SOUTH AFRICA: GROWING INEQUALITY IN HEALTH SERVICES People's Health Movement Statement Resolutions of the People's Health Summit (Published 13 July 2004) Co-hosted by the Treatment Action Campaign (TAC), the Health & Other Services Personnel Trade Union of South Africa (HOSPERSA), the South African Democratic Nurses' Union (SADNU), the Public Service Accountability Monitor (PSAM), the Eastern Cape Provincial Council of Churches, the Rural Doctors Association of Southern Africa (RuDASA) and Médecins San Frontières (MSF) Adopted in plenary session on July 4, 2004, East London, South Africa General Summit Statement On 2 - 4 July 2004, more than 530 delegates - including more than 80 health workers and representing over 60 organisations and institutions - met at the first People's Health Summit (PHS) to discuss the crisis and inequity in the health system and the roll-out of antiretroviral (ARV) treatment. While recognising the impact of the legacy of injustice and inequality of apartheid on the health service of our country and our people, delegates to the PHS expressed grave concern that in spite of many good policies, laws and programmes, the public health service is in crisis and the quality of many services is in decline. This is an emergency and needs urgent solutions from government, the private health sector and civil society. In spite of significant attempts to transform the health system in the first decade of democracy, based on the ANC's vision of equality in access to health care, there is growing inequity between the health care services received by people who can afford to use the private sector and those received by people whose poverty makes them largely or wholly dependent on the public sector. There are also growing inequalities between urban and rural areas. Amongst other problems, people in rural areas face the chronic understaffing of health facilities and large distances to travel to access health care. In particular, the PHS recognises that: a.. Our struggle for a quality people's health service is a struggle for the realisation of the rights to life, dignity, access to health care services, equality, autonomy and social justice. b.. The worthy vision of the public sector as being the lead provider of quality health care seems to have crumbled. This crisis has come about as a result of a number of factors, including the - a.. Underfunding of public health; b.. Overpriced, inefficient and exclusive private health sector; c.. HIV/AIDS epidemic; d.. Failure to train and re-train health workers; and e.. High degree of corruption and mismanagement in the delivery of public health services. a.. Refusing to recognise or confront this crisis is a violation of the principle of a better life for all. b.. All organisations represented at the PHS are committed to working with the Department of Health all levels to build a quality people's health service. c.. There is an urgent need for the establishment of a permanent and broad-based consultative forum to discuss, debate and formulate all aspects of health care policy. 1. Crisis in the public health system: defining an agenda for resolving it Recognising the need to transform the public health sector, the PHS resolves to: a.. Campaign to create a unified people's health system based on the principle of free and equal access for all. As part of this campaign, we resolve to strengthen the public health sector by: a.. Monitoring the implementation and ensuring the success of the ARV treatment programme across all provinces a.. Ensuring that the rollout of the ARV treatment programme is used to improve the health service generally, and calling public meetings about the programme to explain how it can and should be used to build a better public health system a.. Encouraging government officials and employees to use public health services a.. Calling for unity and better co-ordination between public sector health worker trade unions a.. Exploring the formation of a people's health movement. a.. Support public health care workers' by calling for: a.. The establishment of a Commission of Inquiry to make recommendations on conditions of service and employment for all health workers in the public sector b.. The urgent development of a long-term human resource strategy for the public sector which links hospital renovation and clinic construction plans directly to human resource needs c.. Negotiations for better wages and conditions of employment d.. Endorsing and supporting the quality services campaign of Public Services International (PSI) e.. Better management of HIV/AIDS among health care workers, including access to confidential counselling, HIV testing and ARV treatment f.. Better attention to human resources for mental health. a.. Campaign to improve access to and the quality of health care services for women and girls, in particular services for survivors of sexual violence b.. Ensure effective health service delivery at provincial and district level by obtaining business plans for key health programmes in all provinces and by monitoring their implementation. 2. Crisis in the private sector: defining an agenda for resolving it Recognising that access to health care services is a human right and that all health care providers need to take this into account when providing health care services, the PHS resolves to: a.. Campaign against exploitation and over-pricing within the private heal th care system so that it is made more efficient, accountable and transparent. In particular, the PHS resolves to: a.. Raise public debate on the inefficiency of and lack of accountability within the private health system b.. Investigate the extent of profiteering within the private sector and how this can be addressed a.. Campaign for necessary reforms to ensure greater access to private health care services and thereby reduce some of the public sector burden by: a.. Challenging the high costs of private hospitals, particularly by those major hospital groups that operate as a cartel b.. Challenging the high costs of medicines, specialist services, and non-health expenditure c.. Ensuring that medical scheme members access prescribed minimum benefits (PMBs), regardless of which sector provides the required health services d.. Ensuring that ARV treatment is provided as a PMB from 2005 e.. Engaging more directly in the medicines pricing and dispensing debates a.. Campaign against the privatisation of health-care services and for more responsibility for community health to be taken by private providers operating in poor communities by: a.. Calling on AngloGold to complement the services offered by the community clinics in Lusikisiki by making the AngloGold clinic in Lusikisiki available for public sector use b.. Calling for plans to privatise hospitals, such as Lentegeur Hospital in Cape Town, to be set aside Believing that civil society must increase its understanding of the health care system, and recognising the need to build knowledge amongst health activists on alternative funding mechanisms for a unified health service (such as the shifting of spending from private to public health care), the PHS further resolves to initiate public campaigns in this regard. Further, the PHS demands that the proposed Health Sector Charter be negotiated in an open, accountable and transparent manner that involves all sectors with an interest in health matters. 