tshwane (Pretoria), East Rand, Cape Town, Durban
and Nelson Mandela (Port Elizabeth) currently account for about
R700 million of the R1 billion annual primary health-care
spending, which they fund from local taxes. Primary health-
care facilities include clinics, community health centers and
some hospitals. Treasury's health policy director, Mark
Bletcher, said one option was to make the metropolitan
authorities responsible for primary health care and fund them
directly. Another possibility would be for the metros to run
the services and provide top-up funding above a norm supplied
via the provinces. Bletcher also said February's budget would
include allocations to the nonmetropolitan areas via the
equitable share, starting with about R200m in 2005-06, and
rising to R300m in 2006-07 and R400m in 2007-08. The
Department of Treasury was concerned about the ability of some
of the weaker district councils to manage the primary health
care transition. Source: Business Day, November 1.

Obesity a Problem in Africa


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3. The first international obesity conference in Africa
highlighted the health problems associated with overweight
adults and pointed out that Africa suffers health impacts from
obesity as well as the rest of the world. There are over 300
million overweight adults worldwide, suffering from weight-
related illnesses like diabetes, heart disease and sleeping
disorders. One in three South Africa males and over one in two
adult women are overweight. In Morocco, 40 percent of the
population is overweight, while in Kenya it is 12 percent. In
Nigeria, 6 to 8 percent of people are obese. Obesity has
created a double burden in parts of Africa still struggling to
overcome malnutrition. Obesity among the young was pointing to
a large increase in type 2 diabetes. The spread of AIDS
dissuades people from losing weight. AIDS is nicknamed "slim"
(thin) throughout Africa as victims waste away. People do not
want to lose weight in case others think they have HIV. About
25 percent of people living in the Middle East are overweight,
while obesity has doubled among Japanese men since 1982.
Children around the world are also growing obese, with the
fattest children living in the Middle East, Chile, Greece and
southern Italy. Source: The Cape Times, November 2.

Cape Study Shows Most Addicts Share Needles


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4. Between 12,000 and 18,000 Capetonians are addicted to
heroin and almost all those who inject the drug share needles,
according to a recent report by the Medical Research Council
(MRC) on drug use in South African cities. The report found
that escalating numbers of Capetonians are seeking help for
addiction to heroin and to tik (methamphetamine), which was
hardly in use four years ago. An MRC study conducted in July
and August found that around a quarter of heroin addicts in
treatment centers in Cape Town had been injecting the drug and
four out of five had shared a needle within the previous 30
days. Two years ago only one percent of all those getting
treatment at the centre were addicted to tik. Last year it
increased to five percent and this year to at least 40 percent.
The study found that a quarter of all addicts receiving
treatment in the city use tik as their main or secondary drug.
Source: Cape Times, November 1.

Real Health Care Spending 4.8 Percent Lower in 2003


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5. The South Africa Survey shows that healthcare spending in
2003 was 4.8 percent lower in real terms than in 1996, with
large inequities still existing between the provinces. Some
provinces spent as little as 75 rand ($1.23 using 6.1 rands per
dollar) per capita per annum, where the government goal is 200
rand. Two of the provinces with the highest HIV/AIDS infection
rates, Gauteng and Mpumalanga, failed to spend all the money
allocated to them in conditional grants to fight the pandemic
in 2002/03. Gauteng spent only 52 percent of its funds, while
Mpumalanga spent only 38 percent. In 1995 an estimated 85
percent of companies were providing benefits to their
pensioners, while in 2003 this number had fallen to only 43
percent. The government increased the value of the old-age
social pension by 13 percent between April 2002 and April 2003.
During the same period, the number of beneficiaries of child
support grants increased by 45 percent. Between 1997 and
2003, the number of welfare grant beneficiaries in South Africa
grew by 124 percent from 2.5 million to 5.6 million. Source:
I-Net Bridge, November 3.

