Professional Documents
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South African Health Review 2016
South African Health Review 2016
South African Health Review 2016
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South African
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South African
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Published by
Health Systems Trust
Information presented in this Review is based on best available data derived from numerous
sources. Discrepancies between different sources reflect the current quality of data. All data
should thus be interpreted carefully and with recognition of potential inaccuracy.
The views expressed in this Review are those of the individual authors and do not represent
the views of their respective organisations / institutions or Health Systems Trust.
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http://www.hst.org.za/publications/south-african-health-review-2016
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Health Systems Trust
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ISSN 1025-1715
May 2016
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This publication was supported by a grant from the South African National Department of Health.
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Gray A, Vawda Y. Health Policy and Legislation. In: Padarath A, King J, Mackie E, Casciola J, editors.
South African Health Review 2016. Durban: Health Systems Trust; 2016.
URL: http://www.hst.org.za/publications/south-african-health-review-2016
The information contained in this publication may be freely distributed and reproduced,
provided that the source is acknowledged and it is used for non-commercial purposes.
Layout by Lynda Campbell, The Press Gang : Telephone +27 (0)82 410 9936
Foreword
I am pleased to introduce this 19th edition of the South African Health Review, published at a time of critical and far-
reaching changes in national and global health and human development.
The 17 Sustainable Development Goals launched in 2015 represent a vision of health that embraces economic, social
and environmental determinants, with a new agenda to uplift and protect “people, planet, prosperity, peace and
partnership”.
We all share the responsibility for comprehensive understanding and social action to alleviate and overcome South
Africa’s quadruple burden of disease, prevailing threats to our natural world, and abiding socio-economic inequality.
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As South Africa contends with multiple challenges in adapting and refining our health system, the ideas that permeate this
Review are centred, as ever, on the trials of health service delivery. One is struck by the progress made by the chapters’
authors towards identifying opportunities and solutions in response to the obstacles investigated.
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Producing this edition of the Review has been singularly demanding, and its successful completion is attributed to
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the insightful guidance, deft industry and ardent commitment invested by the authors, reviewers, Editorial Advisory
Committee members, editorial team and administrative personnel who contributed to its creation. On behalf of the Board,
I wish to express our gratitude to the teams for their production of another excellent edition of the South African Health
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Review and encourage them to continue with their good work.
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We are grateful to the South African National Department of Health for its steadfast support of this publication, thereby
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fostering much more than a contribution to intellectual capital and strategic development planning for health; this project
helps to develop solidarity of purpose that offers hope for a healthy nation and an inclusive future.
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Table of Contents
Acknowledgements v
Editorial vii
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Andy Gray, Yousuf Vawda
2 Analysing the progress and fault lines of health sector transformation in South Africa 17
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Laetitia Rispel
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3 Water, sanitation and health: South Africa’s remaining and existing issues 25
David Hemson Y T
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4 Diet-related non-communicable diseases in South Africa : determinants and policy responses 35
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8 Bridging the gap between biomedical and traditional health practitioners in South Africa 83
Mosa Moshabela, Thembelihle Zuma, Bernhard Gaede
Service Delivery 93
9 Achieving universal access to sexual and reproductive health services: the potential and
pitfalls for contraceptive services in South Africa 95
Naomi Lince-Deroche, Melanie Pleaner, Jane Harries, Chelsea Morroni,
Saiqa Mullick, Cindy Firnhaber, Masangu Mulongo, Pearl Holele, Edina Sinanovic
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10 Breastfeeding in South Africa : are we making progress? 109
Lisanne du Plessis, Nazia Peer, Simone Honikman, René English
13 Integrating mental health into South Africa’s health system: current status and way forward 153
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Marguerite Schneider, Emily Baron, Erica Breuer, Sumaiyah Docrat,
Simone Honikman, Ashraf Kagee, Michael Onah, Sarah Skeen,
Katherine Sorsdahl, Mark Tomlinson, Claire van der Westhuizen, Crick Lund
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14 Sex work and South Africa’s health system: addressing the needs of the underserved 165
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Andrew Scheibe, Marlise Richter, Jo Vearey
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Trauma, a preventable burden of disease in South Africa : review of the evidence,
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with a focus on KwaZulu-Natal 179
Timothy C. Hardcastle, George Oosthuizen,
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17 HIV and AIDS financing in South Africa : sustainability and fiscal space 203
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18 Towards a transparent pricing system in South Africa : trends in pharmaceutical logistics fees 221
Varsha Bangalee, Fatima Suleman
Information 233
Abbreviations 349
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Acknowledgements
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and to uphold high standards of academic rigour: a wide range of people. In particular, we thank:
Peter Barron, Rene English, Andy Gray, Thulani Masilela, Judith Annakie, Janet Dladla, Shumeez Dollie, Ndumiso Jali,
Tracey Naledi, Laetitia Rispel and Flavia Senkubuge. Delene King, Sakhiwo Mahlumba, Themba Moeti,
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Bongi Mthembu, Melody Naidoo, Primrose Ndokweni,
Contributing authors Thesandree Padayachee, Kemona Pillai, Ronel Visser,
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Nompumelelo Xulu, and Duduzile Zondi.
We commend the commitment of individual authors to contributing
to the Review and their co-operation in responding to editing
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requirements, often at short notice. Gang for striving against arduous deadlines to produce the Review’s
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distinctive quality of layout and design. Thanks are also due to
Peer reviewers Anjana Bugwandeen who assisted with editing and references.
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Cover art
Andrew Crichton, Robin Dyers, Stefan Gebhardt,
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Nelouise Geyer, Andrew Gibbs, Ameena Goga, Andy Gray, The cover art for the 2016 edition of the South African Health Review
Teresa Guthrie, David Harrison, Karen Hermanus, is an oil-on-canvas painting by David Wheildon Oosthuizen. The
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Nadia Hussey, Ehimario Igumbor, Emma Kalk, Michael Levin, painting is one in a series of paintings by David entitled Reflections
Ozayr Mahomed, Carol Marshall, Verona Mathews, on African Life.
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Editorial
The Global Report on Urban Health: Equitable, healthier cities of primary health care, and the unsolved health workforce crisis,
for sustainable development issued in March 2016 by the World constitute a conjoined threat to the feasibility of National Health
Health Organization and the United Nations Human Settlements Insurance (NHI).
Programme (UN-Habitat) emphasises the need for enhanced
In November 2015, the South African Medical Association (SAMA)
governance and leadership to achieve universal health coverage
warned that climate change will produce a surge in waterborne
and the Sustainable Development Goals (SDGs). Noting that a
diseases. David Hemson’s timely research on water, sanitation and
healthy population forms the foundation for “sustainable economic
health in South Africa, presented in Chapter 3, portrays the factors
growth, social stability, and full realisation of human potential”,
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indicating a need for improved water and health management, with
the report presents “practical, proven solutions for working across
greater surveillance of water quality – particularly in vulnerable
sectors to tackle these … health challenges”, and includes examples
communities – and the delivery of universal water services to
of such successes in South Africa.a
ensure health and prevent disease outbreaks. His recommendations
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The 20 chapters that make up the 2016 edition of the South African include regular review and routine public reporting of water quality
Health Review mirror this global health and development agenda
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management, and further research into the development and
in a local context and offer evidence-based recommendations for sustainability of sanitation services.
resolving our country’s health challenges. Binding this content is the
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aspiration for an accessible, high-performing public health system
that ameliorates health disparities and provides quality health care,
In Chapter 4, Mark Spires, David Sanders, Phillipp Hoelzel, Peter
Delobelle, Thandi Puoane and Rina Swart focus on evidence relating
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to change from a traditional diet to a ‘western’ diet with more
bolstered by multisectoral mobilisation under adept management,
processed foods, more foods of animal origin, and more added
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areas: Leadership and governance, Human resources for health, have been made at national level, but consequent action has been
Service delivery, Financing and medical products, and Information. lacking, and a sustained public health effort is required to address
the environmental factors and knowledge, attitudes and behaviours
Leadership and governance
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in South Africa’s health policy and legislation over the past year,
and the delays and challenges beleaguering the development and Human resources for health
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NHI White Paper was released, related funding and policy issues
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a http://www.who.int/kobe_centre/measuring/urban-global-report/en/
S A H R 20 1 6 v ii
authors propose that institutional responsibility for a work-focused authors urge for dissemination of evidence to promote a culture
approach be adopted to address the health of healthcare workers, of breastfeeding; political will; removal of societal and structural
and thereby improve productivity and patient care; this would entail barriers to breastfeeding; regulation of the breast-milk substitute
involvement of the Employee Health Service for periods of five days industry; interventions tailored to local needs; appropriate capacity
of absence, or of the Occupational Medical Practitioner for repeated and resources; good-quality data; standardised messages, and
short-term absences and assessment of fitness to work. explicit guidelines.
The focus of Chapter 7 is on addressing language barriers in South MomConnect – a national digital maternal health program that
African health care using trained interpreters. Ereshia Benjamin, implements the South African mHealth Strategy and the National
Leslie Swartz, Linda Hering and Bonginkosi Chiliza identify themes Health Normative Standards Framework (HNSF) for Interoperability
emerging from mentor sessions in a pilot project conducted in in eHealth – has drawn global attention due to its innovative features
Western Cape hospitals. Community interpreters were found to and its avoidance of many of the common pitfalls of implementing
experience their work as challenging on practical and emotional digital health projects at scale in low-resource settings. Enrolment of
levels, and to be uncertain about their location and role in the health more than half a million women from all regions of the country in the
system. The authors highlight the potential to develop a multilingual first year of operation (representing approximately half the number
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health service for South Africa’s culturally and linguistically diverse of pregnancies in the public health sector) has generated a national
population; they argue for the promotion of language access in registry of pregnant individuals and a national feedback system
health services and the professionalisation of health interpreters, to clients. In Chapter 11, Christopher Seebregts, Peter Barron,
and suggest areas for further research. Gaurang Tanna, Peter Benjamin and Thomas Fogwill focus on the
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design and development of the technical infrastructure supporting
Mosa Moshabela, Thembelihle Zuma and Bernhard Gaede
MomConnect, and offer evidence-based recommendations for the
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provide a compelling account (Chapter 8) of the need for
future development of the MomConnect technical infrastructure and
respectful engagement between biomedical and traditional health
related projects as part of the HNSF implementation; several of these
practitioners, following the promulgation of the Traditional Health
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Practitioners Act (22 of 2007). In foregrounding the resilience of
the NDoH.
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indigenous knowledge, practice and experience, they advocate for
the ‘reclamation’ of traditional medicine and healing through policy, Chapter 12, written by Helen Malherbe, Colleen Aldous, Dave
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legislation and research that will resolve continuing tensions between Woods and Arnold Christianson, explores the virtually hidden
the two paradigms of health care and, through the lens of mutuality disease burden of congenital disorders (CDs) as a cause of child
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rather than opposition, prioritise the needs of the large proportion of mortality in South Africa. As the CD mortality rate drops, the
South Africa’s patient population. A merged, complementary system proportion of deaths from undiagnosed or misdiagnosed CDs is
of plural health care would benefit both arms of healthcare practice, increasing in South Africa. Inaccurate data for CDs as the cause of
the patients themselves, and other countries in the African region death has masked the true scale of the role of CDs in child mortality
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that seek to institutionalise traditional healing. and morbidity. The authors note that the re-engineering of the
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and the country’s commitment to integrated, rights-based service In order to improve national and global health, mental, neurological
delivery in the context of the SDGs and the Family Planning 2020 and substance use (MNS) disorders should be integrated into health
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(FP2020) initiative. However, scarce resources and South Africa’s policy and practice. Chapter 13 demonstrates that integration
HIV epidemic, and their impact on delivery of contraceptive of mental health into primary care in South Africa is challenging
services, are health systems constraints that demand accountability but can be both efficient and cost-effective, and that not doing
for related budgeting and dispensing methods. The authors suggest so will result in mental health continuing to be underfunded and
that shift and scale-up of contraceptive use in South Africa requires marginalised. Marguerite Schneider et al. provide an overview
ongoing assessment of the couple year protection rate and unmet of existing policies and services in place for mental health care in
contraception need, along with counselling, education and South Africa, describe current research on effective strategies for
supportive interactions with the healthcare system for all women, in providing such services, and identify key barriers and facilitators in
order to optimise improved contraceptive uptake. implementing and scaling up mental health services.
Knowledge and evidence, politics and governance, and capacity The rights and health issues of South Africa’s sex workers form
and resources are the three linked elements of an enabling the focus of Chapter 14, authored by Andrew Scheibe, Marlise
environment for breastfeeding. In Chapter 10, Lisanne du Plessis, Richter and Jo Vearey, who assert that South Africa will not reach
Nazia Peer, Simone Honikman and René English observe that the United Nations Joint Programme on HIV and AIDS (UNAIDS)
enhancing and broadening breastfeeding interventions at all levels 90-90-90 targets unless adequate attention and political will are
of impact will contribute extensively to the achievement of the health, invested in sensitive, appropriate and evidence-based responses
food security, education, equity, development and environmental to sex worker health. The South African National AIDS Council’s
SDG targets. To support breastfeeding through a multi-layered SANAC Sex Worker Programme 2016–2019 represents limited
approach across the various levels of government and society, the but important progress in expanding appropriate programmes for
v iii S A H R 20 1 6
sex workers in South Africa, but this requires rapid implementation, In Chapter 18, Varsha Bangalee and Fatima Suleman discuss South
and much more is needed to reach and empower sex workers to Africa’s pharmaceutical pricing dynamics and related transparency
keep themselves safe, safeguard public health, and achieve health- issues. As more countries look to South Africa for lessons from its
related SDGs. Delays in addressing data gaps, implementing global pricing policies, an understanding of the manufacturer’s price,
recommendations on sex work law reform and a lack of evidence- logistics fees and the relationship between the two has become
based interventions continue to impact negatively on sex worker increasingly necessary to support the principle that the Single Exit
morbidity and mortality, and have wide-ranging implications for Price (SEP) – which clarifies the price at which a manufacturer may
public health and related expenditure. sell a medicine to logistics service providers or medicine dispensers
– leads to more transparent prices. Their findings reveal that prices
Another aspect of public health requiring urgent attention in order for
reflected in South African medicine price registries may not be a
NHI to succeed is South Africa’s extensive injury burden. Addressing
true reflection of those negotiated between manufacturers and
the causes and treatment of trauma requires specialist services and
distributors/wholesalers. To guide further policy decisions, gauge
multidisciplinary care. Chapter 15 presents data from numerous
market changes in response to the various policies, and ensure
studies giving insight into the options for establishing systems of
transparent pricing, more robust information is needed on medicine
quality trauma care and accreditation programmes for hospitals. The
pricing in the South African pharmaceutical sector, gleaned from
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authors, Timothy Hardcastle, George Oosthuizen, Damien Clarke
larger, in-depth pharmaco-economic evaluations.
and Elizabeth Lutge, address current and optimal staffing of trauma-
care facilities, compliance with minimum equipment standards,
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and the potential for patient harm, and call for the establishment
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of a National Trauma Data Bank. They emphasise the need for Chapter 19 reviews the concept of health research observatories as
prevention programmes and the cost implications of trauma care, globally recognised proactive institutions that provide appropriate
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noting the cost-benefit ratio of good trauma care compared with the evidence-based information to guide policy-making decisions
litigation risk to government when such care cannot be provided. for improving a country’s health care. The chapter describes the
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The last chapter in the section related to health service delivery
vision, mandate, purpose, scope and benefits of, as well as key
challenges to, South Africa’s proposed National Health Research
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speaks to clinical quality of care and client satisfaction. Ronelle
Observatory (NHRO). Nobelungu Mekwa et al. identify the NHRO
Burger, Shivani Ranchod, Laura Roussouw and Anja Smith propose
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S A H R 20 1 6 ix
with prevailing infectious diseases. The imminently devastating effects
of climate change, and the vulnerability of economically deprived
and socially unprotected members of our communities requires
innovative and decisive action. It has never been more important
to abandon vertical and fragmented approaches and to opt for
an inclusive coalition of roleplayers to address the interdependent
factors benefiting human health, the environment and the economy.
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Leadership and Governance
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Leadership and Governance
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Health Policy and Legislation 1
Authors:
Andy Gray i
Yousuf Vawda ii
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he health policy and legislation arena has been dominated in 2015/2016 by Although a White Paper
the release, after much delay, of the White Paper on National Health Insurance
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(NHI). Although a White Paper is expected to provide finality on a policy in is expected to provide
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a manner which is ready for implementation, including the development of any finality on a policy in a
necessary legislation, the NHI document leaves many questions unanswered. The
manner which is ready for
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need for major changes to existing legislation is signalled in the White Paper, but
few details are provided on exactly how those changes might be made. In addition implementation, including
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to changes to the National Health Act and the Medical Schemes Act, and perhaps the development of any
even the Constitution, the possibility of a new NHI Act is also flighted. Two small steps,
in the form of drafts Bills to amend the National Health Laboratory Service Act and necessary legislation, the
National Health Insurance
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to create a new National Public Health Institute of South Africa, have been taken.
However, neither Bill has yet been tabled in Parliament.
document leaves many
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The Medicines and Related Substances Amendment Acts of 2008 and 2015 will
questions unanswered.
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need careful promulgation, once the necessary secondary (regulations) and tertiary
(guidelines) legislation have been developed. The new South African Health Products
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Regulatory Authority is not expected to come into operation before 2017, and will
have to face not only the backlog in registration applications for medicines that is the
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legacy of the Medicines Control Council, but also complete and entrench the effective
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While there have been strident calls for a fundamental redesign of the Health
Professions Council of South Africa in order to create an independent, self-regulatory
council for the medical and dental professions, it is unclear whether these calls will
be heeded.
The Medical Innovation Bill, one of the few Private Member’s Bills to be tabled, still
languishes in Parliament.
