This record is a partial extract of the original cable. The full text of the original cable is not available.

UNCLAS SECTION 01 OF 04 PRETORIA 004947 
 
SIPDIS 
 
DEPT FOR AF/S; AF/EPS; AF/EPS/SDRIANO 
DEPT FOR S/OFFICE OF GLOBAL AIDS COORDINATOR 
STATE PLEASE PASS TO USAID FOR GLOBAL BUREAU APETERSON 
USAID ALSO FOR GH/OHA/CCARRINO AND RROGERS, AFR/SD/DOTT 
ALSO FOR AA/EGAT SIMMONS, AA/DCHA WINTER 
HHS FOR THE OFFICE OF THE SECRETARY,WSTEIGER AND NIH,HFRANCIS 
CDC FOR SBLOUNT AND EMCCRAY 
 
E.O.  12958: N/A 
TAGS: ECON KHIV SOCI TBIO EAID SF
SUBJECT:  SOUTH AFRICA PUBLIC HEALTH NOVEMBER 12 ISSUE 
 
Summary 
------- 
 
¶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 
--------------------------------------------- -------------- 
 
¶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 
--------------------------- 
 
¶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 
------------------------------------------- 
 
¶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 
--------------------------------------------- ------ 
 
¶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 
--------------------------------------------- ------- 
 
¶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 
--------------------------------------------- ------ 
 
¶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 
--------------------------- 
 
¶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 
--------------------------------------------- ------------- 
 
¶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 
--------------------------------------------- --- 
 
¶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