Increasing Welfare Grants Crowd Out Other Government
Expenditures


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6. Welfare grants will comprise over 40 percent of the
government expenditure increases for the next three years.
Finance Minister Manuel allocated R20.8 billion ($3.4 billion
using 6.1 rands per dollar) of the R50 billion ($8.2 billion)
for welfare grants. Two million people were added to the
beneficiary lists for various grants between April and
September this year alone, pushing the total number of
recipients to nine million, about one in five of the total
population. Much of the increase was in the unexplained
escalation in disability and foster care grants, which Manuel
said was most likely due to poor administration. Manuel said
that in some provinces, officials were adding applicants to the
list without any checks, families were registering their own
children as foster children and government officials were
illegally claiming childcare support for their own children.
The government has no figures on the number of people claiming
disability grants as a result of HIV/AIDS and there are no firm
guidelines on their eligibility. In addition, there are plans
to raise the ceiling for child grants from 10 to 13 years
through 2008. Welfare grant administration will be shifted to
a national social welfare agency in 2006, but Manuel moved this
week to limit the damage to other services by shifting welfare
funds from the equitable share paid to provinces to the
conditional grants that go to these regional governments. The
change would mean that overruns would be the responsibility of
the national department even though distribution would remain a
provincial responsibility until March 2006. At present,
welfare claims take precedence over other provincial
expenditure. Provinces have had to cut back on critical health
and education budgets or have taken out bank overdrafts to pay
welfare grants expected to total R38.4 billion ($6.3 billion)
in the current financial year, rising to R47 billion ($7.7
billion) in the 2007/08 fiscal year. In the financial year
through March 2004, Northern Cape overspent on welfare grants
by 8.6 percent, KwaZulu-Natal by 7.2 percent, Eastern Cape by
7.7 percent and Gauteng by 4.1 percent. Western Cape and North
West provinces under spent in this regard. Source: Business
Times and I-Net Bridge, November 3.

Alcohol-related Sexual Risk Behavior Study Released


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7. The Medical Research Council (MRC) released a report
investigating alcohol-related sexual risk behavior, funded by
the World Health Organization. The study included qualitative
assessments involving interviews and focus groups, developing
in-depth questionnaires and finally testing the survey using
160 24-44 adults in two townships and one city in Gauteng. Key
findings were: (1) Alcohol use was widespread among adults in
the 25-44 year age group. Although less likely to drink,
females were more involved in risky drinking (defined as 5 or
more drinks per day for males and 3 or more drinks for
females); (2) Sexual gender differences exist; males were more
likely to have younger and multiple sexual partners and use
condoms, while females were more likely to have older partners
and view sexual intercourse as safer with older men; (3)
Access to condoms and knowledge about HIV infection due to
multiple sexual partners were high, but condom use was not.
Condom use was more common with a casual rather than a regular
sexual partner; (4) Sexual risk behavior was identified as one
of the consequences of heavy drinking; and (5) there was no
correlation between various alcohol use variables and condom
use. The research suggests that reductions of heavy alcohol
consumption and sexual risk behavior should be targeted to
families and communities as well as individual treatment.
Treatment should reduce opportunities and demand for heavy
drinking, leading to possible reductions in sexual risk
behaviors. Source: www.sahealthinfo.org, November 1.

Shortage in Health Staffing


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8. According to Health Systems Trust's (HST) 2003-04 South
African Health Review, 31.1 percent of health posts in the
public sector were vacant between 2001 and 2003, and health
care vacancies differed widely among provinces, with 67.4
percent of Mpumalanga's posts vacant, 13.4 percent in Limpopo
and 13.8 percent in Western Cape. HST asserts that the
migration of graduates to other countries is probably the
largest contributor to the shortage of health care
professionals. In addition, the introduction of the rural and
scarce skills allowances this year, designed to attract health
professionals to the public sector and keep them there, had
limited success in increasing the supply of personnel in
underserved areas. The number of medical graduates involved in
community service has declined. To increase black health
professionals, Health Professions Council of SA registrar Boyce
Mkhize called for equity targets to be set for training
institutions, and suggested there be broadened criteria for the
admission of black students, asserting that many blacks were
excluded due to poor matric grades from poorly resourced
schools. The Council's statistics show that only 23,419, or 22
percent, of the 104,463 health professionals registered with it
describe themselves as black or African, and when those
describing themselves as Asian (5491) and coloured (1708) are
added, the percentage is only 25 percent. But new registrations
of black, coloured and Asian professionals have increased to
70.2 percent this year, from 42.7 percent in 2000. Since 1998,
most of South Africa's eight medical universities have used
"alternative admissions tests", which take non-academic
criteria into account in an effort to increase admissions of
black students. In 2003, 45 percent of first year medical
students were black, about 10 percent coloured, 15 percent
Indian and 30 percent white. Source: Business Day, November


5.