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Introduction
A number of targets for reform of legislative instruments under the by-laws are outside of the scope of this chapter. Important health-
control of the National Department of Health were included in the related jurisprudence is also described. In addition, the chapter
Strategic Plan 2014/15–2018/19.1 Those listed included: briefly covers major national health-related policy documents. In
2015/2016, the policy and legislation arena was dominated by
➢➢ promulgation into law of a National Health Insurance Bill by
the release of the White Paper on National Health Insurance.2
2018/19;
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With the release of the White Paper on National Health Insurance White Paper on National Health Insurance (NHI).2 The expectation
in December 2015,2 and the Presidential assent to the Medicines was that the document would provide a clear way forward, fill the
and Related Substances Amendment Act (14 of 2015)3 this process gaps identified in relation to the Green Paper,11 and in particular
can be considered to be under way. However, as is described in
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include clear guidance, backed by the Treasury, on the financing
more detail below, both of these processes still face considerable options to be exercised. The White Paper falls short of a number of
challenges and will require concerted effort if the ambitious
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these expectations, and leaves many questions unanswered. To what
deadlines are to be met. As always, the Annual Report of the extent this is a reflection of ongoing differences of opinion between
National Department of Health provides a listing of legislation which the Department of Health and the Treasury is unclear. In the Budget
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falls under the portfolio of the Minister of Health, as well as other
legislation with which the National Department must comply.4
Speech delivered by the Minister of Finance on 24 February 2016,
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it was announced that a document on the financing options would
As in 2014/2015, the pace of health legislation in Parliament has be released “shortly”.12 The attainment of universal health coverage
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again been slow in the 2015/2016 period, with only the Medicines (UHC) is a complex process, but a necessary one which has been
Amendment Bill having been finalised. Parliament is still in the process enshrined as one of the Sustainable Development Goals (SDGs).13
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of discussing the Medical Innovation Bill (Private Member’s Bill 1 of The basic premise of the NHI proposals is redress of the current
2014), but no progress seems to have been made in this regard.5 fragmentation between the public and private sectors. The ultimate
The Medical Research Council has released a policy brief on the goals are those of UHC: “Population coverage under NHI will
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issue of ‘medical marijuana’.6 Drawing heavily on a published meta- ensure that all South Africans have access to comprehensive quality
analysis,7 the policy brief notes the dearth of high-quality evidence health care services”. The cardinal features of NHI are summarised
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for the claimed efficacy and safety of cannabinoids. as “universal access”, “mandatory prepayment of health care”,
It is unclear whether the International Health Regulations Bill, “comprehensive services”, financial risk protection”, a “single
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which was initially published for comment in 2013,8 will be tabled fund”, using a “strategic purchaser” and a “single payer”.
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in Parliament. The draft Bill provides for the domestication of the The White Paper describes a three-phase process of implementation
International Health Regulations (IHR) of 2005.9 However, the over a 14-year period:
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the national sphere. The Annual Report 2014/2015 stated that this strengthening the public health sector, but also implementing
transfer was completed by March 2015 and that 44 ports of entry key enablers such as the Office of Health Standards
were assessed as being compliant with the IHR. Compliance (OHSC).
4 S A H R 20 1 6
Health Policy and Legislation
policy envisaged by draft Regulation 21 has also not been issued. new platform for service provision and health care financing”. In
Such steps are critical to ensuring that the OHSC has the necessary particular, the policy document proposes that legislative changes
powers to ensure compliance with the standards that are endorsed to the “functions, responsibilities and relationships within the three
or created. spheres of government”. This implies wide-ranging changes to the
National Health Act, and perhaps to the Constitution. However, no
From a legislative perspective, one of the key steps in the
specific examples are identified, nor are draft amendments provided
implementation process will be the amendment of the Medical
in the White Paper. An early intervention, which has been repeatedly
Schemes Act (131 of 1998). The White Paper is rather vague
signalled but not yet implemented, is the transfer of central hospitals
on the exact reforms to be implemented. The contribution of the
to the national sphere. However, in addition, an NHI Act is planned,
existing Prescribed Minimum Benefits (PMBs) to the “rising costs
which will establish the NHI Fund and its governance structure, the
of the private health sector” is acknowledged, but the problem is
NHI Commission. It is envisaged that the NHI Fund will report to the
also firmly located within the context of the dominance of the fee-
NHI Commission on a quarterly basis and to Parliament annually.
for-service reimbursement model in that sector. However, another
Surprisingly, and perhaps naïvely, the White Paper states that
key cost driver is identified as the “uncontrolled introduction of new
“[e] stablishing the Fund and the accompanying public entity will be
healthcare technology”, which is alleged to be associated with “cost
a straight process legislatively”.
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increases without an improvement in the quality of care”. A poorly
referenced claim is made that “[s]pending through medical schemes The creation of the NHI Fund requires attention to more than
in South Africa is the highest in the world and is six times higher just the financial flows. The White Paper identifies the need for
than in OECD countries”. A later reference seems to indicate that governance and accreditation structures, purchasing systems, risk
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this refers to the percentage of expenditure on medical schemes, mitigation systems, health technology assessment, and monitoring
claimed to be “more than 6 times the 2013 OECD average of and evaluation systems. The basic structure will need to be in place
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6.3%”, rather than the quantum of per capita expenditure. by the early stages of Phase 2, when the transitional Fund will need
to be able to purchase PHC services “from certified and accredited
One of the most debated points in relation to NHI is that of the basket
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of services to be covered, also referred to as the benefit package.
from Emergency Medical Services (EMS) and the National Health
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The White Paper states that “NHI will provide a comprehensive
Laboratory Service (NHLS).
package of personal health services”, but also that priority-setting
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and progressive realisation will characterise that process: “NHI will While vague in relation to many PHC services, some detail is
not cover everything for everyone”. Instead of providing details provided in relation to pharmaceutical supply and laboratory
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of the proposed benefit package, the policy document proposes services. It is envisaged that accredited and contracted private sector
the creation of an NHI Benefits Advisory Committee to determine community (retail) pharmacies will be enabled to procure medicines
“service entitlements for all levels of care”. This set of “benefits” on nationally agreed pharmaceutical contracts (presumably tenders),
will be clearly linked to detailed treatment guidelines, an Essential and will be paid a “capitated administration fee”. In addition to
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Medicines List, and an essential devices and diagnostics list, based contracting with the NHLS, it is envisaged that the NHI Fund will also
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on the best available evidence and assessments of cost-effectiveness. contract with “certified and accredited private laboratory service
To do so will require the creation of a substantial health technology providers”, but only “based on need”. It is suggested that volume
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assessment (HTA) capacity, where at present the only sustained thresholds will be set for such providers, above which reimbursement
effort has been in relation to the public sector Standard Treatment will be limited to the marginal cost of providing the service.
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In order to ensure that financial risk protection is extended to those Much of the media coverage of the White Paper and the reactions
who use the public sector, the White Paper proposes that the Uniform from various stakeholders have focused on the financing options
Patient Fee Schedule (UPFS) in the public sector be abolished in the listed. Only “illustrative projections” are provided, and no clear
early stages of the transition. In addition, it states that “a massive preference between the listed funding options (direct taxation,
reorganization of the health system would be required to create a indirect taxation, payroll taxation and premiums) or their
S A H R 20 1 6 5
Health Professions Act
combinations is evident. Five scenarios are painted instead; the Although no draft amendment to the Health Professions Act has yet
first combines a surcharge on taxable income, an increase in been prepared by the Ministry or the Department of Health, there
value-added tax (VAT) and a payroll tax. The other scenarios each is a widespread belief among the medical and dental profession
eliminate one or more of those components. It is stated that: “NHI’s that fundamental change is needed. It has been reported that the
financing requirements are uncertain, and in part depend on public South African Medical Association (SAMA) had commenced with
health system improvements and medical scheme regulatory reforms the development of a “legal white paper” in 2012.26 The intention
which have not yet been fully articulated”. This is perhaps the is to provide for an autonomous self-regulatory body for the medical
clearest indication that the White Paper is not the final word on and dental professions, separate from those for the other health
the matter, and that the policy development process is continuing. professions currently regulated by the Health Professions Council
Consultation with various structures will be required, including the of South Africa (HPCSA). A newly appointed HPCSA is in the
Presidential Coordination Committee (PCC) on Intergovernmental process of reacting to the findings of a Ministerial task team into the
Relations and Fiscal Arrangements (IGFR) and the Financial and functioning of the Council and its secretariat.
Fiscal Commission (FFC). In order to formalise the development
Despite these seismic events, the Minister and HPCSA continue to
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process, terms of reference for National Health Insurance “work
issue subordinate legislation in the form of Regulations and Rules.
streams” have been gazetted.21 The six work streams are:
These included an exception to the process of registration as a
➢➢ Prepare for the establishment of the NHI Fund; specialist in family medicine,27 draft regulations creating a list of
16 6
➢➢ Design and Implementation of NHI Health Care Service new sub-specialities in medicine (allergology, forensic psychiatry,
Benefits; geriatric psychiatry and neuropsychiatry),28 and draft regulations
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defining the scope of the profession of oral hygiene.29
➢➢ Prepare for the purchaser-provider split and accreditation of
providers; The last of these was not contested, as was a previous Regulation
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➢➢ The role of medical schemes in an NHI environment;
issued in 2005, which created the profession of dental assistants.30
Although a period of 10 years was allowed before this provision
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➢➢ Complete NHI Policy paper for public release; and became effective, many dental assistants remained unregistered in
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➢➢ Strengthening the District Health System. 2015, with predictions of major disruptions to service provision.31 A
rejection of a Court challenge to the regulations by the South African
Work Stream five which relates to the finalisation of the NHI policy
Dental Association (SADA) was upheld by the Supreme Court of
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December 2016.22
and higher-quality service due to the mandatory training required.
SADA challenged the Regulations on the basis of administrative law
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Secondary legislation
principles, arguing firstly, that the Minister was not empowered to
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6 S A H R 20 1 6
Health Policy and Legislation
SADA’s representations had fallen on deaf ears. Additionally, the This guideline would seem to ignore a number of circumstances
Court noted that the actions taken by the Minister and the HPCSA that can lead to increased demand for services. For instance, the
were in line with global trends related to the regulation of health- population using a shopping mall may be drawn from an area
related professions. Finally, SADA attracted the opprobrium of the far wider than a sub-district, especially in a metropolitan area or
majority of the Court for its conduct towards dental assistants which other large city, and therefore support more than one pharmacy. In
were described as “condescending, patronising, disingenuous”. The private hospitals, a separate community and institutional pharmacy
Court thus issued an order, unusual in constitutional litigation, that may be present, in part driven by the presence of a large number of
SADA pay the costs of the respondents. The decision is significant prescribers’ consulting rooms. In such settings, the 500m proximity
in that the members of DAASA, comprising predominantly black rule would seem to be unjustified. In the absence of an implementable
female dental assistants, now enjoy statutory recognition which will, ‘certificate of need’ as contemplated in the National Health Act,
among other benefits, provide them with a measure of protection in the imposition of strict ‘need’ criteria for one category of health
the workplace. The case also has a wider import in that the ability professionals appears to be arbitrary and possibly discriminatory.
of statutory health councils to create new registers, for example
for newly-designated mid-level health cadres, has been confirmed. Allied Health Professions Act
However, despite this very clear signal from the Court, subsequent
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The Allied Health Professions Council of South Africa (AHPCSA)
media coverage has indicated that the HPCSA may well be
issued a final Code of Ethics in December 2015.38 This document
reconsidering the deadline for registration of dental assistants.33 The
exposes one of the contradictions that exist between the Allied
HPCSA has just made a statement, but no change to the Regulation
Health Professions Act and the Medicines and Related Substances
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has been made.
Act. Even though complementary medicines are currently defined
in the Regulations to the Medicines Act as being those associated
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Nursing Act
with one of the allied health professions regulated by the AHPCSA,
In the period under review, no new legislative instruments were issued section 22A of the Medicines Act only allows a practitioner
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in terms of the Nursing Act. The existing, and most unsatisfactory
arrangement, whereby nurses are issued with permits in terms of
(someone registered as such in terms of the Allied Health Professions
Act) to prescribe substances listed specifically for that purpose in
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section 56(6) in order to be able to prescribe medicines, remains in the Schedules. No such lists exist. Practitioners can only dispense
if they hold a section 22C(1)(a) dispensing licence. However, as
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Registrar of the Pharmacy Council announced in February 2016 that qualifications outside of South Africa (with two of these, Board
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the ban on the sale of HIV self-tests by pharmacists had been lifted Notices 146 and 148 issued and then replaced by later versions,
in May 2015.34 Updated GPP standards will also have to take into Board Notices 176 and 177 of 2015).39–47 In addition, it
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account the outcome of the Medirite challenge, which was finally prescribed the professional titles and designations to be used,48
decided in March 2015.35 amended the Continuing Education requirements for practitioners
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are among the few health facilities that require the equivalent of a Naturopathy and Phytotherapy.50
‘certificate of need’ before they can be opened, moved or altered.12
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The publication of proposed criteria for the issuing of licences for However, the most important statement made by the AHPCSA in
pharmacy premises in February 2014 was heavily contested.36 A 2015 relates to the concept of homeopathic ‘vaccines’. Noting the
subsequent draft set of guidelines was published by the Minister of standard meaning of the term ‘vaccine’,a the AHPCSA resolved that
“no homeopathic substance should be termed or purported to be
Health in November 2015.37 In addition to setting new proposed
a homeopathic ‘vaccine’”.51 For a homeopath to do so would thus
criteria, the guidelines included recognition of the specific
constitute unprofessional conduct.
requirements of pharmacies which offer only a limited service, such
as the conduct of clinical trials, the supply of veterinary medicines
Medical Schemes Act
or the compounding of oncology products. Such pharmacies would
be exempted from the requirements for meeting the norms for No finality has yet been reached in relation to the challenge to
establishing new pharmacy premises. The proposed norms were Regulation 8, which governs the application of the prescribed
for at least one community pharmacy per sub-district, with a usual minimum benefits (PMBs), by Genesis Medical Scheme (Western
ratio of one pharmacy per 5 000 population and one per 2 500 Cape High Court Case No. 15268/14). Nor has finality been
population in rural sub-districts. In rural sub-districts, exceptions reached in relation to the draft set of amendments to Regulation 8
could be considered if the proposed pharmacy is more than 20km which were published for comment in July 2015.52 However, in
from an existing pharmacy. Normally, new pharmacies should not
be located closer than 500m from an existing pharmacy, except in a The definition relied upon is as follows: “Vaccines are biological
rural sub-districts. A short comment period (45 days) was provided preparations of antigenic materials that are believed to develop adaptive-
immunity in recipients of the vaccine to a specific disease, are typically
for, but no final guideline has yet been published. manufactured from attenuated or inert antigenic materials and are
administered in either a prophylactic or therapeutic conventional medical
approach against disease”.
S A H R 20 1 6 7
March 2016, the Constitutional Court dismissed Genesis Medical A confusing element is introduced by section 2(c) of Act 14 of 2015.
Scheme’s application to appeal a 2015 judgment by the Supreme This section of the Amendment Act introduces a new section 2(5)
Court of Appeal to the effect that medical schemes could only direct to the substantive Act, as follows: “The Authority acts through its
patients to public sector hospitals for treatment of PMB conditions if Board”. At the level of governance, this is clear. However the basic
they had a designated service provider contract in place with the premise of the shift from the MCC to SAHPRA is that decision-making
relevant public health authorities.53,54 power in relation to the regulation of medicines and medical devices
is to be vested in the Authority (comprising full-time employed staff),
In September 2015, the Council for Medical Schemes (CMS)
rather than in the Council (comprised of external experts). Section
released guidelines for low-cost benefit options (LCBOs), which would
2H of Act 14 of 2015 enables the Board to “appoint one or more
enable a scheme to apply for exemption in terms of section 8(h) of
committees from among its members to assist it with the performance
the Act.55 In terms of these guidelines, LCBOs would be allowed
of its functions”. It would therefore seem unlikely that these committees
greater flexibility in terms of the requirements for open enrolment,
would be sufficiently broad in composition and scope to provide the
PMB coverage and/or broker remuneration. However, in October
staff of SAHPRA with technical advice on regulatory applications
2015, this draft guideline was withdrawn by the CMS.56 Although
(such as applications for registration), in the same way that the
the CMS indicated that it would publish a revised guideline, no date
expert committees of the MCC do now. A new section 3(9) of the Act
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for such publication was set, and no such draft guidelines have yet
therefore enables the Chief Executive Officer of SAHPRA (who will
been published. As outlined above, the implementation of NHI will
replace the Registrar of Medicines) to appoint “committees, as he or
require extensive review of the Medical Schemes Act, the details of
she may deem necessary, to investigate and report to the Authority
which are as yet unclear.
16 6
on any matter within its purview”. One of the sections that has not
been amended by either the 2008 or the 2015 Amendment Acts is
Medicines and Related Substances Act
20 IL
that related to “secrecy”. Instead, SAHPRA will need to ensure the
Planning for SAHPRA maximal degree of transparency, and in particular ensure that the
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Despite being erroneously tagged as a section 76 Bill (an ordinary technical advice provided by expert committees is made available
Bill affecting the provinces), the Medicines and Related Substances to the public, and can be contrasted with the decisions eventually
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Amendment Act (14 of 2015) was passed by Parliament after an taken by the staff, as delegated by the Chief Executive Officer. It is
extensive series of public hearings in the provinces, and assented to exactly this ability to hold SAHPRA accountable that will foster the
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by the President in December 2015.3 However, the next steps are development of trust in its regulatory decisions, in the eyes of the
complex. Act 14 of 2015 comes into effect as soon as the previous public, health professionals and the pharmaceutical and medical
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Medicines and Related Substances Amendment Act (72 of 2008) device industries. Very carefully drafted regulations and guidelines
is promulgated. It is unclear how this provision (section 27 of the will be needed before such processes can be implemented. Another
Amendment Act) will operate if, as is expected, Act 72 of 2008 urgent need is for final regulations in respect of medical devices,
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is brought into effect in phases. Most critically, the promulgation taking into account the comments elicited in April 2014.57
should be co-ordinated with the development of extensive new As expected, the final wording of the 2015 Amendment Act
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regulations and guidelines. In addition, the creation of SAHPRA will entrenched the role of the Pricing Committee in advising the Minister
require careful attention to labour law issues as staff are transferred on matters relating to pricing policy, notably in section 18A of the
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from the National Department of Health to the new Authority, and to Medicines Act. While the regular updates to the single exit price58,59
the appropriate financing and initial capitalisation of the structure.
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Medicines Control Council (MCC) with a new South African Health acts” referred to in section 18A of the Act, which was published
for comment in August 2014.61 The draft included an extensive list
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8 S A H R 20 1 6
Health Policy and Legislation
applicable standards. In August 2015, the MCC used section 23 of and traditional surgeon (circumcision) practice is set at ABET Level
the Medicines Act to declare a list of topical preparations containing 1, equivalent to a school Grade 3, the Regulations require that the
corticosteroids as undesirable.64–66 The products were imported into tutor or institution be “registered and accredited by the Council to
the country and were purportedly manufactured in India, Indonesia provide the training or course”. The specified durations of training
and Italy. are as follows:
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Model Law in recognition of the need to promote and protect ➢➢ traditional surgeon (circumcision) practice – five years
the public health of Africa’s citizens.67 (including observation of three initiation schools and
supervised practice for two years).