3. Mobilising communities for antiretroviral treatment Re-stating that the HIV/AIDS epidemic is a crisis for South Africa, accepting the report on the ARV roll-out produced by TAC and the AIDS Law Project, and calling for more resources to be made available to ensure the programme's success (including support from the SA Military Health Services with campaigns of HIV and CD4 testing, ensuring availability of medicines, etc.), the PHS resolves that - a.. All TAC branches, the labour movement and civil society organisations represented at the PHS should a.. Act to make the ARV rollout a reality that saves millions of lives b.. Campaign for better public information, calling on - a.. National government to publish the report of its accreditation team b.. Provincial health departments, on a monthly basis, to publish an accurate and updated list of active ARV rollout sites with contact information c.. Government at all levels to provide civil society with regular information about the plans for every health district c.. Insist that resources for the ARV programme focus on establishing this programme primarily at primary health care (PHC) level - and not primarily in hospitals which are inaccessible to the majority that need treatment d.. Encourage more men to get tested and join treatment literacy programmes e.. Encourage every TAC member to have a personal treatment plan f.. In addition to providing treatment literacy to all TAC branches and clinics, targeted treatment literacy programmes for traditional healers, health care workers (including nurses and doctors) and school teachers must be developed g.. Government must utilise every form of media to advertise the ARV rollout - a massive radio campaign in all languages and at local stations is needed a.. Continuing Professional Development (CPD) programmes must be extended to all professional health workers. Accredited CPD workshops should require doctors to obtain compulsory CPD points regarding HIV b.. There is a need to consider how general practitioners and other private health care providers can partner with government to provide access to ARV treatment c.. Large companies providing treatment to their employees need to find ways to provide treatment to the partners of employees on treatment d.. There is a special need to improve treatment access for children and the following children-specific issues need to be addressed: a.. The development of paediatric fixed-dose combinations and better-flavoured medicines b.. The implementation of strict protocols for the diagnosis and treatment of children and special training programmes for paediatricians c.. The use of PCR tests as the standard test for the diagnosis of infants d.. Mobilisation to ensure a sustainable supply of ARV medicines, in particular to guard against the shortage of Lamivudine a.. Regarding voluntary counselling and testing (VCT), there should be - a.. The offer of VCT to in- and out-patients at every level of the health service b.. Educational programmes for children to bring the message home to their parents c.. Jobs and salary increases for VCT counsellors, as well as standardised national guidelines for counsellors d.. Private rooms for VCT counselling to address issues of confidentiality e.. Double rapid tests to avoid unnecessary misdiagnoses f.. Action taken by the AIDS Law Project to investigate ways in which a VCT counsellor can do the rapid test a.. The PHS further recognises that the success of the ARV rollout depends on civil society joining and supporting campaigns for better salaries and conditions for all health workers. 4. Antiretrovirals for children & youth friendly clinics The PHS resolves - a.. Regarding pregnant women: a.. Capacity must be created where needs exist to ensure that pregnant women, where medically appropriate, access combination ARV therapy instead of single-dose nevirapine to prevent mother-to-child transmission of HIV (MTCT). In this regard, it is noted that combination ARV therapy is being used in the Western Cape to reduce drug resistance and achieve a further significant reduction in the risk of MTCT and that it is urgent to scale this up to rest of country a.. Noting the important role to be played by support groups, women should be encouraged to test early for HIV b.. Regarding infants and children: a.. Encourage parents (and other appropriate care-givers) to have babies tested for HIV at 6 - 10 weeks using PCR tests b.. Campaign for the use of PCR tests in the public sector c.. Campaign to lower the costs of paediatric ARV formulations and diagnostics, including PCR tests d.. Integrate children's issues into all treatment literacy work e.. Campaign for nutritional support and access to formula feed security for women equally in all provinces for at least two years f.. Mobilise communities to ensure that children access ARV treatment in the public sector. c.. Regarding youth: a.. Every organisation should discuss issues about youth and HIV amongst its members; campaigns against alcohol and drug abuse would help reduce young people's risks of pregnancy, sexually transmitted infections (STIs) and HIV b.. All organisations should approach their clinics to make them youth friendly by setting aside special times for youth as part of the adoption of a youth-friendly clinic campaign c.. Civil society organisations should host a meeting to discuss issues such as correct condom use and lesbian/gay/bisexual/transgender youth 5. Towards an international agenda for people's health Noting the deterioration of health and health care that is taking place in many poor and even middle-income countries, condemning the US-led war on Iraq and the manner in which this is diverting attention and resources from global health challenges, the PHS resolves to pressure the UN system, and in particular the UN Secretary General, to