South Africa: AIDS Drugs Needed for HIV-positive Children


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9. Although there is no separate national target, the number
of children currently receiving ARVs is low. The AIDS lobby
group, Treatment Action Campaign (TAC), recently conducted a
survey in 13 of KwaZulu-Natal's largest public hospitals and
found that only 39 children were receiving anti-AIDS
medication. According to Dr Neil McKerrow at Grey Hospital in
Pietermaritzburg, the province's unofficial target is to have
2,000 children on ARV treatment by March 2005. The national
treatment plan, unveiled last November, initially targeted the
treatment of 53,000 people by March 2004, which has since been
extended to March 2005. Efforts to establish the national
status of the ARV rollout for children were difficult, as the
National Department of Health would not disclose the number of
children on treatment in the public sector. Nevertheless,
doctors and healthcare workers are still debating at what age a
child should start taking ARVs. Under South African law, a
child younger than 14 years requires consent from a parent or
guardian to be given the drugs, but TAC is saying the 'right
age' cannot be regulated by government and should be assessed
by doctors on a case-by- case basis. Another obstacle to
providing free drugs to children is the prohibitive cost of
specialized tests for diagnosing HIV in children younger than
18 months. The most commonly used HIV antibody test, the rapid
test, is unable to discern between maternal and child
antibodies in infants. Because HIV antibodies can cross the
placenta and stay in a child's bloodstream for 15 months, a
baby needs a Polymerase Chain Reaction (PCR) test, which can
detect small quantities of viral protein in the blood, to
establish their status. This test is not widely available and
is substantially more expensive than rapid tests. Adult ARVs
are available to children above three years of age, with
specific formulations and dosages based on age and weight.
Despite pediatric syrup having been made more widely available
over the last few months, not all caregivers, particularly
those living in remote rural areas, have the refrigeration
facilities needed to store the medication. The adherence of
children to the drugs is another challenge. According to Noreen
Ramsden from the Children's Rights Centre in Durban, only 70
percent of children adhered to the treatment plan. Orphaned
children in child-headed households in both urban and rural
areas, who lack supportive care and proximity to treatment
centers, find it even more difficult to access the drugs.
Source: PLUSNEWS, November 3, hst.org.za; UN Integrated
Regional Information Networks, November 5.

Insurance Companies Remove HIV Exclusion Clauses


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10. South Africa's R163.8 billion ($26.9 billion using 6.1
rands per dollar) insurance industry could drop HIV/AIDS
exclusion clauses on all new policies starting January 2005.
The Life Offices' Association (LOA) is expected to issue a
statement to this affect just after its annual general meeting
on November 19, when the issue will be put to the vote.
Already some insurance companies have dropped HIV/AIDS
exclusions from certain products in anticipation of the
agreement. African Life last week removed all HIV/AIDS
exclusions on its new and existing burial policies and Old
Mutual, the country's largest life insurer, removed one of its
few remaining HIV exclusions by scrapping the clause from its
premium waiver cover on newer life and investment products.
Gerhard Joubert, the executive director of the LOA, said that
the removal of the exclusion clauses effectively placed
HIV/AIDS equal to any other medical condition as far as long-
term insurance policies were concerned. For most insurance
companies, this will mean that applicants who initially tested
HIV-negative would have to be paid out in full even if the
eventual cause of death is AIDS-related. While insurance
companies may still require HIV testing, they would no longer
be allowed to deny new applications from those who test HIV-
positive. Joubert said on average 5 percent of applicants for
long-term insurance risk products were HIV-positive. Source:
Business Report, November 9.

FRAZER