The Model Law is designed as an enabling framework, intended to
16 6
assist countries which have no or inadequate regulatory frameworks In addition, it is stipulated that a student practitioner in divination
for the approval of medical products (defined as medicines, or herbalism must be at least 18 years of age, and a student
20 IL
vaccines, diagnostics and medical devices). A 2010 World Health practitioner in traditional birth attendant practice or traditional
Organization (WHO) study of 26 sub-Saharan countries found that, surgeon (circumcision) practice must be at least 25 years of age at
while most of them had legal provisions for the most essential aspects
Y T registration in order to practise.
of medicines control, their regulatory systems presented some critical
The application form for “trainers” requires submission of “copies
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weaknesses (fragmentation of responsibilities; many gaps and grey
of teaching/learning materials”, which seems to anticipate the
areas; a multitude of provisions which were difficult to implement; little
availability of such materials. Whether that is practical in this setting
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of their people and, especially, to contribute to building stronger systems strengthening have been published for comment, but have
regulatory systems to tackle the proliferation of substandard medical not yet tabled in Parliament.70
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primary objectives:
Regional Economic Communities (RECs) with the support of the
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African Medicines Regulatory Harmonization (AMRH) Programme. ➢➢ to amend the National Health Laboratory Service Act, 2000,
Through the programme, RECs are harmonising medicines so as to define certain expressions and to delete a definition;
regulations and facilitating work-sharing among countries for faster, ➢➢ to make the Preferential Procurement Policy Framework Act,
quality, predictable and transparent approval of medical products in 2000, applicable to the National Health Laboratory Service;
African countries. The ultimate goal is to facilitate faster access to life
➢➢ to adjust the objects and duties of the Service; and
saving medical products.63
➢➢ to strengthen the governance and funding mechanism of the
Traditional Health Practitioners Act National Health Laboratory Service.18
Progress in relation to the effective operation of the Traditional The proposed amendments are routine in nature, except for two
Health Practitioners Council has been slow. A necessary step was issues. Apart from a reference to the Preferential Procurement Policy
taken in November 2015, with the publication for comment of draft Framework in the proposed amendment to section 3, no other
Regulations in terms of the Traditional Health Practitioners Act (22 funding mechanism is spelt out for the National Health Laboratory
of 2007) into operation.69 Given the nature of traditional health Service (NHLS). As regards governance, the Board and executive
practice and the training of practitioners, some of the proposed positions indicated in the Act are to be appointed and accountable
Regulations seem ill-suited, and reliant on mechanisms of control to the Minister (section 9), placing control of this Service firmly in the
that are more appropriate to more formalised settings. For example, hands of the Minister. This is somewhat of a departure from other
while a minimum level of education for a student practitioner in the governance mechanisms, such as the proposed SAHPRA Board.
categories divination, herbalism, traditional birth attendant practice
S A H R 20 1 6 9
National Public Health Institute of South Africa Bill and co-operation from the Department of Agriculture, Forestry and
Fisheries (DAFF). The National Department of Health has issued a
The National Public Health Institute of South Africa Bill has as its
call for nominations to the National Ministerial Advisory Committee
primary objectives:
(MAC) on Antimicrobial Resistance, which will be tasked with
“to provide for the establishment of the National Public Health working not only with DAFF, but also with the Departments of Trade
Institute of South Africa in order to conduct disease and injury and Industry, Science and Technology, Basic Education, Higher
surveillance and to provide specialised public health services, Education and Training, Water and Sanitation, Mining, Justice,
public health interventions, training and research directed Correctional Services, and Transport. The MAC will be tasked with
towards the major health challenges affecting the population a daunting range of interventions, including:
of the Republic.19 ➢➢ institutionalisation of effective systems of antimicrobial
The intent is therefore to separate the routine services of the NHLS stewardship (AMS) at national, provincial, and institutional
from its research activities and devolve them on the new structure, levels in both the public and private sectors using the ‘one
the National Public Health Institute of South Africa (NAPHISA). The health’ approach;
governance structure consists of a semi-autonomous Board, not ➢➢ structured national surveillance and reporting systems for
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dissimilar to that envisaged for SAHPRA in terms of the Medicines antimicrobial use and resistance in the human health and
and Related Substances Amendment Act (14 of 2015). agriculture sectors for the detection of newly emerged
Among the submissions made in response to the notice for comment resistance;
16 6
are that, the Bill should adopt an unequivocally public health focus ➢➢ the selection of antimicrobial agents on the Essential Medicine
and approach; an integrated risk factor surveillance strategy, should List (EML) based on trends and patterns of resistance;
20 IL
ensure greater co-ordination between reference laboratories and ➢➢ progress towards achieving compliance with the standards
referral services, and the intellectual property rights acquired by within the National Core Standards in all health establishments;
NAPHISA should not be used to shore up commercial monopoly.71
Y T ➢➢ the phased rationalisation or elimination of the use of
antimicrobials in agriculture or as growth promoters in food
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Health-related policy animals;
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This chapter does not attempt to track the implementation of all ➢➢ prevention strategies focusing on infection prevention and
existing health-related policies, even at a national level. However, control and enhanced vaccination programmes;
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it does draw attention to major policy documents released by the ➢➢ core curricula on antimicrobial resistance (AMR) for health and
National Department of Health in the period under review. All veterinary professionals;
health policy should be considered for coherence with the demands
➢➢ national community advocacy, awareness and education
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as to “[p]hase in national health insurance, with a focus on upgrading ➢➢ research into molecular mechanisms of resistance, and
public health facilities, producing more health professionals and dissemination of information on resistance, new medicines
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reducing the relative cost of private health care”. It is clear that these and diagnostics.
concerns are directly addressed by the recently released White
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10 S A H R 20 1 6
Health Policy and Legislation
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often conflating distinct types of relationships. It also does not
sufficiently address the critical need for and role of psychological
services in adolescent sexuality. As with all government policy and
strategies, implementation will be key.
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Conclusion
For a number of years, successive editions of the Review have
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recorded that, yet again, the much-anticipated White Paper on
National Health Insurance had not been issued. This year, the
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publication of this seminal policy document can be recorded, but so
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can the sense that much remains unsettled and far from final. Some of
the critical systems strengthening steps, such as the operationalisation
of the independent Office of Health Standards Compliance, are far
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Progress on this policy has been, at best, glacial. There is still much
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to be done.
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S A H R 20 1 6 11
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2014/15–2018/19. functioning of the Office of Health Standards Compliance
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27 Health Professions Council of South Africa. Registration of 40 Allied Health Professions Council of South Africa. Policy on
specialists in family medicine. Board Notice 230 of 2015, criteria for registration of persons with qualifications obtained
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URL: http://www.gov.za/sites/www.gov.za/files/39299_ Government Gazette No. 39074, 7 August 2015.
bn230.pdf URL: http://www.gov.za/sites/www.gov.za/files/39074_
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28 Minister of Health. Health Professions Act: Regulations
relating to the specialities and subspecialities in medicine 41 Allied Health Professions Council of South Africa. Policy on
and dentistry: Amendment. Government Notice No. 992, criteria for registration of persons with qualifications obtained
Government Gazette No. 39304, 20 October 2015. outside South Africa: Chinese medicine and acupuncture,
URL: http://www.gov.za/sites/www.gov.za/files/39304_ acupuncture and Unani-Tibb. Board Notice 147 of 2015,
gon992.pdf Government Gazette No. 39074, 7 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
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defining scope of profession of oral hygiene. Government
Notice No. 1171, Government Gazette No. 39453, 26 42 Allied Health Professions Council of South Africa. Policy on
November 2015. criteria for registration of persons with qualifications obtained
URL: http://www.gov.za/sites/www.gov.za/files/39453_ outside South Africa: Chiropractic. Board Notice 148 of
gon1171.pdf 2015, Government Gazette No. 39074, 7 August 2015.
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Qualifications for registration of dental assistants. Government
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April 2005, corrected by Government Notice No. 338, criteria for registration of persons with qualifications obtained
16 6
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20 IL
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31 Child K. New drill for assistants an ache for dental industry.
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A N
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industry obtained outside South Africa: Homeopathy, naturopathy
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bn175.pdf
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criteria for registration of persons with qualifications obtained
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47 Health Professions Council of South Africa. Policy on criteria
37 Minister of Health. Pharmacy Act: Guidelines for issuing of for registration of persons with qualifications obtained outside
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1065, Government Gazette No. 39376, 6 November 2015. Government Gazette No. 39143, 28 August 2015.
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38 Allied Health Professions Council of South Africa. Code of 48 Allied Health Professions Council of South Africa.
ethics. Board Notice No. 268, Government Gazette No. Unprofessional conduct: Use of professional titles and
39531, 18 December 2015. designations. Board Notice 138 of 2015, Government
URL: http://www.gov.za/sites/www.gov.za/files/39531_ Gazette No. 39220, 18 September 2015.
bn268.pdf URL: http://www.gov.za/sites/www.gov.za/files/39220_
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outside South Africa: Ayurveda. Board Notice 144 of 2015, Requirements for continuing professional development:
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bn144.pdf URL: http://www.gov.za/sites/www.gov.za/files/39143_
bn178.pdf
S A H R 20 1 6 13
50 Allied Health Professions Council of South Africa. Professional 60 Minister of Health. Medicines and Related Substances Act:
Board for Homeopathy, Naturopathy and Phytotherapy: Regulations: Transparent pricing system for medicines and
Unprofessional conduct: Composition of inquiring body. Board scheduled substances: Dispensing fee for pharmacists.
Notice 189 of 2015, Government Gazette No. 39243, 2 Government Notice No. 153, Government Gazette No.
October 2015. 39658, 5 February 2016.
URL: http://www.gov.za/sites/www.gov.za/files/39243_ URL: http://www.gov.za/sites/www.gov.za/files/39658_
bn189.pdf gon153.pdf
51 Allied Health Professions Council of South Africa. 61 Minister of Health. General regulations relating to bonusing
Unprofessional conduct: Concept of homeopathic ‘vaccines’ and sampling. Government Notice No. R.642, Government
within the philosophy of homeopathy or homeopathic Gazette No. 37936, 22 August 2014.
methodology. Board Notice 145 of 2015, Government URL: http://www.gov.za/sites/www.gov.za/files/37936_
Gazette No. 39074, 7 August 2015. rg10251_gon642.pdf
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn145.pdf 62 Minister of Health. Regulations relating to a transparent
pricing system for medicines and scheduled substances:
52 Minister of Health. Amendment of General Regulations made (benchmark methodology). Government Notice No. R.324,
in terms of the Medical Schemes Act, 1998. Government Government Gazette No. 37625, 12 May 2014.
Notice No. 603, Government Gazette No. 38990, 14 July URL: http://www.gov.za/sites/www.gov.za/files/37625_
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2015. rg10189_gon354.pdf
URL: http://www.gov.za/sites/www.gov.za/files/38990_
gon603.pdf 63 Minister of Health. General Regulations made in terms of
the Medicines and Related Substances Act 101 of 1965:
53 Kahn T. Benefits decision a boon for medical scheme amendment. Government Notice No. R.716, Government
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members. Business Day, 1 March 2016. Gazette No. 37995, 15 September 2014.
URL: http://www.bdlive.co.za/national/ URL: http://www.gov.za/sites/www.gov.za/files/37995_
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health/2016/03/01/benefits-decision-a-boon-for-medical- rg10267_gon716.pdf
scheme-members
64 Registrar of Medicines. Medicines and Related Substance
54 The Council for Medical Schemes v Genesis Medical Scheme
Y T Act: Undesirable medicines. Government Notice No. 734,
(20518/14) [2015] ZASCA 161 (16 November 2015). Government Gazette No. 39114, 19 August 2015.
URL: http://www.justice.gov.za/sca/judgments/sca_2015/ URL: http://www.gov.za/sites/www.gov.za/files/39114_
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sca2015-161.pdf gon734.pdf
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55 Council for Medical Schemes. Circular 54 of 2015: Low cost 65 Registrar of Medicines. Medicines and Related Substance
benefit options (LCBOs) framework and principles approved Act: Undesirable medicines. Government Notice No. 735,
as well as guidelines for preparation of a business plan Government Gazette No. 39114, 19 August 2015.
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56 Kahn T. Low-cost medical schemes delayed. BDLive 16 Government Gazette No. 39121, 20 August 2015.
October 2015. URL: http://www.gov.za/sites/www.gov.za/files/39121_
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57 Minister of Health. General regulations relating to medical policy decision to improve medicines regulation. 1 February
devices and in vitro diagnostic medical devices (IVDs). 2016.
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Analysing the progress and fault lines of
health sector transformation in South Africa
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Author:
Laetitia Rispel i
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outh Africa has implemented a number of policies that focus explicitly on A primary health care
equity and that seek to provide redress to those most affected by previous
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apartheid policies. Examples include the adoption of a primary health care approach was adopted,
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approach, which in itself is a social justice philosophy, and the use of a combination which in itself is a social
of legislative, policy and resource allocation levers to achieve transformation and to
justice philosophy, and a
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health policies in South Africa and the fault lines in implementation. Notwithstanding policy and resource-
the progress made since 1994, the chapter presents a critical analysis of and reasons allocation measures have
for the relatively poor performance of the South African health system compared with
been used to achieve
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other countries of similar income level, and in light of the country’s quantum of health
care spending. transformation and improve
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Three fault lines are identified: tolerance of ineptitude as well as leadership, population health.
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management and governance failures; lack of a fully functional district health system,
which is the main vehicle for the delivery of primary health care; and inability or
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These fault lines have negative consequences for patients, health professionals
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and policy implementation. Patients, who are relatively powerless, bear the brunt
through negative experiences and sub-optimal care. Health care providers on the
front line and at the bottom of the hierarchy also suffer. Faced with an unsupportive
management environment, staff shortages and health system deficiencies, they find it
difficult to uphold their professional code of ethics and provide good quality of care.
The chapter concludes with a call for the metaphorical ‘repair of the fault lines’ to
ensure the success of the proposed national health insurance system.
Centre for Health Policy, School of Public Health, Facult y of Health Sciences, Universit y of the Wit watersrand, Johannesburg
17
Introduction
South Africa is a profoundly better place than it was before 1994,1 Huge health and health care inequalities remain between the public
with significant progress recorded in the health sector.2 Set against and private health sectors, between urban and rural areas, among
the backdrop of the 1997 White Paper for the Transformation the nine provinces, and even within provinces.4,10,12,13 Three
of the Health System,3 the first wave of transformation saw the seminal documents: the national development plan13 (NDP); a 20-
development of an enabling policy and legal framework for the Year Review by the Presidency;4 and the 2015 White Paper on the
complete overhaul of the health care system, the establishment of proposed National Health Insurance (NHI)14 acknowledged that we
an integrated national public health system from 14 fragmented, should be doing much better.
racialised or Bantustan ‘health’ departments, and the removal
This chapter provides an analytical perspective on the fault lines in
of racial barriers in access to health care.4 Free health care for
South Africa’s revolutionary health policies in praxis and their failure
pregnant women and children was implemented within the first 100
to realise fully both the promise and intentions of a transformative,
days of the late President Mandela’s inauguration to demonstrate the
high-performing health system. These fault lines are explored
new government’s commitment to service delivery.
in the next section of the chapter. The concluding section makes
recommendations on what needs to be done about the fault lines
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On paper, primary health care (PHC) delivered through the district
health system (DHS) became the cornerstone of health care policy.4 to ensure the success of the proposed NHI system. The chapter
The 2003 National Health Act formalised the legal status of the draws on health systems research conducted over more than two
DHS, which is the vehicle for PHC service delivery.5 Free PHC decades, with methodologies ranging from reflective diaries and
16 6
services and the clinic-building programme played a big role in ethnographic research to large-scale surveys.15
removing access barriers to basic health care. This is illustrated by
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an increase in visits to PHC facilities from 67 million in 1998 to 129
Fault lines in health sector transformation
million by the end of March 2013,4 and near doubling of total PHC
expenditure per capita in real terms.6 Y T There are three major fault lines in health sector transformation,
shown in Box 1.
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Similar encouraging developments have been recorded in the
implementation of priority health programmes, such as the expanded
Box 1: Fault lines in health sector transformation
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These policies are revolutionary because of the explicit focus findings from research projects.
on equity and redress in order to benefit those most affected by
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previous apartheid policies. Primary health care, in itself a social Tolerance of ineptitude and leadership, management
and governance failures
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18 S A H R 20 1 6
Health sector transformation
health programme linkages, co-ordination and integration both inappropriate selection and appointment of officials in various
within the national health department, and between national and provincial administrations.17
provincial health departments; and 10 de facto health departments
There are other examples of leadership and governance failures.
rather than one strong national health system, mitigated optimal
The latter can also be seen in the failure to implement key reforms.
performance of the health system.16 Four years later, both the
For example, health professional education reforms are widely seen
National Development Plan13 and the 20-Year review by the
as an important strategy to improve the functioning of the health
Presidency have indicated that many of these problems remain.4
system because these reforms enhance the performance of the health
In one of the first studies to explore corruption in the South workforce.20–24 In South Africa, as elsewhere, nurses make up the
African health sector,17 trends in irregular expenditure (defined majority of healthcare providers. The development of proposals to
as expenditure incurred without complying with applicable laws reform the education and training of nurses took more than 10 years
and regulations), was used as one of the indirect measures of to complete and the Regulations were eventually promulgated in
corruption.18 Although irregular or unprocedural spending does not 2013.24
always result in personal gain, corruption – of necessity – involves
Recent policy studies on these education reforms 24,25 have found
irregular or unprocedural activities.19
ineffective governance on the part of both the South African Nursing
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The study found that over the four-year period from the financial year Council and the National Department of Health (NDoH), and
2009/10 to 2012/13, around R24 billion of combined provincial significant weaknesses in the policy-making and implementation
health expenditure was classified as irregular by the Auditor-General capacity of these institutions.24 Once again, the Nursing Council
16 6
of South Africa.17 In the 2012/13 financial year alone, irregular has postponed implementation of the new nursing qualifications
spending amounted to around 6% of combined provincial health framework until 2018.25 Despite the existence of a detailed plan
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expenditure in South Africa.17 There were also varying and erratic on nursing education, training and practice for the period 2012–
expenditure patterns in the nine provinces. The reality is that we do 2017,26 the NDoH has established yet another task team (with
not know how much of the irregular expenditure is due to corruption,
Y T external consultants) to develop proposals for nursing education and
because of difficulties with direct measures or validated indicators training. Hence implementation of the actual education reforms and
A N
to measure corruption. We can only postulate different scenarios: recommendations is unlikely to happen soon.
a worst-case scenario where R24 billion was lost due to corruption
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Sadly, the Nursing Council is not the only important governance body
over a four-year period, or the best-case scenario where R24 billion
that is in disarray – a Ministerial investigation into the effectiveness
was lost due to ineptitude or incompetence of public servants and
of the Health Professions Council of South Africa (HPCSA) found
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The study also found suboptimal audit outcomes for the nine
The HPCSA is in a state of multi-system organisational dysfunction
provincial health departments, as shown in Table 1.17,18
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08/09 09/10 10/11 11/12 12/13 The Council for Medical Schemes, a statutory body to regulate
Western Cape Medical Schemes in South Africa, has been without a permanent
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Eastern Cape registrar (chief executive officer) for more than a year. The Registrar
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Key: Unqualified Qualified Adverse or disclaimer Lack of a fully functional district health system
Source: Auditor-General of South Africa, 2014.18 Although there has been progress, 22 years into democracy, we still
do not have a fully functional DHS.a A functional DHS is expected
More importantly, the findings on irregular spending and audit to ensure the delivery of quality, equitable PHC services,29 improve
outcomes underscore the fault lines in leadership, management health outcomes for all South Africans30 (but especially those worst
and governance, namely: difficulty managing a ‘federal’ health off), address the social determinants of health, involve communities,
system; institutional characteristics of provincial administrations and change the power relations between the centre (province) and
(which includes the legacy of overcoming practices and the culture the periphery (the district).31
of Bantustan administrations); lack of enforcement of existing
legislation (rather than inherent legislative short-comings); capacity a Much of this analysis is contained in a forthcoming chapter by L Rispel
and J Moorman, entitled ‘Health system decentralization in South Africa’
constraints and different skill levels across provinces; and the (in Federations and Health System Decentralization, publication date
2016/17).