provide greater political leadership on health matters. We hold the Secretary General accountable for continued failures to pressure and expose those governments that continue to fail in combating epidemics such as HIV. Recognising that HIV/AIDS remains a global health emergency and that - a.. Approximately 5,5 million people are currently in need of ARV treatment globally b.. The World Health Organisation's 3x5 targets aim to ensure treatment for 3 million people by 2005 c.. There are 77 weeks left and a lot of urgent work to be done d.. On a national level, the South African government and civil society can contribute to ensuring that the 3x5 targets are reached by ensuring that the ARV rollout in South Africa is rapidly escalated and assistance is provided to other countries where needed The PHS resolves to - a.. At the organisational level: a.. Facilitate branch discussion on developments in other countries, the 3x5 targets and international solidarity action b.. Do an audit of commitments the South African government has made on the national and international level and educate TAC branches on these commitments and government's lack of adherence thereto a.. At the national level: a.. Work towards civil society participation in the 2005 UNGASS country report to ensure more objective reporting b.. With regard to human resources, call upon health care workers from developed countries to come to South Africa to volunteer their services and call on government to implement measures to make it easier for them to do so, as well as campaign for the employment of more health care workers and better working conditions c.. Ensure the Medicines Control Council (MCC) complies with its statutory and constitutional obligations and takes advantage of the WHO medicines and diagnostic services to register generic ARV medicines d.. Place pressure on the South African government to: a.. Adhere to commitments it has made on national and international platforms including the commitment to spend at least 15% of the budget on health in terms of the Abuja Declaration b.. Make use of voluntary and compulsory licences to access generic medicines c.. Fast-track ARV procurement a.. At the regional level: a.. Actively participate in building the Pan African Treatment Access Movement (PATAM) b.. With the commitment of UNAIDS, encourage interactive information exchanges between countries on treatment access and treatment literacy a.. At the international level: a.. Participate in international solidarity actions aimed at increased funding for the Global Fund to Fight TB, AIDS and Malaria (GFATM) and urge the WHO and UNAIDS to lead negotiations on this issue, including a campaign for greater and more equitable contributions to the GFATM b.. Campaign for developing countries to take advantage of the Doha Declaration on TRIPS and Public Health and the public health safeguards and flexibilities within TRIPS regarding the compulsory licensing of essential medicines and diagnostics c.. Campaign against the conditionality attached to PEPFAR funding by the Bush administration, such as discouraging the use of generic medicines, measures that are against sexual and reproductive choice etc. d.. Participate in initiatives to increase civil society representation in all decision-making processes that affect access to treatment e.. Urge the WHO to provide adequate technical assistance to enable countries to provide ARV treatment f.. Urge civil society to raise these issues at international platforms including the labour movement 6. Access to comprehensive social security Noting that the system of social grants is in crisis, that there are unreasonable delays in processing grant applications and that pressure on government is vital to ensure that the system works efficiently and transparently, the PHS resolves that civil society needs to focus attention on: a.. Support for the BIG campaign whilst at the same time expanding the campaign to deal with the problems of the existing social security system b.. Ensuring that all babies are properly registered with the Department of Home Affairs (DHA) c.. Effecting better links between the DHA and the Department of Health d.. Reviewing the criteria for accessing grants, so as to deal with current problems such as the inability of child-headed households to access grants e.. The particular problems faced by people with HIV regarding accessing social grants. (In this regard, it is noted that the system needs to respond to the particular needs of orphans as well as people with AIDS who are often too poor and sick to be able to access the grants to which they are entitled.) 7. The South African National AIDS Council (SANAC) Expressing its disappointment and anger that the South African National AIDS Council (SANAC) and many provincial AIDS councils are not functioning properly (if at all), the PHS notes that - a.. There is a clear need for such bodies to be independent and representative, and to meet regularly to advise and assist government on all aspects of HIV/AIDS, including all public prevention, treatment, care and support programmes b.. Issues that ought to be regularly on the agenda of SANAC and the various provincial AIDS councils include the impact of the crisis in the public and private health care sectors on HIV/AIDS prevention, treatment, care and support, as well as issues of social security and social assistance, including access to existing social grants by people living with HIV/AIDS. The PHS therefore - a.. Calls on the civil society representatives on SANAC to report in three months on whether the council was functioning efficiently, accountably and responsively b.. Resolves to call for the immediate resignation of civil society representatives if SANAC is not properly functioning within three months. 8. Other resolutions The PHS also resolves as follows - a.. To call on the President urgently to assent to the National Health Bill or else to refer it back to Parliament if he is of the opinion that any of its provisions are unconstitutional. In this regard, the PHS notes that over seven months have elapsed since Parliament passed the bill b.. To request that the Department of Labour investigate concerns that home-based care volunteers are being exploited c.. To ensure that human rights training for health activists takes place d.. To host a second People's Health Summit in the next 12 to 24 months. In this regard, the PHS mandates the co-hosts to establish a formal co-ordinating committee to plan the next PHS and to endeavour to broaden the range of organisations participating in the PHS process. [ENDS]