S A H R 20 1 6 19
With the introduction of democracy, a large study on the development Indeed, several positive health workforce interventions, including
of norms needed for PHC services underscored the possibilities of a number of financial incentives, have been implemented since
changing a fragmented and racially divided health system into one 1994.40 The most recent and highly publicised financial incentive,
based on the PHC philosophy.32 Far-reaching recommendations which boosted health professional remuneration levels considerably,
were made on an essential package of PHC services, which was the Occupation-specific Dispensation (OSD). However, many of
comprised a range of comprehensive services, including women’s the positive aspects of the OSD have been marred by implementation
health, mental health, and rehabilitation services, provided in flaws, and evaluations of its impact have seen mixed results.16,41,42
an integrated fashion.32 Quality control and continuous quality
In theory, we have a five-year national Human Resources for Health
assessments were built into the proposed package, and its cost
(HRH) Strategic Plan to address the South African health workforce
components.32 Facility and staff requirements were closely aligned
crisis.43 However, the plan lacks detail, it largely ignores lower
with the PHC service package. The recommendations highlighted
levels of government, and the vast human resource implications
the importance of establishing a functional DHS and managing
NHI appear to be underestimated.40 The critical issue of how to
change in the health sector.32
secure the right skills and the right numbers of health professionals
Almost 20 years later, recent studies have highlighted several at different levels of the health system is not even dealt with in the
PM
constraints on achieving a fully functional DHS.33,34 These include: plan.40
policy changes on the envisaged role of local government in PHC
More importantly, implementation of the strategies contained in
service delivery, in part because of the lack of clarity on the meaning
the plan has been slow or non-existent, and the NDoH has missed
of municipal health services in the South African Constitution; lack of
16 6
many of its own deadlines listed in the plan. This is in part because
role clarity among national, provincial and local government health
of the extremely limited technical capacity at the NDoH, the over-
departments; tension and lack of trust between staff employed by
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reliance on costly external consultants, and organisational structures
provincial and local government health departments, funding and
at both national and provincial health departments that are not
capacity problems; and ineffective and inefficient management
Y T commensurate with the size and scale of the effort required to deal
systems.31
with the health workforce crisis.
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Moreover, the constitutional autonomy of provincial health Depart-
A critical question is whether we have a health workforce crisis in
ments creates the conditions for different interpretations of what
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not functioning as decentralised authorities as originally intended; higher ratios of health professionals than its minimum norms.39
the head of the provincial Department of Health remains the We also have well-established training institutions (among the best
accounting officer, and there are marked variations in financial and in the world), highly skilled health workers, effective professional
human resource delegations across provinces.36 The problems are regulation, and sufficient fiscal space for relatively high remuneration
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exacerbated by human resource shortages, suboptimal stewardship levels compared with many other countries.44
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from and are poorly co-ordinated with PHC services in many places. management and governance, which has been described earlier.
Without the appropriate delegations, district health managers cannot
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20 S A H R 20 1 6
Health sector transformation
years.48,49 Because there are no national norms and standards, it is positive change.
difficult to determine the extent and nature of staff shortages in the
Addressing the leadership, management and governance failures
public sector and in different types of health facilities.
requires political will; meritocratic appointment of public service
Furthermore, moonlighting and agency nursing among nurses, and managers with the right skills, competencies, ethics and value
private practice among public sector doctors, exacerbate the staff- systems; effective governance at all levels of the health system
shortage crisis. In a 2010 study, 40.7% of the 3 700 participating to enforce laws; appropriate management systems; and citizen
nurses reported moonlighting or working for an agency in the year involvement and advocacy to hold public officials accountable.17
before the study.50 The reported health system consequences were
Primary health care is at the core of revitalising and strengthening the
serious, with half the participating nurses reporting that they felt too
South African health system, as enunciated once again in the 2015
tired to work whilst on duty.51
White Paper on NHI.14 However, this can only happen through
Fourthly, we face a crisis of unprofessional behaviour, poor staff a well-functioning DHS. Hence, the NDoH must develop a clear
motivation, suboptimal performance, and unacceptable attitudes of implementation plan for the establishment of a well-functioning DHS.
health workers towards patients, all of which compromise quality This implementation plan should include: a clear outline of the roles
of patient care and health service efficiency.44 These problems are and responsibilities of different levels of government; strategies for
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exacerbated by a general lack of accountability, reported by health strengthening management both at district level and at all facilities
service managers in several studies,48,49 and emphasised as an issue within the district; a clear communication strategy to communicate
that requires attention by the Presidency. The lack of accountability the vision of PHC and of a DHS, and to ensure buy-in from various
is illustrated by research on moonlighting which found that 10% of
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stakeholders and partners, as well as from the general public and
nurses took sick leave to do moonlighting when they were not sick.51 health service users; support structures with expert capacity in each
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Lastly, South Africa faces a crisis of inadequate human resource of the provinces; and clear indicators to monitor progress.34
information systems. Current information systems are fragmented This chapter has highlighted the inability or failure to deal with
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and unable to inform health workforce planning and training.
There are also technical problems of data quality, coverage and
the health workforce crisis. An adequately skilled, productive and
well-motivated health workforce is a prerequisite for universal health
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comparability.16 Even where information is available, it is not used coverage.53 The experience in Brazil has shown that universal
to inform decision-making.
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These fault lines coalesce to produce a number of negative countries. The process requires the active participation of all
consequences for patients, for health professionals, and for policy stakeholders, including the Academy.
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S A H R 20 1 6 21
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SA since 1994 and Implications of the New Vision for PHC re- Nurses’ perspectives on the Code of Ethics and Service
engineering. In: Padarath A, English R, editors. South African Pledge in five South African hospitals. Glob Health Action.
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42 Motsosi K, Rispel LC. Nurses perceptions of the 2014.
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of Health; 2011.
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and enrolment figures. Pretoria: South African Nursing
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18 April 2016].
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48 Munyewende P, Rispel LC. Using diaries to explore the work
experiences of primary health care nursing managers in two
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[Internet]. [cited 18 April 2016].
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49 Armstrong SJ, Rispel LC, Penn-Kekana L. The activities
of hospital unit managers and quality of patient care in
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50 Rispel LC, Blaauw D, Chirwa T, de Wet K. Factors influencing
agency nursing and moonlighting among nurses in South
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51 Rispel LC, Blaauw D. The health system consequences of
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Water, sanitation and health: South Africa’s
remaining and existing issues
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David Hemson i
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ost-apartheid South Africa can lay claim to having substantially increased The water-related Sustainable
access to piped drinking water for all. Virtually all urban households and
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most rural households now have access to piped drinking water, with Development Goals extend
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the remaining deprived communities located in more remote rural areas and the range of commitment
in urban informal settlements. While drinking water may not necessarily be safe
beyond access to basic
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child under-five diarrhoea case fatality rates indicate ongoing health issues in rural improved water quality,
communities deprived of water services.
enhanced water use and
Water-related health issues are emerging due to conditions of water stress and climate
re-use and better water-
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change. Constraints on supply call for greater water re-use and better management
of treatment plants to ensure river health and safe drinking water. The process of related ecosystems.
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eutrophication is degrading water and habitat quality, and the results are difficult to
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treat. With climate change, existing microbial diseases could become more prevalent
which is especially disturbing as water treatment plants are discharging insufficiently
BA
treated effluent into rivers. Contamination of groundwater and surface water from
acid mine drainage requires specialised treatment. All of these factors indicate the
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need for improved water and health management, with greater surveillance of water
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quality and the delivery of universal water services to ensure health and prevent
disease outbreaks.
i Independent Consultant
25
Introduction
South Africa has made considerable progress in providing water South Africa’s post-apartheid government has set a higher standard
services, including both piped water and improved sanitation, of service in water and sanitation than that of international monitoring
to those who were previously deprived of such essential services organisations. The Department of Water and Sanitation (DWS)
during the apartheid era. This has resulted in significant benefits defines basic water supply as access to piped water, rather than to
for rural populations, which now have improved access to greater a range of improved ‘rudimentary’ sources. The standard sets the
volumes of water for domestic use, and some relief for women and minimum quantity of potable or safe drinking water at 25 litres per
girl children who bear the burden of collecting water from distant person per day (or six kilolitres per household per month), with flow
water sources. Although improved sanitation has not advanced to of 10 litres/second to a facility within 200m from the household.6
the same extent, increased levels of coverage have been achieved. Free basic water is available at this volume of consumption, although
a rising tariff applies thereafter.
However, certain structural weaknesses persist; a proportion of the
population either has no water services or due to uneven access Since the quality and safety of drinking water are not directly
to functioning systems, remain vulnerable to waterborne disease. measured in household surveys, the government has adopted
In urban areas, households are disconnected when there is non-
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a proxy measure, namely access to piped water, based on the
payment, and there can be ongoing challenges in the provision of assumption that all piped water is safe. This follows the practice of
water services to informal urban settlements. The current water crisis, international monitoring organisations in assessing progress.7 While
with water constraints and limited supply in some areas, raises national Regulations specify that water supply should be tested,6 this
16 6
questions about the overall management of water resources and appears to be applied more in urban than rural water systems.
infrastructure to ensure water quality in sufficient quantity for health,
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particularly under the demanding conditions of climate change. Access to piped water
Safe drinking water is essential to life, and water services are Levels of access to piped water have improved nationally when
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crucial for personal health and hygiene. A health-sustaining living
environment depends on access to water services supported by
compared with the deprivation of the past. Analysis of the data
over time is difficult, largely because apartheid-era statistics did not
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resilient water ecosystems that can provide water in sufficient include sections of the black population in ‘independent’ Bantustans
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quantity and quality for health and the enjoyment of life. as part of the national population. The baseline figures are therefore
difficult to establish and the Joint Monitoring Project (JMP) data,
This chapter focuses on waterborne diseases rather than water-
which draw on South African surveys to model access data, are
4 ED
with unsafe water, inadequate sanitation or insufficient hygiene,1 Over the period 1990–2015, access to piped water and other
the focus is on access to water services. While these diseases are improved sources increased from 66% to 81% of the rural population,
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widely understood, there is less public awareness of the transmission signifying an increase of 15%.8 Targets for universal access to water
of viruses (such as hepatitis A and E, and influenza) through services were set by the post-apartheid government: all households
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contaminated water or inadequate hygiene.2 In addition, non- were to receive piped water by 2008 and improved sanitation by
communicable diseases are associated with harmful environmental 2010;9 these target dates were later modified to 2014.
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water systems and drinking water quality, with particular emphasis either with direct connections to the house or yard connections.
on conditions in rural areas, including an assessment of the 2000– Table 1 shows that a further 2 290 000 households, or 15.2% of
2001 cholera epidemic and its impact on water services, and the the total surveyed, access public standpipes. Taken together, they
incidence of diarrhoea and other water-borne diseases. The current represent the proportion of the total survey households included in
2016 water crisis is reviewed in relation to increasingly varied the defined basic standard.
weather conditions and emerging health challenges. Findings and
conclusions are drawn on the issues of public health surveillance, Table 1: Levels of access to water services and facilities
prevention and promotion, water-quality reporting, and on the
Water source Households, Percent
health impacts of environmental toxicants.
000 of national total
House connection 6 845 45.3%
Access to safe drinking water and improved sanitation Site or yard access 4 051 26.8%
Public tap 2 290 15.2%
Increased access to piped water by the majority of the population
Other 1 921 12.7%
has been described as a “remarkable achievement”4 or even
Total 15 107 100.0
“one of the greatest feats in delivering on human rights”5 of the
post-apartheid government. Improved access to piped water and Source: Statistics South Africa, 2014.10
improved sanitation mark a considerable advance in public health,
particularly for those living in rural areas. Such access does more
than reduce water-related diseases, as improved hygiene also helps
to reduce vulnerability to other infections, such as influenza.
26 S A H R 20 1 6
Water, sanitation and health
These data further indicate that 1 921 000 households (or 12.7% (coagulant and chlorine) dosing, which led to low chlorine
of all households) accessed water from a range of water sources residuals”15 Another study of rural groundwater systems found that
such as wells, dams, ponds, springs, rivers and streams, all of which the majority of those tested did not meet national water standards
represent types of sources that fall below the basic standard in South and that the groundwater systems were of inferior quality compared
African water regulation. to surface water systems.16 A study of groundwater quality in
Mpumalanga found similar conditions and concluded that some
There is a constitutional right to ‘sufficient’ water in South Africa;
water tested “pose[s] a serious threat to the health of consumers”.17
however, there are questions about the volume and affordability
Such deficiencies in the qualitative aspects of water services indicate
of the water and about water access when disconnections or flow
that reports of high levels of access may have to be moderated, as
restrictors are enforced. Although DWS Regulations specify a basic
they may not signify access to continuous service or necessarily to
minimum standard of 25 litres per person per day, this has been
safe drinking water in line with national water standards.
assessed as insufficient to meet basic needs. One calculation puts
the basic water requirement at 50 litres per person per day,11 but
Sanitation
access at this amount is regarded as unaffordable.12
Access to improved sanitation – defined in water Regulations6 as
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Functionality of rural water systems access to a ventilated toilet facility or better – has also improved
substantially during the post-apartheid period. The most recent
Government regulations describe functionality as the continuous
data illustrate that the insanitary conditions that typified the
supply of piped water flowing at 10 litres/second.6 However,
apartheid era, during which most of the rural population had either
surveys have found uneven levels of functionality. For example,
16 6
inadequate or no facility, have been partially redressed. Over the
a review of 23 rural water systems in KwaZulu-Natal Province in
period 1990–2015, access to improved sanitation (using JMP data
20 IL
200313 found that 78% were working (as water was flowing),
including ‘privy not ventilated’) changed from 52% to 77% of the
which implied a high level of functioning systems. However, 56% of
rural population – representing an increase of 29% over the past 25
these systems either did not meet the standards of basic service or
Y T years (Table 2).
did not work at all.
A N
The shortcomings included gaps in accessibility, ineffective Table 2: Levels of access to sanitation, 2013
operation, incomplete construction and financial exclusion (some
M U
has benefited from changes in the government allocation of revenue, 15 107 100.0%
some of these unsatisfactory features have been resolved, but there
G
A review of the data in national surveys14 found that the shortfalls in At the time of the General Household Survey conducted by Statistics
functionality were predominantly in rural provinces, some of which South Africa in 2013, the two levels of access (which met or
BA
had high levels of interrupted supply. exceeded the basic standard of sanitation) amounted to 14 170 000
households, or 77.5% of all survey households. The remaining
O
Province) reported interrupted supply over the previous 12 months. none (937 000, or 6.2% of all households). While 93.8% accessed
Interruptions were caused mainly by burst pipes, water leaks, poor some type of toilet facility, the 16.3% with ‘unimproved’ privies and
general maintenance and insufficient water, and were not always the 6.2% with none represent the challenge in improving sanitation,
speedily resolved; for example, in 2010, 68% of interruptions in particularly in rural areas.
Mpumalanga lasted for more than 15 days.14 Although there has been progress in the post-apartheid period,
there has also been unevenness in the delivery of water services.
Water quality in rural systems South Africa has for instance met the Millennium Development
In addition to the problem of functionality, deficiencies have been Goal (MDG) target in water delivery but not in sanitation.7 Equally,
reported in the quality of drinking water in rural water systems,15 the government’s targets of universal access to piped water and
with a proportion of plants not achieving the South African National improved sanitation by 2014 have not been met and a section of
Standard (SANS 241) for the quality of drinking water. On its own, the population continues to experience uneven quality in terms of
access to piped water may not signify access to safe drinking water. sanitation facilities and water services.7
S A H R 20 1 6 27
The cholera epidemic of 2000–2001 and outbreaks in waterborne proportion of households deprived of water services in all district
disease illustrate the health risks resulting from shortfalls in achieving municipalities was examined and then compared with the under-five
a health-sustaining environment. The cholera epidemic was year diarrhoea case fatality rate.
unexpected, spread widely and led to 114 000 cases resulting in
Figure 1 shows the number of households deprived of water
260 deaths, the majority of which were in KwaZulu-Natal Province
services, i.e. deprived of both piped water and improved sanitation,
where the outbreak originated. Despite the high incidence, there
in the six district municipalities surveyed. The majority of the district
was (using various comparative standards) a comparatively low
municipalities with lower numbers of deprived households and
level of mortality, estimated at 0.31% of those infected.18
lower percentages of these as a proportion of total population are
The epidemic raised questions about access, functionality and water reflected in the lower left quadrant, indicating that many of the
quality – questions that had been identified earlier in scientific district municipalities are approaching universal access to water
studies and national surveys. The communities at the epicentre of the services.
epidemic were found to have access to infrastructure but since piped
The district municipalities with the greatest numbers and the highest
water supply was at times irregular, and metered taps excluded
percentages of vulnerable households are reflected in the upper right-
households that were unable to pay a monthly fee, continuous
hand quadrant and appear as a smaller set of scattered outliers. In
PM
access was compromised.19 Households excluded from access by
these municipalities the number of households without water services
constant interruptions and cost-recovery measures reverted to using
ranged downwards from 100 000 to 40 000 as follows (with the
traditional water sources which were often contaminated.
percentage of the total population shown in brackets): OR Tambo
16 6
The rapid spread of cholera through northern KwaZulu-Natal to the (Eastern Cape) 34%, Alfred Nzo (Eastern Cape) 33%, Amathole
Eastern Cape and beyond, highlighted gaps and weaknesses across (Eastern Cape) (25%), Greater Sekhukhune (Limpopo)(22%),
20 IL
the rural water and sanitation landscape. Expansion of the disease Ehlanzeni (Mpumulanga) 16%, and Bojanala (Limpopo) 8%.
from ‘epidemic hotbeds’ to distant areas has been attributed to
Figure 2 shows the data for the child under-five-years diarrhoea
transport of the pathogen through hydrological networks along and
Y T case fatality rate in relation to data on water services for four
upstream from coastal areas, and to the mobility of people, possibly
district municipalities. The number (rather than the proportion) of
A N
without symptoms, across catchment areas who then transmit the
households without water services was used to highlight the extent
bacteria faecally.20 While the primary route for the disease appears
M U
inadequate water services may not have impeded hydrological of severe diarrhoea, there was greater confidence in the under-five
transport or human transmission. diarrhoea case fatality rate data. However, the graph is illustrative
rather than indicative of correlation, as the under-five case fatality
The Regulations published in April 2001 requiring a defined volume
rate reflects not only the level of access to water services but also the
O
services.
and typhoid in the town of Delmas in 2005,21 when the lack of
O
well-managed water treatment, particularly chlorination, was Again, most the municipalities are reflected in the lower left quadrant
identified as a significant causative factor. The second outbreak, of the graph, indicating lower numbers of deprived households and
EM
in uKhahlamba District in 2008, involved the contamination of lower under-five case fatality rates. In contrast, municipalities with
drinking water with E. coli following the breakdown of the local higher numbers of deprived households are reflected in the right-
waste-water treatment plant; the outbreak was reported to have led hand quadrant of the scatterplot.
to the death of 78 infants.22
The trendline illustrates the relationship between deprivation (in
The report of such outbreaks appears episodic. While the incidence the poor quality of water and health services) and disease; district
of diarrhoea in under-five-year-olds is recorded in the District municipalities with the highest number of deprived households
Health Barometer,23 reporting of the specific types of waterborne are generally (but not consistently) associated with higher child
diseases appears to be dependent on whether or not there is an under-five-year diarrhoea case fatality rates. Municipalities with
outbreak. Despite the reporting of a lower occurrence of outbreaks high concentrations of households without water services (in a
in recent years, analysis of the data indicates ongoing high levels of downwards range from 100 000 to 40 000 and with the under-five
diarrhoeal infection in vulnerable rural areas (even if these infections case fatality rates for diarrhoea in brackets) include OR Tambo (173
do not necessarily constitute an outbreak), with incidence spreading per 1 000), Ehlanzeni (95 per 1 000), Mopani (86 per 1 000) and
across geographical areas. Alfred Nzo (57 per 1 000).
28 S A H R 20 1 6
Water, sanitation and health
sources of revenue, and are more dependent on intergovernmental Such models utilising data on climate, living environment and
transfers.25 They are also found to lack experienced staff and well- incidence of waterborne disease should be updated if they are to
established procedures to access and manage these funds effectively. serve as tools for contemporary analysis and disease management.
The most useful output from renewed exercises of this kind would be
Surveillance and predictive analysis the development of maps of vulnerable areas so that national and
The broad association between patterns of disease and service local government officials can visualise the most vulnerable areas
levels in water and sanitation, plus the cholera epidemic of 2000– and prioritise interventions.
2001 and the concern to prepare adequately for such outbreaks,
stimulated two studies that systematically examine risk of waterborne Water crisis, climate change and health
disease in rural populations. The 2016 water crisis, precipitated by the worst drought since
The first study was undertaken in 2000, prior to the cholera 1933, has resulted in widespread water shortages that are
epidemic, by a unit in the Department of Water and Sanitation,26 increasing stress on an already challenged infrastructure. Although
and the second study was conducted after the cholera epidemic, by South Africa’s annual rainfall is below the world average, water
an independent group of researchers.20 The first study employed a consumption is above the world average. This has resulted in a water
PM
method of weighting risk factors (such as level of access to water demand–supply gap. Population growth and greater urbanisation
services and other indicators) to identify and prioritise areas of high will increase the demand for water supply in the future and require
risk for waterborne disease. The second study developed a model that greater attention be given to improving the overall quality of
of cholera transmission from available epidemiological records readily available water supply. Demand is therefore anticipated to
16 6
and a range of demographic, service-level and mobility data. The rise over the next 20 years, while the country’s water resources are
modelling of the pathways of a cholera epidemic was tested against considered to be almost fully allocated – leading to an ongoing
20 IL
the historic data to provide a predictive planning tool. critical period in water management.27
120 000
dry seasons and increased evaporation from dams.28 While these
effects will be uneven geographically and accompanied by larger
4 ED
OR Tambo
100 000
rainfall variances, there may be greater contamination of rivers and
other water sources because of a reduced dilution effect.27 A study
Number of households
80 000
Ehlanzeni of the ecological consequences of climate change finds that water
Amathole
O
60 000 Greater Sekhukhune quality is likely to be affected by the mobilisation of pollutants such
Alfred Nzo
as metals, as well as the increased transport of dissolved pollutants,
40 000 Bojanala
G
including pathogens.29
20 000
Under these conditions, greater care and improvement in the
R
Figure 2: Access to water services, and child under-five-years There is evidence of growing public concern about the quality of
diarrhoea case fatality rate (per 1 000) in four water, and increased sensitivity to service issues. General household
municipal districts in South Africa, 2011 surveys report lower levels of satisfaction over time; for example, less
200
than two-thirds of households rated their water services as ‘good’ in
180 OR Tambo 2013.10 Deterioration in levels of satisfaction is associated with a
decline in the percentage of households that feel that their water is
Under-5 case fatality per 1 000
160
S A H R 20 1 6 29
There has been considerable discussion about the types of acid mine drainage (AMD), which is the outflow of acidic water
contamination that could pose the most immediate threats to health, after mines are closed and tailing dams are decommissioned. AMD
particularly eutrophication, and microbial pollution from poorly is characterised by high salinity levels, elevated concentrations of
managed waste-water treatment. Turton30 has persistently raised the sulphate, iron, aluminium and manganese, and raised levels of toxic
question of eutrophication, which leads to the growth of blue-green heavy metals such as cadmium, cobalt, copper, molybdenum, zinc
algae (cyanobacteria) and results from the presence of nutrients and radionuclides.32 Specialised treatment has been researched and
existing in sewage effluent. Cyanobacteria are difficult to treat developed but not yet generally applied; it appears that much of the
and eliminate, and threaten the health of humans and livestock, in AMD leaches into rivers, resulting in the dilution of contaminants.27
addition to damaging the ecosystem. The DWS acknowledges this There is a considerable range of potential impacts associated with
threat and has a monitoring system in place28 although the planned AMD, including on health. For instance, high levels of uranium
regular reporting does not appear to be evident. have been found in surface water at the Wonderfontein Spruit33
which if consumed untreated, can have serious health implications,
There is also ongoing concern about the direct health impact of the
in particular kidney toxicity. It appears that the health impacts of
presence of microbial pathogens in the effluent from water treatment
many environmental toxicants in water are internationally known but
works. A study of pond systems in rural hospitals in northern
should be grounded in the local context.
PM
KwaZulu-Natal, for instance, found that the effluent was being
used to water crops and even, indirectly, for domestic purposes.31
Anticipated trends in water and health
The researchers concluded that they “consistently found that such
effluents were either inadequately disinfected or not disinfected at Water-related health issues resulting from climate change may be
16 6
all”. These researchers traced the existence of Vibrio cholera in raw evidenced in the worsening of existing health outcomes rather than
sewage months before the cholera outbreak in October 2000. in unexpected diseases.34 The risk of adverse health impacts can be
20 IL
expected to follow the anticipated results of climate change; changes
Municipal waste-water treatment plants are discharging effluent
in temperature and precipitation, for example, may provide more
that has not been properly treated. South Africa has 986 municipal
Y T favourable conditions for the concentration of microbial pathogens.
water-treatment facilities currently in operation, which discharge
A N
2.1km3 (or 2 100 million kl) of treated water into river systems, Reviews of likely health impacts from climate change in South Africa
although the quality is uncertain,27 and inadequate treatment is conclude that enteric (intestinal) waterborne diseases will be more
M U
responsible for the existence of high levels of faecal coliforms in likely,35 and extreme events associated with changing climate
effluent entering rivers. Drawing from the Green Drop (waste-water) conditions may precipitate outbreaks of waterborne disease. E.coli,
4 ED
monitoring reports, Turton concludes that only 26% of sewage is types of which are pathogenic, reproduce optimally in dark, warm,
adequately treated before being discharged into rivers.30 Apart moist environments found in warmer conditions in coastal areas.
from the additional cost of water treatment downstream, high levels Growth of the bacterium Vibrio cholera is affected by water salinity,
of contaminants in rivers and streams pose a direct health risk to
O
The Green Drop monitoring programme, which reports on the surface water indicate varying results, although extreme precipitation
quality of waste-water treatment, involves a complex assessment events (which will become more prevalent) are found to increase
R
Municipalities in the Eastern Cape that have been previously services) as by environmental and climate factors; the evidence27 is
that good access to water services can constitute an effective barrier
EM
30 S A H R 20 1 6
Water, sanitation and health
PM
Development Goals Framework
Target 6.1: Universal access to Existing government targets diarrhoea case fatality rates that are much higher than that
safe, affordable drinking water by predate this goal and should be of populations with virtually universal access to piped water.
2030 reviewed
Target 6.2: Universal access to Existing government targets ➢➢ Health-risk modelling is possible. The two types of mapping
16 6
adequate and equitable sanitation predate this goal and should be
of the potential vulnerability of populations to water-related
and hygiene by 2030 reviewed
diseases demonstrate that the areas for priority intervention
20 IL
Target 6.3: Improved water quality, Dealt with in Department of Water
better pollution control and and Sanitation (DWS) Water can be identified and that the likely pathways of cholera and
treatment of waste water, recycling Quality frameworks;38 public
other water-related diseases can be tracked. Under conditions
and re-use oversight of sanctions for polluters
Y T
and public access to Green and of climate change, which will be associated with a greater
Blue Drop reports and other number of extreme events with potential for waterborne
A N
reviews must be enabled
epidemics, priority-setting for intervention should be guided by
Target 6.4: Increase water use Municipal and DWS guidelines and
M U
efficiency and sustainable use incentives needed; referred to in greater surveillance of the epidemiological and environmental
the National Development Plan39 data.
Target 6.5: Integrated water The National Water Act (NWA) 36
4 ED
resources management including of 199840 provides a framework ➢➢ Climate change impacts require improved management of
transboundary co-operation but some revision may be required water services. The current water crisis shows that the supply of
Target 6.6: Protect water-related Dealt with in the Environment
water in sufficient quantity and quality is a challenge to water
ecosystems Conservation Act 73 of 198941 and
governance; this focuses attention on the need for improved
O
Target 6.b: Participation of Local Government: Municipal management of river water quality, firstly poorly treated
local communities in water and Structures Act 117 of 1998 42
effluent from waste-water plants, and secondly contamination
sanitation management lays down basic provision for
BA
participation in local government; from acid mine drainage, both of which are reducing the
however, this should be reinforced quantity of readily available water of reasonable quality and
O
framework
➢➢ Environmental toxicants transported in water are linked to non-
communicable diseases. Environmental toxicants contamina-
The wide range of the SDGs will place greater demands on integrated ting drinking water can lead to early-life exposures that can
governance, as they go well beyond the provision of basic services have developmental health impacts.43 Lapses in water-quality
to improve the quality and accessibility of services, and include the monitoring for such contaminants can have wide-ranging
environmentally associated issues of water re-use and ecological effects on child development and adult health.
commitments. Objectives such as the protection and restoration of
water-related ecosystems will require extensive interdepartmental
co-operation and co-ordination across multiple tiers of government. Recommendations
The formal approach of the SDGs is intentionally top-down, but there ➢➢ Improved public health surveillance in vulnerable communities
are other possibilities that could encourage bottom-up approaches. is needed. Mapped outputs from an appropriate model would
Public participation, which has been formally instituted at the local provide the information to focus attention on vulnerable
government planning level and in other ways, will be important populations particularly at the district municipality level.
in achieving water efficiency as well as environmental and other This will provide early warning of outbreaks, and serve
objectives. Such focus could be the positive basis for discussion with as an important planning tool for health and water service
municipalities and be part of a wider debate about efficiency in interventions.
water use and public concern about water quality.
S A H R 20 1 6 31
➢➢ Disease prevention and health promotion should be focused
where they are most needed. The re-engineering of primary
health care through Ward-based Outreach Teams should
lead to improved disease prevention and health promotion in
vulnerable populations without water services. Environmental
Health Practitioners trained in water-related disease prevention
should be involved to support such interventions. In key areas
of identified need, interventions to achieve disease prevention
and health promotion should be substantially improved.
PM
still have to access potentially contaminated natural water
sources and suffer higher rates of waterborne disease. The
modelling and mapping of public health should provide
an instrument to track water system delivery and provide
16 6
appropriate health system support. These interventions,
and hospital access and treatment in district municipalities
20 IL
with high under-five diarrhoea case fatality rates should be
reviewed and reported for further action.
Y T
➢➢ Make reporting of water quality management more readily
A N
and publicly accessible. The Green and Blue Drop monitoring
and reporting systems include a well-established annual review
M U
Acknowledgments
The data analysis utilised datasets provided by Michael Noble from
the Southern African Social Policy Research Institute (SASPRI), and
Health Systems Trust.
32 S A H R 20 1 6
Water, sanitation and health
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34 S A H R 20 1 6
Diet-related non-communicable diseases
in South Africa: determinants and policy
4
responses
Authors:
Mark Spires i Peter Delobelle i
David Sanders i Thandi Puoane i
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Philipp Hoelzel i Rina Swart ii
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N 20 IL
on-communicable diseases (NCDs) are the leading cause of death globally Increasingly, international
and they are on the rise both in low- and middle-income countries, with South
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Africa being no exception. Implicated in this upward trend in the country is an research links rapidly
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observed change in diet – a transition from traditional foods, to what has come to be changing food environment
known as the ‘western’ diet, i.e. more energy-dense, processed foods, more foods
with escalating chronic
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of animal origin, and more added sugar, salt and fat. Increasingly, international
research links rapidly changing food environment with escalating chronic disease, disease, i.e. it implicates
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i.e. it implicates population-level dietary change over individual factors such as population-level dietary
knowledge, attitudes and behaviours. Environmental and/or policy interventions can
be some of the most effective strategies for creating healthier food environments. change over individual
factors such as knowledge,
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This chapter explores the link between the rise in diet-related NCDs, their proximal
determinants (specifically an observed change in diet patterns), contributing attitudes and behaviours.
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internationally, and the most relevant national-level policies for South Africa.
The authors conclude that to improve dietary patterns and reduce chronic diseases in
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South Africa will require a sustained public health effort that addresses environmental
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factors and the conditions in which people live and make choices. Overall, positive
policies have been made at national level; however, many initiatives have suffered
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from a lack of concerted action. Key actions will be to reduce the intake of unhealthy
foods and make healthy foods more available, affordable and acceptable in South
Africa.
35
Introduction Proximal determinants
Chronic non-communicable diseases (NCDs), mainly heart disease, The leading behavioural risk factors for NCDs are tobacco use,
stroke, cancer, diabetes and chronic respiratory disease, account harmful alcohol consumption, unhealthy diets that include high
for more than two-thirds of global deaths, at least half of which are sugar, salt and fat intake, physical inactivity, and overweight and
caused by common, modifiable risk factors such as unhealthy diet, obesity.15 More specifically, in terms of this chapter, the continuing
obesity, tobacco use and lack of physical activity.1 rise in prevalence of overweight and obesity in an increasing number
of LMICs has been associated with a dramatic change in diet. Poor
Currently, NCDs are the leading causes of death worldwide, resulting
diet now generates more disease than physical inactivity, alcohol
in 16 million premature deaths each year;2 and this is projected
and smoking combined,16 which is largely due to an observed
to worsen: in 1999, NCDs were estimated to have contributed
change in diet at the population level. This change, dubbed the
to just under 60% of worldwide deaths and around 43% of the
‘nutrition transition’, is characterised by a shift from traditional diets
global burden of disease.3 Based on current trends forecast by the
based largely on staple grains or starchy roots, legumes, vegetables
World Health Organization (WHO), these diseases are predicted to
and fruits but minimal animal foods, towards more energy-dense,
account for 73% of deaths and 60% of the disease burden by the
processed foods, more foods of animal origin and more added
year 2020.1 Global projections indicate that the biggest increase
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sugar, salt and fat.17–19 This new diet, commonly known as the
in NCD deaths will occur in low- and middle-income countries
‘western’ diet, is primarily made up of cheap, highly palatable,
(LMICs); currently already 80% of global NCD deaths occur in these
heavily promoted, energy-dense and nutrient-poor foods.18
regions.4,5
16 6
The transition is also evident in South Africa. The change in nutrient
The United Nations (UN) recently recognised NCDs as an increasing
intake among South Africans has been associated with change in
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threat and a major contributor to preventable disease and premature
population-level dietary patterns.20 Although dietary differences are
mortality. This has been a monumental step in placing NCDs on the
still evident among South Africans, increasing changes to the food
global health and development agenda. A UN High-Level Meeting
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of Heads of State and Governments on the Prevention and Control
of Non-communicable Diseases was held in September, 2011. This
environment indicate that the ‘western’ diet will one day be common
fare across the country.21
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meeting classified NCDs not just as a health concern but as a major
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healthy food options generally have poorer diets and are at a higher
South Africa was a participant and signatory to this meeting and risk for certain diet-related diseases.22–27 Local food environments,
supported the final political declaration. NCDs impose a large defined here as “the physical presence of food that affects a person’s
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and continuously growing burden on the health, economy and diet; a person’s proximity to food store locations; the distribution of
development of South Africa, and currently accounts for a staggering food stores, food service, and any physical entity by which food may
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43% of recorded deaths. Rates of overweight and obesity (together be obtained; or a connected system that allows access to food”,28
the second-leading metabolic risk factor in NCD-attributable death play a key role in individual, family, and population-level health.
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in South Africa6), have risen sharply over recent years,7–10 in International research increasingly implicates a rapidly changing
conjunction with ongoing high levels of underweight and nutritional food environment dominated by processed products high in sugar,
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deficiencies. In the year 2000, an estimated 7% of all nationally salt and fat, and demonstrates that these environments contribute
recorded deaths were attributed to excess body weight,11 while
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diseases, contributed 12% to the overall disease burden.12 Currently, put: unhealthy food environments foster unhealthy diets. This has
more than 45% of men and women above the age of 35 are either been especially true for communities with predominantly low-
overweight or obese.13 While NCDs have historically affected the income, low socio-economic status residents.27–32
more affluent and mainly White population, these conditions are
South Africa is rapidly catching up with high-income countries as the
now affecting other population groups as well. It is believed that in
‘western’ diet is becoming increasingly accessible to all segments
the coming decades, NCDs will further exacerbate wide inequalities
of society. This transition has accelerated dramatically since the
in longevity and quality of life in South Africa.14 Additionally, the
mid-90s when the post-apartheid government opened the borders to
chronic nature of NCDs demands long-term care and imposes a
trade and foreign direct investment.29 Since then ‘Big Food’ (a term
significant burden on an overstretched health system already
used to label large commercial entities that dominate the food and
having to cope with the HIV and AIDS epidemic, a high burden of
beverage environment) has come to dominate the food supply by
tuberculosis (TB), maternal and child mortality, and high levels of
making its products more available and affordable. Although there
violence and injuries.
are over 1 800 food manufacturing companies in South Africa, Big
This chapter explores the link between the rise in diet-related NCDs, Food manufacturers account for a disproportionately large number
their proximal determinants (specifically an observed change in diet of sales.30 According to a recent publication, Big Food is becoming
patterns), contributing environmental factors, what is currently being more widespread in South Africa and has been implicated in
done or recommended to address this internationally, and the most unhealthy eating.31 Igumbor et al. report that there has been an
relevant national-level policies for South Africa. observed increase in the sale of almost all categories of packaged
36 S A H R 20 1 6
Diet-related diseases
foods in the country from 2005 to 2010. for example: sales of In the United States of America studies have shown greater effects
snack bars, prepared meals and noodles all rose by more than 40%; of food policies related to bans/restrictions on unhealthy foods,
and when compared with the worldwide average of 89 Coca-Cola mandates offering healthier foods, and altering purchase/payment
products per person per year, in 2010 “South Africans consumed rules on foods purchased using low-income food vouchers compared
254 Coca-Cola products per person per year, an increase from with other interventions such as menu labelling or the introduction of
around 130 in 1992 and 175 in 1997”.32 Another study found that new supermarkets.51 There is also consistent evidence that taxation
in 2010, up to half of all young people were reported to consume and subsidy intervention influence dietary behaviour.52 Mexico, for
fast foods, cakes and biscuits, cold drinks and sweets on at least example, implemented taxation of sugar-sweetened beverages and
four days a week.13 It is worth noting that of the top 10 companies other so-called junk foods, and many other countries have or are
that dominate food processing/manufacturing in the country, five actively pursuing taxes on sugar-sweetened beverages to combat
(including the most dominant company) are South African. Igumbor both obesity and dental disease.46 Early results from the sugar
et al. conclude that: taxation in Mexico indicate that in 2014 the purchase of soda and
other taxed drinks had dropped by 10% compared with the previous
various strategies adopted by Big Food to increase the
year, whereas the purchase of bottled water rose by 13%, showing
availability, affordability, and acceptability of their products
that people were indeed changing to a healthier alternative.53
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have contributed to … dietary changes in South Africa and to
the increased burden of obesity and NCDs. Sugar taxes have been implemented in Denmark, Finland, France,
Hungary, Ireland and Norway, based on substantial scientific
Also accelerating the spread of the ‘western’ diet in South Africa
evidence showning that decreased sugar-sweetened beverage
16 6
has been the rapid expansion of supermarkets, with chain outlets
consumption reduces the prevalence of obesity and obesity-related
now owning more than 50% of the retail food market,33 making
diseases and that a tax on sugar-sweetened beverages reduces
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supermarkets the primary place South Africans purchase their
the obesity rate.54,55 However, in order for full health benefits to
foods.34 In general, supermarkets have made both staple and
be achieved, a tax on sugar-sweetened beverages would need to
packaged foods more affordable;35 however, healthier food options
Y T be part of a wider approach to obesity that includes for example,
typically cost between 10% and 60% more when compared with
food labelling, advertising regulations, reformulation of foods and
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unhealthier options in these retail outlets.36 Availability of these
drinks by industry and consumer-awareness programmes as well as
healthier options has also been observed as an issue, particularly for
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wealthier areas and, as a result, the supermarkets do not increase associated with obesity, the International Network for Food and
access to healthy foods and may, in fact, accelerate the nutrition Obesity/non-communicable diseases Research, Monitoring and
transition”.37 Action Support (INFORMAS) has developed a set of modules.
It includes a framework to monitor, assess and provide input on
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Policy approaches have been developed for each of these domains and are used as
benchmarks when assessing or rating existing policies in a given
International research has shown that “environmental and policy
jurisdiction. Currently, this rating process is taking place in South
interventions may be among the most effective strategies for
Africa and results should be available soon.
creating population-wide improvements in eating”.45 Based on
research and practice, consensus now exists regarding core policy
Current national policy context
actions that can be taken to promote healthy diets.46,47 The policy
actions have been grouped into three domains in the NOURISHING Poverty and food insecurity in South Africa have a unique and long
framework,48 including the food environment (e.g. nutrition labelling, history that has been traced back and linked to colonialism and the
food taxation, restriction of food advertising); the food system (e.g. legacy of apartheid: “The former [colonialism] disrupted the African
supply-chain incentives); and behaviour-change communication (e.g. production and indigenous knowledge on food security. The latter
mass-media campaigns, nutritional advice and education). Evidence [apartheid] designed a system that generally created unfavourable
exists to support the benefits of focused mass-media campaigns, conditions for black people in all aspects of livelihood”.57
food-pricing strategies, school-procurement policies and worksite Currently, under a rights-based system such as South Africa’s,
wellness programmes, but there is less conclusive evidence for food the government “must provide an enabling environment in which
and menu labelling and changes in the local built environment.49 In people can adequately produce or procure food for themselves
addition, there is a dearth of research into how nutrition labels are and their families”.58 Section 27 of the South African Constitution
being received in the global South, especially among the urban and states that “everyone has the right to have access to sufficient food
rural poor, in order to assess the effectiveness of labelling policies.50 and water”,59 and points out that “the state must take reasonable
S A H R 20 1 6 37
legislative and other measures, within its available resources, to “Africans are eating more and more junk processed foods instead
achieve the progressive realisation of each of these rights”. As a of their traditional diet,” and [he] affirmed his desire to regulate junk
result, the South African government as ‘duty bearers’ is obliged to food starting with reducing salt in bread and eliminating trans-fats.67
respect peoples’ rights, protect these rights, and do all they can to
In his 2016 budget speech, South African Finance Minister Pravin
realise these rights, which means that decision-makers must generate
Gordhan revealed plans to introduce a tax on sugar-sweetened
conditions in which everyone can be as healthy as possible, without
beverages, similar to the sin taxes on alcohol and tobacco.68 The
discrimination.60
sugar tax will be implemented from 1 April 2017 and will be levied
Rapidly changing local food environments in South Africa have led on soft drinks, fruit juices, energy drinks and vitamin water. This
to the call for labelling and fiscal policy measures to address the decision was informed by research indicating that a 20% tax on
availability, acceptability and affordability of healthy versus less- sugary drinks could bring in an estimated R7-billion in additional
healthy foods, and for improved implementation of regulations for revenues each year and reduce obesity among 220 000 adults.69,70
the marketing of foods and beverages to children.31 Since 1994,
Other relevant national level-policies, programmes and strategies
South Africa has taken some positive policy steps at national level
that shape provincial and community-level actions impacting food
to address issues related to NCD prevention and/or healthy food
environments are the Integrated Food Security Strategy,71 the
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access. In September 2011, the South African Minister and Deputy-
Integrated Nutrition Programme,72 the National School Nutrition
Minister of Health convened a summit on the Prevention and Control
Programme,73 the National Policy on Food and Nutrition Security,74
of Non-Communicable Diseases.61 The summit included various
and the National Development Plan.75 However, collectively,
governmental departments, researchers, private sector and civil
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these policies frame food insecurity as primarily a rural and food-
society stakeholders, and resulted in a declaration that endorsed
production issue; few resources have been allocated to municipalities
action aimed at various risk factors (behavioural, environmental and
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to address urban concerns around this issue, which some argue is
structural). Subsequently, the national government has released its
where the focus is currently needed.76 On the whole, these policies
Strategic Plan for Non-Communicable Diseases, 2013–2017,62
Y T do not take environmental issues into account or spatial contexts
which provides a short-term framework to reduce the burden of
around access; rather, they focus on household-level issues such as
NCDs, including actions related to specific targets identified and
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income-generation, government safety nets, nutritional programmes,
agreed upon at the 2011 Summit. The plan outlines cost-effective
and on increasing production.77
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on to point out that dietary changes are needed in South Africa if All government departments and their respective policies have
NCDs are to be combatted effectively, and that food environments the potential to affect the health of the population/s they serve.
play a key role in this. The plan advocates for a legislative approach While health may not be the main aim of all these policies, their
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to improve food environments, including legislation/regulations to implementation has the potential to have either a positive or a
reduce trans-fatty acids; regulations to reduce salt in processed food; negative effect on population health. Consequently, the World Health
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consideration to be given to the ban of junk food advertisements Organization has said that policy coherence is vital across different
directed at children during key television programmes; the taxation of government sectors, and that when it comes to the promotion of
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undesirable processed foods and the exemption of healthier choices health, various government department policies should complement
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from taxation; and better control of food and nutrient supplements. rather than contradict each other.78
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investment policy and our national health policy, with trade and
sustained over the next decades to combat the current trend and
foreign direct investment promoting the influx of large amounts of
achieve a real reduction in the NCD-related burden”,14 and that
processed foods and sugary beverages, giving free rein to fast
additional rigorous measures are required to continue to address the
food companies like McDonalds and Burger King. In more recent
common risk factors NCDs for South Africa.
documents, there has been an increasing call for an inter-sectoral
With regard to reduced salt intake, voluntary measures have been approach, which has yet to be realised in the South Africa Declaration
discussed with the appropriate consumer and industry groups and on the Prevention and Control of Non-Communicable Diseases,62
a comprehensive salt-reduction plan, including legislative measures, the National Strategy for Prevention and Control of Obesity79 and
has been implemented.64 The Department of Health has approved the South Africa Strategic Plan for Non-Communicable Diseases,
regulations which will come into effect in 2016.65 In addition, a new 2013–2017.62 These types of approaches have been successfully
advocacy group has been established, along with an educational used in initiatives such as the Health Promoting Schools Programme,
campaign launched by the Heart and Stroke Foundation to which was developed in response to a shared policy concern across
communicate about the harms of high salt consumption. Similarly, the health and education sector. The approach is obviously more
regulations relating to trans-fats in food already exist as of 2010,66 problematic when dealing with sectors with conflicting interests, e.g.
while new food labelling and advertising legislation came into being between health policy and trade and investment. As pointed out
in March 2012. It is encouraging that the current (February 2016) in the Report of the Commission on Social Determinants of Health,
South African Minister of Health, Dr Aaron Motsoaledi, stated that: “trade policy that actively encourages unfettered production, trade,
38 S A H R 20 1 6
Diet-related diseases
and consumption of foods high in fats and sugars to the detriment of Acknowledgements
fruit and vegetable production is contradictory to health policy”.80
The writing of this chapter was made possible by generous support
The reduction of obesity and promotion of health, including the from the DST-NRF Centre of Excellence in Food Security (University
promotion of healthy food choices, will benefit directly from a of the Western Cape) and from the SMART2D project funded by
systems approach, including ‘upstream’ policy actions beyond the the European Commission’s Horizon 2020 Health Coordination
traditional health sector.81 Health-in-All Policies (HiAP) is one such Activities (Grant Agreement No. 643692) under call “HCO-
approach. It has been described as a way that considers the impact 05-2014: Global Alliance for Chronic Diseases:prevention and
of policies on health outcomes, determinants and health systems, treatment of type 2 diabetes”. The contents of this article are solely
with special emphasis on the distribution of these impacts.82 The the responsibility of the authors and do not reflect the views of the
HiAP approach was adopted in South Australia, where the regional EU.
government mapped the core business and policy directions of
local state departments against research showing what works in
combatting obesity. “Negotiations then developed high-level policy
commitments to address factors promoting healthy weight which
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predominantly changed ways of working rather than requiring new
expenditure and also assisted departments in meeting their own
goals.”81 This initiative achieved buy-in from traditionally non-health
departments and an increased level of commitment to a broader
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range of policy actions. In the South African context, HiAP could
be advocated and monitored through the establishment of an
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independent-of-government Health Promotion Foundation (HPF).83
HPFs work across sectors to support government and contribute
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to the development of evidence-based policy in collaboration with
government, academia and civil society. HPFs have successfully
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influenced population health in countries such as Thailand
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Conclusion
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S A H R 20 1 6 39
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The contribution of specialist training
programmes to the development of a
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public health workforce in South Africa
Authors:
Virginia Zweigenthal i
Leslie London i
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William Pick i
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population perspective on health underpins the 17 newly adopted Sustainable Public health is an inter-
Development Goals (SDGs) and South Africa’s recently promulgated White
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Paper on National Health Insurance (NHI). Monitoring their progress, disciplinary field that aims to
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identifying health service priorities and implementing effective delivery strategies understand health problems,
requires a skilled public health (PH) workforce. Yet several key policies intended to
and to develop and evaluate
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transform the country’s health system radically make no mention of this workforce.
programmes to improve the
This chapter investigates the potential contribution of the Public Health Medicine
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(PHM) specialty to a public health workforce in South Africa. We describe the nature health status of populations.
of PH, the competencies anticipated of a PH workforce and the training programmes However, current South
for PHM specialists and the Master of Public Health (MPH). The discordance between
African health reform
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the need for PH expertise generated by the current policy juncture in South Africa
and the current invisibility of graduates of PH programmes is explored. initiatives whilst flagging the
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PH is an inter-disciplinary field that aims to understand health problems, and to importance of PH for the
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develop and evaluate programmes to improve the health status of populations. The health service, give little
evolution of PH in South Africa reflects two trends: one focused on compliance with
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measures protecting human health, and the other focused on the development of detail on the role of
PH professionals.
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Both trends were led by doctors and historically, PH training was reserved for doctors.
After 1994, graduate PH programmes were opened to other health professionals
and social scientists. Legislation no longer reserved senior PH functions for doctors.
However, current South African health reform initiatives – the NHI, PHC re-engineering
and health workforce policies – whilst flagging the importance of PH for the health
service, give little detail on the role of PH professionals.
45
Introduction
Health is central to many global and national development agendas. and methods of these disciplines together provide information that
The recently adopted Sustainable Development Goals (SDGs) present can inform health interventions. Information may come from lifestyle
one explicit health goal: to “ensure healthy lives and promote well- risk factor analysis (epidemiology), economic cost-benefit analysis
being”,1 and population health concerns underlie 13 other SDGs.2 of health policies (health economics), and organisational change
The South African Constitution foregrounds access to health care as (management sciences). PH provides a mind-set that considers
a right, and population approaches to health underpin the National different explanations for health phenomena which, in turn, inform
Health Act of 20033 and other policies. Despite this philosophical complex and multiple approaches, thus avoiding piecemeal insights
commitment to a public health (PH) approach in the health system, and interventions.14 PH practice is a multi-disciplinary enterprise.
the role of personnel trained in PH is not formally recognised, nor
‘Social determinants of health’ form a component of the PH
are the institutions that train PH professionals accorded any special
paradigm, and describe underlying conditions that interact with and
responsibilities in human resource planning for health.
influence risks to health and well-being. These include the conditions
Resource allocation in the South African health system primarily of everyday life and systems that help keep people healthy and
support them when they become sick.15 Most social factors lie
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prioritises clinical services and focuses on individual ‘personal
health’ services, which are largely facility- and hospital-based. outside the scope of health services,11 and require engagement
Health services do not emphasise interventions addressing the with stakeholders beyond the formal health sector. This intersectoral
social determinants of health. This is evident in the recently released nature of PH practice requires PH professionals to work with others
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National Health Insurance (NHI) White Paper,4 as well as other on factors determining human health and in systems to improve
recent national policy directives.5,6 These address system and health status, using levers for change such as the development of
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workforce barriers to achieve health outcomes appropriate to South social interventions, policy change and advocacy.16 The World
Africa’s per capita spend on health. However, only with the 2015 Health Organization (WHO) has framed this mandate as the ‘health
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Bill proposing a National Public Health Institute of South Africa
(NAPHISA)7 has there been any attempt to institutionalise South
in all policies’ approach, which asserts that PH professionals need
to ensure that a health agenda is part of all government initiatives
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Africa’s PH capacity. and policies – in, for example, housing, education and energy,17
which is a recognised challenge in South Africa.18 Following
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Public health Before the 20th century, coercive PH measures – such as health
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The term ‘public health’ is used in the literature in a number of ways: inspection, isolation of cases and quarantine – protected populations
an “activity, a discipline, a profession, an infrastructure, or even against infectious diseases. The decrease of epidemics due to
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a movement”.8 Some narrowly view PH as government-funded or effective control measures and the rise of effective diagnostics and
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public sector health services as opposed to private sector health therapeutics resulted in health care becoming synonymous with
services,9 or as ‘community health’ in contrast to ‘personal health’ clinical medicine.9 ‘Personal’ health care, focusing on preventive
services rendered by clinical medicine.10 and curative services at an individual level, became the domain of
health services and health professionals.
PH is most often defined as a field that focuses on the maintenance
and promotion of health at a population level,11 “assuring conditions Modern health systems comprise organisations and people who act
in which people can be healthy”.12 Winslow, an American PH to “promote, restore or maintain health”.21 Indicators measure the
practitioner in the early 20th century, argued that PH was “the success of service delivery, and include inputs; processes – access,
science and art of preventing disease, prolonging life and promoting coverage, quality and safety; outputs; outcomes; and impact – equity,
physical and mental health and efficiency through organized risk protection and efficiency and improved health.22 PH expertise is
community efforts”.13 PH aims firstly to understand health problems needed for the effective implementation of these approaches.
and systems before developing and managing programmes in
At a global level, health is seen to underpin social development.
prevention and control to improve the health status of communities.
Health was central to the Millennium Development Goals (MDGs)
It is an inter-disciplinary field, encompassing a number of and is key to the successive goals, the SDGs. The notion of ‘universal
disciplines including environmental health, occupational health, health coverage’ (UHC),23 adopted by the UN General Assembly in
epidemiology, biostatistics, demography, economics, and health 2012,24 promotes equity and access to health care which underpins
care organisation and management.11 Social science disciplines the NHI White Paper and the SDGs.19,25 As articulated in the NHI
such as geography, psychology, sociology and anthropology have White Paper, UHC requires strengthened health systems as critical to
increasingly become integrated into PH practice.10 The perspectives the achievement of major health goals. PH skills and competencies
46 S A H R 20 1 6
Public health workforce
are core to the production of robust health research, evidence- such as environmental health, health promotion or surveillance.
based policy and services management to support health systems Professionals come from a range of occupational backgrounds –
strengthening.26 doctors, nurses, health managers, health economists, environmental
health specialists, health promotion specialists and community
Globally there is agreement that PH functions centre on identifying
development workers.8 The range of PH workers in South Africa is
the health status and needs of populations and their surveillance;
depicted in Figure 1.
developing policy; implementing and evaluating promotive,
preventive and disease control programmes; ensuring the delivery A barrier to improved health outcomes is widespread health service
and quality of services; and developing a competent workforce that personnel shortages, which are the result of inadequate numbers
is able to lead and develop partnerships.27–30 of trainees, geographical maldistributions, and losses due to
death, retirement, migration or career change.36 Poor knowledge
In many countries, PH institutes31 lead and co-ordinate PH functions
about the health workforce, its size, function, and optimal skill
with capacity for surveillance, response to PH emergencies, and
mix, compounds this crisis.37 Globally, PH personnel are also both
the development of national diagnostic and reference laboratory
insufficient in numbers8,38 and maldistributed. They have been
systems with transnational links. Key disease control programmes
largely overlooked in national human resources health plans, and
are required (including those for chronic disease addressing
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allocated a meagre budget. The reasons for this neglect may be due
behavioural risk factors), as are solution- and action-orientated
to resource allocation prioritising curative health care39 in the face
research to identify new and improve existing health interventions.26
of imperatives to reduce health costs. These shortages are profound
The US Centers for Disease Control and Prevention (CDC) proposed in resource-poor countries, as reported for the Democratic Republic
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a set of core functions, competencies and organisations that require of the Congo, Ethiopia, India, Nigeria, Sri-Lanka and the Sudan.40
strengthening to maximise impact on health systems and population
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Competencies for PH professionals are in disciplinary domains
health.26 As valid epidemiological data are the foundation for
such as PH sciences, management, policy-making and assessment,
policy, decision-making and interventions, skilled personnel are
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needed who can work on surveillance, track vital statistics, estimate
cultural competence, leadership and communication. A review of
disease burden, and evaluate determinants of health and impacts
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competencies for low- and middle-income countries (LMICs) using
of interventions. Personnel in health ministries who collect, interpret
a Delphi technique identified the following PH competencies: the
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Investment in PH strategies to prevent and therefore reduce ill-health, management skills to implement decisions; report and research
decrease health inequalities, and increase life expectancy, is ethical proposal-writing skills, and intersectoral skills.41 In a commentary
and reflective of the right to health32,33 However, these goals are on PH training and its relationship with health systems development
difficult to achieve due to the complexity of PH challenges such as in sub-Saharan Africa, Fonn identified leadership in health and the
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social and economic inequalities, an underdeveloped evidence understanding of disease burden and the social determinants of
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base for PH interventions, and the demands of curative care which health as key competencies.42
overshadow longer-term investment in population health.34
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improve health through a population focus.35 They work in technical often conflicting paths. The first entrenched the ‘status quo’ and
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and line functions within health services, and in research and the other innovated models of health care responsive to social
specialist institutions, as managers, leaders, planners, implementers determinants of health and was a precursor to the primary health
or researchers. They work at all levels of health services – national, care (PHC) approach.
provincial/state, district or municipal levels – and in defined spheres
Health professionals
with postgraduate PH
Other professionals training
Others involved with postgraduate PH Public Health Medicine
with public health training involved with specialists
public health Doctors with
postgraduate PH
training
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Colonial and early post-colonial period : 1652—1920 notable progressive exceptions), was laid in this early period of PH
development.
Due to colonial influences, South Africa’s early health system was
doctor- and hospi-centric, and by the end of the 19th century there
Pre-apartheid period
were hospitals in most major towns and in some rural areas built
by missionaries and mining companies for their employees.43 Most Health challenges in the 1920s and 1930s were due to the
hospitals and clinics were taken over by national, provincial and development of urban slums and the growing TB epidemic affecting
local government departments of health under apartheid during the mineworkers. Widespread migration of black people to cities
third quarter of the 20th century. resulted in diseases caused by “overcrowding, poor sanitation, diets
and social disintegration”.54 During this period, the divide between
In 1807, the first PH legislation was introduced due to the epidemics
‘personal’ and ‘public health’ services in South Africa’s emerging
of the 18th and 19th centuries that had decimated the population
health system persisted, and ‘personal’ health services were mostly
of the Cape Colony. It provided for the registration of medical
delivered in racially segregated hospitals which were curatively
practitioners, and for PH measures controlling infectious diseases
orientated. Services were inequitable along race, and urban and
through disease notification and inoculation against smallpox.44
rural lines.
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There are some examples of innovative health care in this era. One
A key initiative to transform the fragmented and inequitable nature
of the first hospitals for local indigenous people, Grey Hospital in
of South Africa’s health services – the National Health Services
King William’s Town, used trained orderlies before nurses were
Commission – led by Dr Henry Gluckman, was established by
appointed, and in 1858, the hospital started a three-year general
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the South African Party in 1942. Its brief was to advise on the
practitioners’ training programme.45 In 1891, the Cape Colony
establishment of a National Health Service (NHS) for South Africa’s
introduced registration for nurses and midwives – the first legislature
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population. The impetus for its establishment was government’s
in the world to do so – due to the work of Henrietta Stockdale, an
recognition of the health problems of ‘poor Whites’, who had little
English nun and nurse who helped establish hospitals and maternity
Y T access to health care, a phenomenon that had grown during the
services in Kimberley.46 She developed the first nursing training
war.55
schools in South Africa, took nursing outside of hospitals into
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community and mining settings, and is credited with establishing Gluckman identified four major problems in the organisation of
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nursing as a profession in South Africa.47 health care: poor co-ordination due to the three-tier health system;
maldistribution and shortages of human resources and facilities; an
As in Britain, South Africa’s early 20th century PH services were
inappropriate emphasis on curative and institutional care; and a
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The Act established a fragmented health service – a three-tiered preventative care with curative services.58 A Department of Health
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national, provincial and municipal system – which, with some was established in 1945, with Gluckman as its first Minister.57
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health workers led by Drs Sydney and Emily Kark who pioneered an
concession to persuade the Boer republics to accept the Union.49
integrated model of clinical medicine and PH services – including
Hospitals were segregated racially with separate facilities or wards
education, agriculture and income generation – in rural Natal, the
for different racial designations. PH functions were focused at local-
most notable example being the Pholela Clinic. Government did not
authority level and, as in the UK, powers were given to municipal
share their vision, and in 1939 the Secretary of Health, Eustace
Medical Officers of Health (MOHs) to control infectious diseases.
Cluver, initiated centres to provide inexpensive services for African
MOH appointments were subject to ministerial approval, with
people who had a high burden of tuberculosis (TB), venereal diseases
preference given to doctors qualified in PH.
and malnutrition, who filled urban hospitals and were considered
PH legislation in Europe enabled the provision of potable water, a burden on the economy.49 The ‘Kark’ model, an example of
and the protection of air and food from pollutants and contaminants. social epidemiology,59 was named Community-Orientated Primary
Many commentators argue that these measures were introduced for Care (COPC), and over 40 clinics were established in Natal and
utilitarian reasons – the creation of healthy workers for commercial elsewhere in South Africa during the 1940s and 50s. Teams of
purposes and fitter soldiers for military purposes.50–52 This social trained lay health workers and professionals assessed, monitored
engineering function is echoed in South Africa’s history, with PH and delivered health care, focusing on individuals and communities
measures often being invoked to clear urban settlements, enabling in defined populations.60 This model combined PH functions such
the development of segregated and apartheid cities.53 as prevention, promotion, surveillance, intersectoral work and
community participation with primary clinical care.
The basis for a more authoritarian and state-supportive role for
PH, which persisted through to the end of the apartheid era and Resistance from district surgeons who saw the centres as a threat to
promoted the interests of the dominant social classes (despite their practices – the care of the indigent49 – together with the hostile
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policy environment following the 1948 National Party ascendance In 1987, CHWs and community health projects coalesced into the
to power, resulted in the emigration of many professionals and the National Progressive Primary Health Care Network (NPPHCN), a
end of the social medicine/COPC movement in South Africa.49 civil society advocacy group that included PH professionals, and
Health centres reverted to being “inexpensive clinics for the early called for the implementation of a PHC-oriented service based on four
treatment of disease amongst Natives”.49 principles: “socio-economic development, community accountability,
concerned health worker practice and comprehensive care”.74
Nonetheless, the COPC legacy, together with China’s ‘barefoot
Member organisations had spearheaded earlier CHW projects.
doctor’61 movement (later called ‘village doctors’), contributed to the
The network became a space wherein government policies could be
PHC approach, adopted by the WHO and reflected in the Alma Ata
challenged and a future national health system debated, but it did
Declaration,53 a 20th century milestone in PH. The PHC approach is
not advocate epidemiological approaches to evaluate the impact of
based on health being a human right, requiring the action of social
health services.75
and economic sectors in addition to the health sector.62
Some health projects were forerunners of functioning district health
Apartheid period : 1948—1994 systems. Services in ‘health wards’ were linked to rural district
hospital services, with hospital outreach services supporting clinic
In 1948, the National Party came to political power on an
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and community health services. Community participation in health
election platform that promised intensified racial segregation, and
care and community health committees developed in some areas,76,77
consolidated a racially segregated social system. Fragmentation of
pre-dating post-apartheid legislation mandating the establishment of
a hospicentric health service into 14 health departments resulted
formal structures to facilitate community participation.
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in massive duplication of service delivery, waste and inequity.
There were marked differences in disease prevalence and mortality
The post-apartheid period
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between races, with Africans faring the worst and Whites the best.63
These outcomes reflected differences in living conditions, work, In 1994, South Africa transitioned to a non-racial democracy. The
nutrition and access to services. Y T extraordinary processes of health transformation after apartheid
are documented in detail elsewhere.25,66,78–80 This section focuses
Interestingly, even in this ideologically driven era, there was
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on the main features of post-apartheid transformation of the health
government recognition of a disorganised health service that was
system relevant to human resources in PH.
“bewildering in complexity and diversity … and fragmentation”,64 a
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comment made by the Secretary of Health in 1976. A new Health Act Major obstacles tackled were the unbundling of homeland
was introduced in 1977 to “provide measures for the promotion of and ‘own/general affairs’ health administrations, and building
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the health of the inhabitants of the Republic… and define the duties, management capacity for the new district health system. Inadequate
powers and responsibilities of authorities which render services”.65 numbers and inequitably distributed health professionals particularly
Local authorities were responsible for maintaining environmental affected rural areas and provinces. Restructuring involved merging
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health, preventing communicable diseases, and health promotion the myriad health authorities and resolving disparities in salaries
and rehabilitation, and the head of these – a Medical Officer of and conditions of service. Incongruence of geographical boundaries
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Health – was to be “a medical practitioner who possesses a degree with local government, as well protracted discussions about which
or diploma in community health registerable with the Medical, level of government (provincial or local) would be responsible for
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Dental and Supplementary Health Professions Act of 1974”.65 “comprehensive service provision”, consumed energy and delayed
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implementation.79
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health initiatives during the later apartheid era. In the 1980s, health services. New clinics were built, hospitals ‘revitalised’ and
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initiatives developed based on a commitment to socio-economic systems developed: management, human resources, pharmacy and
development, community accountability and comprehensive care. information systems, and tracking service performance. Progress
These included the establishment of community clinics by health was made in redistributing resources geographically and between
workers, including doctors, humanitarian and political activists, levels of care.54
e.g. Black Consciousness students;66,67 the formation of activist
Two initiatives, the Reconstruction and Development Programme
healthworker organisations such as the National Medical and Dental
(RDP) and the White Paper on the Transformation of the Health Care
Association (NAMDA),68 the Organisation of Appropriate Social
System in South Africa (1997), provided the policy and strategic
Services in South Africa (OASSSA)69 and the Health Workers Society
framework for the reform of the health system.78 These built on the
(HWS).70 Later, the policy frameworks for the new African National
ferment of policy development for a new South Africa during the
Congress (ANC)-led government were produced by progressive
last five to 10 years of apartheid rule. Earlier initiatives included the
academics, activists and PH professionals.71 Lay healthworker
ANC’s National Health Plan, which envisaged the restructuring of
involvement in health service delivery through community health
the health system based on the PHC approach, drawing inspiration
worker (CHW) programmes re-emerged in the 1970s along the lines
from the country’s earlier COPC experience and the Alma Ata
of the COPC initiative.72 Programmes focused on the training and
Declaration, and proposed decentralised services with health
deployment of lay health workers to understand communities’ health
centres being the foundation of service delivery.81
issues, enskilling them to undertake promotive, preventive, curative
as well as rehabilitative and palliative health care. Initiatives were The RDP emphasised the provision of housing, sanitation, water,
prominent in rural and poor peri-urban settlements and positively nutrition and health services as central to people’s needs. It provided
impacted on PH indicators and outcomes such as child and infant for free health care to children under six and to pregnant and breast-
mortality and health knowledge.73
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feeding women, and a primary school nutrition scheme.82 These human resources for health and ‘vested interests’. Competing
initiatives echoed the PH measures introduced in the UK in the 19th interests between the Departments of Health and Higher Education
Century where environmental changes such as housing, sanitation and Training, nursing bodies, and the Health Professions Council of
and later, school meals, were prioritised by MOHs.83 South Africa (HPCSA), have resulted in ineffective implementation of
health workforce strategies.85
The 1997 White Paper proposed the establishment of a unified
health system,84 emphasising the delivery of decentralised health Despite the establishment of the district health system in South Africa
services closest to people, based on the principles of comprehensive and high levels of inputs, health outcomes in South Africa remain
PHC, and laying the basis for the concept of a district health below expectation.80,85 In 2012, men had a life expectancy at birth
system. The new National Health Act (61 of 2003) embodied this of 56 years, and women, 62.93 HIV denialism during the Mbeki
commitment to develop a unified, district-based health system and presidency (1999–2008) undermined programmes for prevention
accessible health services,3 and made provision for community and treatment of the HIV and TB epidemics, which were the main
involvement in health care. causes of premature death, and exacerbated the crisis in healthcare
delivery.94
The Act, whilst valuing population health perspectives, did not create
PH institutions or discuss explicit roles for a PH-trained workforce.
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Public health professionals in South Africa a
With the abolition of the 1977 Health Act, MOH positions in local
authorities fell away, signalling a final end to positions in the health Historically in South Africa, positions were earmarked for doctors
system linked directly to PH training. with PH diplomas (DPH) in MOH posts. In the 1980s, PHM
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specialists replaced the diploma doctors. After the end of apartheid,
The South African health workforce health service posts requiring PHM specialists fell away until
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recently, when a few provinces created provincial or district posts
By the end of the 20th century, South Africa was facing a serious
for PHM specialists. In addition, academic PH specialist positions
health workforce crisis.85,86 The 1997 White Paper84 highlighted
Y T were created and remain. These are ‘joint’ posts – provincial service
staff shortages and geographical inequities, and prioritised
posts linked to academic institutions reserved for registered PHM
training for clinical professions and skills development in health
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specialists. There are also few posts in the public sector for which an
management. It also proposed the establishment of a National
MPH degree is mandated.
School of Public Health. The 2001 Pick Report,87 the first post-
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apartheid government-commissioned human resources report for International experience is varied. The USA licenses medical
a PHC-oriented health service, proposed a restructured clinical specialists in ‘preventive medicine’, and in Australia, New Zealand
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workforce. It argued for expanding numbers and broader scopes of and Ghana there is licensing for medical specialists in PH, but with
practice for lower levels of nursing and pharmacy staff.88 Its terms few posts linked to specialist qualifications. In Canada, public health
of reference did not include the PH workforce per se and, besides physicians are the ‘gold standard’ for MOHs, who play a critical
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training programmes and employment for a range of mid-level role in national and local health systems.96 On the other hand, in the
workers, many recommendations were not implemented. UK, PH specialists are appointed to posts with titles such as ‘public
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Public health workforce
Community Health departments previously offering PH training for on PHM specialists’ career paths, reasons given for not registering
doctor managers. were that: it was not a requirement for a job; it incurred cost but no
benefit; ignorance that registration was not effected automatically;
There is confusion as to what exactly constitutes a ‘public health
difficulty encountered in the process of registration; or emigration.95
specialist’ in South Africa. In practice, the term is no longer reserved
for doctors on the PHM specialist register. ‘Specialist’ designations Currently, registrar programmes are offered at all universities offering
in PH have become broad and include a range of health and non- medical training except Walter Sisulu University, and there are an
health trained PH graduates. PH graduates are often referred to estimated 20 PHM specialists in training with an annual output of
as PH ‘professionals’ or ‘specialists’,99–101 and ‘specialist’ positions six to eight graduates.105 Although the HPCSA register is notoriously
in constituent disciplines of PH are advertised in the South African inaccurate,95 by the end of January 2016, there were 146 doctors
media.c registered as either Community Health or PHM specialists.106
Public Health Medicine training At the end of PHM training, some graduates are unable to find
employment utilising their skills, and there are few public sector
Specialist training posts in PHM for doctors are funded by provincial
positions earmarked specifically for graduates with this training.95
health departments. Undergraduate university training qualifies
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doctors to register as medical practitioners with the HPCSA. While Master of Public Health training
PH forms part of undergraduate medical training, postgraduate
Over the last 20 years, the scope and number of postgraduate
in-depth training facilitates expertise. Specialist training is through
PH training courses in South Africa have grown. Historically, non-
four-year full-time programmes in an apprenticeship model in
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medical postgraduate PH training focused on epidemiology through
service settings. Most programmes include theoretical training.
Honours and later, Masters degrees. Adding in management and
This is a regulated process with HPCSA-designated training posts
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social sciences59 resulted in a range of MPH ‘specialisms’. Courses
linked to approved training programmes at universities. Graduates
are offered by universities through schools of public health within
are assessed by the College of Public Health Medicine (CPHM)
Y T faculties of Health Sciences.g These are one- to two-year course-
examinations according to a defined curriculum,d and are required
work degrees with a minor dissertation component, and are open to
to demonstrate competency in a range of skills,102 qualifying them
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health science, social science and science graduates.
to register as specialists with the HPCSA.
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‘Community Medicine’ and ‘Community Health’, but in 1998 the While it is a requirement for some government posts, this hetero-
fellowship nomenclature changed to Public Health Medicine. Whilst geneous degree is not a professional qualification with core
CPHM or MMed qualifications enable specialist registration with competencies that are standardised, nationally accredited and
statutory councils – the HPCSA from 1983f or its predecessor the monitored. It is not linked to a career track in either the public or
South African Medical and Dental Council (SAMDC) – not all those the private sector, and graduates’ career trajectories are unknown.
qualifying are registered as specialists.
In summary, there are a range of PH professionals in South Africa.
As of 2010, 177 doctors had successfully completed training These include personnel with defined skills such as environmental
entitling them to register as specialists with the HPCSA. However, health officers (EHOs); clinically trained professionals with
only 60% had registered. From the doctoral work of an author (VZ) postgraduate PH training; social scientists with skills in health
promotion; health economists; health systems researchers; managers
c For example, see http://www.indeed.co.za/Public-Health-Specialist-jobs [9
December 2014] for adverts for 1) specialists in Monitoring and Evaluation who are able to identify and address systems failure; and doctors
and 2) Prevention; [13 February 2016]. who have undergone specialist training in PH.105 This is represented
d Learning domains are: Health measurement and informatics; Behavioural
in Figure 1.
and social sciences; Occupational health; Infectious diseases, their
prevention and control; Environmental health; Non-infectious diseases and
their prevention; Health services management; Health economics. This
curriculum, developed over a decade ago, is currently being reviewed in the
light of competencies required in South Africa.
e Correspondence with Prof John Matjila, past Head of the Department of
Community Health, University of Pretoria, 4 June 2014. g Unlike the American model where courses are typically run by autonomous
f This is the first year that specialists with fellowships or MMeds were schools of public health, the standard model in South Africa is a School
registered on the HPCSA register. within a Health Science Faculty.
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The Motsoaledi era reforms assessment of policies led to differences in provincial expenditure
and health outcomes.54
Dr Aaron Motsoaledi recognised the poor performance of the health
system and soon after his 2009 appointment as the Minister of Health, A recognition of the need for health workforce planning,
drew up a 10-point plan108 to improve health system performance management, training and employment was articulated in the
towards achieving the MDGs within a PHC approach.109 The 2011 Human Resources for Health (HRH) policy document.5 This
plan focused on a range of health services challenges that set echoes calls from the international health educational community
the stage for the introduction of NHI services: leadership; facility to train health professionals to be “systems-based, to improve
and health workforce management; improving quality of care and the performance of health systems by adapting core professional
health infrastructure; the prevention and management of infectious competencies to specific contexts”.115
diseases, maternal and child health; and health promotion.109 These The HRH document noted that PH personnel were not institution-
challenges have been addressed by a range of National Department alised and that personnel performing PH functions were “not
of Health policy papers and interventions discussed in this section. appropriately trained in epidemiology, planning and statistical
analysis”.5 It recognised the importance of health system reform and
Health system reforms acknowledged the skills-set needed to support this.
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Specific interventions and policies have been articulated to address The HRH policy document also echoed the memorandum of the
inadequacies and, through a PH lens, these are outlined in Table 1. Heads of Public Health Medicine105 to the National Department
The earliest was the ‘re-engineering of PHC’ which consisted of of Health that called for clarity about career paths for medical
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three streams that have been piloted and implemented since 2010. and other PH professionals, and the establishment of PH units at
These are the establishment of Ward-based PHC Outreach Teams provincial and district levels. PH responsibilities outlined in the HRH
20 IL
(WBOTs), along the lines of the Brazilian Family Health Programme document were to develop provincial and district health strategies,
(PSF); the establishment of District Clinical Specialist Teams (DCSTs); and monitoring and evaluation frameworks to evaluate the outcomes
screening, adherence support, and referrals85 – encompasses both government vigorously about appropriate positions for them.
PH and individual care functions, and is reminiscent of the earlier Other policy initiatives include the re-opening of nursing colleges,
COPC model. incorporation of lay health workers through the PHC health teams,
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health system functioning.111 Notably, PH professionals are omitted The need for competent health managers, however, continues to be
from these teams, and are not mentioned in the PHC re-engineering voiced,116 and is mentioned in the NHI White paper, discussed in
BA
strategy. this section.4 Research among stakeholders has explored the skills
for hospital managers,117 as well as the importance of a range of
O
Other notable reforms are the establishment of the Office for Health
both management and PH competencies for clinic managers and
Standards Compliance (OHSC), a statutory body mandated to
EM
52 S A H R 20 1 6
Public health workforce
The 2015 NAPHISA Bill proposes the establishment of an institution Public health units
for surveillance and ‘public health services’.7 Based on the CDC
Expertise to strengthen the health services is reflected in some
model to institutionalise PH core functions and competencies,26
provincial health plans. For example, the Western Cape Department
it partially addresses the gap for PH leadership to reduce the
of Health’s 2020 Health Plan121 aims to strengthen PH capacity. A
underlying risks to health in South Africa, given the lack of capacity
Health Impact Assessment directorate was established and mandated
to collect, analyse and use population health data to identify
to assess the impact of prevention initiatives and clinical services
appropriate interventions and to model possible gains including
on the population’s health status. This unit monitors outputs against
their cost-effectiveness.120 The proposed national PH institute,
annual performance plans and implementation, and provides “PH
NAPHISA, is to focus on surveillance, training and research on
intelligence, guidance based on national and international research
major threats to health – communicable and non-communicable
to demonstrate which interventions are most cost-effective”.121
diseases, cancers, and violence and injury. Its scope excludes
key drivers of ill-health such as the social determinants of health, This initiative echoes health sector PH functions which had been
occupational health and environmental health. The Bill intends to highlighted in 1994 by UCT’s incoming professor of Public Health,
assimilate staff from the National Institute of Virology (NIV) and the Jonathan Myers. His inaugural speech highlighted PH skills shortages,
National Health Laboratory Service (NHLS). Apart from the mention particularly at senior levels in the health services.122 He argued
PM
of these institutions and outlining the management of NAPHISA, the that PH functions in health plans and provincial organograms were
Bill is silent about the PH human resources required for the range dispersed in clinical services or in planning and human resources
of PH functions listed. In addition, its PH research and training departments, and called for the establishment of PH units to play a
16 6
mandates overlap with those of existing universities and national “critical intelligence function in a context of shifting health priorities
research institutes. and needs with appropriate health interventions”.122 In Myers’
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Whilst skills to transform systems are emphasised in these documents
and attention is given to the competencies of managers, insufficient
Y T
notice is taken of the need for a cadre of skilled health professionals
to develop and evaluate reforms. Policies are focused on clinical staff
A N
supporting or providing ‘personal’ health services, with scarcely any
M U
Table 1: Comparison of public health competencies and specialist roles in key 2011 and 2015 health policy documents
Component Re-engineering NHI White Paper4 Human Resources for NAPHISA Bill7
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service; an approach, skills, preventative health scheme technical skills – prevention, policy and implementation
prevention surveillance
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S A H R 20 1 6 53
Component Re-engineering NHI White Paper4 Human Resources for NAPHISA Bill7
monograph1 Health policy5
Stewardship for public health
Elements Interpretation of information Demographics Surveillance Co-ordination of
surveillance;
Health Reform
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a. District Clinical Specialist Teams
Composition Family physician, mental Principal specialists: Principal specialists: N/A
health, oral health and Obstetrics, Paediatrics, Obstetrics, Paediatrics,
rehabilitation Family Medicine, Family Medicine,
Anaesthetics; Midwife & Anaesthetics
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PHC nurse
Deliverables District teams impacting Mentorship, clinical (Silent) N/A
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on social determinants of governance, data usage for
health planning
b. Ward-based PHC Outreach Teams
Composition
Y T
Nurses, CHWs reporting to
facility manager
Nurses, CHWs reporting to
facility manager
(Silent) N/A
A N
Deliverables Health promotion and Data on population health (Silent) N/A
prevention; Improved child status; health promotion,
M U
Strategy Produce and use district Delegate to hospitals, Institute of Leadership and Training and information
health plans district offices and PHC Management in Health Care
G
facilities
Information system for Upgrade information
monitoring
R
systems
Deliverables Strengthened district and Functional health system for Competency and (Silent)
facility management personal and non-personal management qualification
BA
Strategy PHC outreach teams Multi-sectoral National Ward based outreach teams (Silent)
EM
Health Commission
Deliverables Health promotion & illness Health promotion to reduce Improved population health (Silent)
prevention for health burden of disease
communities
Quality Assurance
54 S A H R 20 1 6
Public health workforce
view, such units could house permanent PH staff – PHM specialists marked to confirm competency. The competencies and career-paths
or post-doctoral employees, together with registrars and Master’s of these and other PH graduates, however, need further research.
graduates. Academic PH specialists would have service roles and
Recent health service reform initiatives provide an opportunity
co-supervise registrars who would rotate through district level units.
to redefine the role of PH professionals in South Africa. Roles
He warned that PH should play a critical role through advocacy and
intimated in policy documents are chiefly technical – in surveillance,
research so that it did not merely prop up a failing health system.
information gathering and are advisory. They provide demographic
and epidemiological information to inform strategic planning and
Conclusion prioritisation of services, monitoring and evaluation of services,
as well as health promotion and prevention. The policy, quality
Over 70 years later, in post-apartheid South Africa, the four health assurance, research, training and implementation mandates are
system challenges identified by the 1942 Gluckman Commission mentioned without elaboration.
persist. Poor health service co-ordination also prevails – between
national, provincial and local health departments, and between Minor attention is given to roles within health service structures at
government departments with responsibilities relating to the social national, provincial and district levels. We have noted, however, that
health managers require management and PH competencies to lead
PM
determinants of health. Policies, particularly those affecting the
health workforce, are also often not congruent. Maldistribution and health system reform and structures. In time, the entry requirement
shortages of human resources and facilities remain, together with for district managers could be a postgraduate PH qualification.
inappropriate emphases on curative and institutional care, as well The advent of the NHI White paper and the NAPHISA Bill at the
16 6
as a profit-orientated private practice focused on curative care. The close of 2015 provides an opportunity for PH-trained professionals
solution to these challenges in 1942 was a national health service to advocate for and demonstrate their value. Their wide and
20 IL
– so too in 2016. versatile skills-base allows them to work in district, provincial and
national units, in technical and service roles. Their functions would
We have aimed to show that PH approaches, competencies and
Y T include population health needs assessments, support for planning,
trained personnel are essential for the success of development and
implementation, service evaluation and the control of health
A N
health systems agendas, and of universal health care globally and
threats. PH units at national, provincial and district levels should
nationally. Human resources for health, including PH in South Africa,
be established, and their design could build on the experience of
M U
There are some positions for PHM specialists but few for other PH
PHM specialists and other PH professionals, and where possible
professionals. Dedicated PH units are rare and their establishment
have strong relationships to academic institutions. They are a
remains ill-defined in current health policy.
potential resource providing ‘intelligence’ to inform the process of
O
The reasons for their poor prominence may be a combination of health system development and restructuring as part of the creation
factors. Firstly, historically, PH professionals in South Africa enforced of a NHI system for South Africa.
G
Is there a critical mass able to contribute, are they ‘fit for purpose’
and, together, have they shown their worth? Uneven competencies
among MPH graduates may be the consequence of burgeoning
‘specialisms’. These heterogeneous courses may need to be bench-
S A H R 20 1 6 55
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60
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Disabling health: the challenge of incapacity
leave and sickness absence management in
6
the public health sector in KwaZulu-Natal
Province
Authors:
Rajen N . Naidoo i
Saloshni Naidoo ii
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Sujatha Hariparsad i
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S 20 IL
ickness absence and long-term incapacity leave contribute substantially to the Management of ill-health
national service delivery challenges that are particularly evident in the public
Y T
health sector. The Auditor-General’s reports, and the Department of Public among healthcare workers
A N
Service and Administration, have highlighted these challenges. is not addressed at the
workplace, resulting in poor
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agencies. Management of ill-health among health-care workers is not addressed at to-work and work incapacity
the workplace; this has resulted in poor decision-making about fitness to work, and contributing to levels of
to work incapacity contributing to levels of absenteeism that exceed international
absenteeism that exceed
O
This chapter reviews and critiques current approaches in the management of ill-
health among healthcare workers and assessment of their ability to work. A review the healthcare sector.
R
The authors propose an approach that ensures institutional responsibility for sickness
absence, involvement of the Employee Health Service in the case of five days of
absence, and involvement of the Occupational Medical Practitioner in cases of
repeated short-term absence and assessment of fitness to work.
i Discipline of Occupational and Environmental Health, School of Nursing and Public Health, Universit y of KwaZulu- Natal
ii Discipline of Public Health Medicine, School of Nursing and Public Health, Universit y of KwaZulu- Natal
61
Introduction
Healthcare workers (HCWs) form a substantial percentage of the Within the UK’s National Health Service (NHS), long-term absence
South African public sector workforce. The Human Resources for accounts for 56% of working days lost, and 70% of the costs of
Health (HRH) Strategy for the Health Sector 2012/13–2016/17 absence.12 According to a 2009 report, staff absenteeism in the
forms part of the State’s 10 Point Plan, and focuses on the NHS was 10.7 days a year, compared with 9.7 days per year in the
improvement, planning, development and management of human public sector, and 6.4 days in the private sector. This translates into a
resources within the National Department of Health (NDoH).1 From loss of 10.3 million working days each year, costing the NHS £1.7
2004 to 2010, the health sector has seen an estimated 37% increase billion each year.13 Although the NHS is not directly comparable to
in the number of health professionals within the public sector.1 the South African context, the extent of the problem in the UK, with
its established management system, would suggest that this issue is
The health of HCWs, particularly those in the public sector,
likely to be substantially greater in South Africa.
persistently occupies a low priority in the broader South African
health agenda. The strategic plans and policy statements of the In other developing countries, the problem is considerably more
NDoH reflect minimal attention to the need to ensure a healthy severe. In a district in Kenya, it was estimated that the average
health staff absenteeism (sickness and general absenteeism) rate
PM
workforce in the public health sector, or to how the health of the
HCW impacts on the delivery of the NDoH’s mandates. While this was 25%, resulting in a loss of US$51 000 per month to each
is symptomatic of the approach for workers in the public sector in health facility.14 In India, the estimated average absenteeism rate is
general, the greatest impact of a lack of such focus is felt in key 40%.13 In a study of several developing countries, including India,
16 6
service delivery arenas such as health and education.2 Bangladesh, Uganda, Peru and Indonesia, health staff absenteeism
rates ranged from 25% to 40%, with higher-skilled staff (doctors) as
20 IL
One of the nine priorities of the National Development Plan 2030
compared to general assistants being more likely to be absent.15
is to “Improve Human Resources in the health sector” to achieve
an effective health system. While this focus centres on training The need for appropriate disease management of HCWs in public
Y T
and accountability, it fails to take cognisance of the inadequate
management of the health of the ‘health workforce’, either in
health facilities in South Africa is of growing concern. In this chapter,
we present the current legislative context and practices for disability
A N
identifying work-related ill-health or managing the impacts of ill- management of HCWs in public sector healthcare facilities in South
M U
health on the ability of workers to provide the services they have Africa. Using our experiences in public sector hospitals in KwaZulu-
been employed to deliver. Natal Province (KZN) and through a review of the literature, we
propose a model for managing HCW disability and sickness
4 ED
Over the last few years medical surveillance of HCWs has increased;
absence in South African public healthcare facilities. We focus our
however, this is largely to identify workers with tuberculosis (TB). As
critique on data available for KZN, and compare these with national
such, the surveillance is not representative of a systematic approach
data where available.
O
outcomes also vary across the different categories of HCWs, from NHS. Several government-level investigations have been conducted
clinical (doctors, nurses, clinical assistants) to laboratory staff, by the NHS and they have made recommendations and proposed
O
general assistants, and administrators in the healthcare sector. The solutions. These documents were identified using Google Scholar
EM
growing burden of these diseases and their natural progression in and PubMed, using the keywords ‘sickness absence’ and ‘health
the presence of modern medical interventions can result in HCWs care’, and by means of a targeted search through the UK NHS
developing related chronic health disabilities. These disabilities and UK government websites. The key documents identified were
can impact on the individual’s work performance in the healthcare “Health at work – an independent review of sickness absence”,11
setting and impacts negatively on service delivery. “Guidelines on prevention and management of sickness absence”,12
and the “NHS Health and Well-being Review”.13
Inadequate management of chronic illnesses results in increased
sickness absence in the workplace. This takes the form of short-term Reports were also reviewed from the Public Services Commission of
absences or long-term sick leave, and is a global phenomenon, South Africa, the Department of Public Services and Administration,
prompting much research and review in the private and public and the national and KZN Departments of Health, accessed through
sectors worldwide. In the United Kingdom (UK), the average a Google search using the keywords ‘sickness absence’, ‘health
number of days of absence per employee per annum in the private care’ and ‘South Africa’. A search was also done on the websites of
sector is approximately 5.5, compared with eight days for those these government agencies. This approach provided the following
in the public sector.10 Approximately 140 million work-days have documents: “Report of the Auditor-General on a Performance Audit
been reported as lost each year to sickness absence in the UK.11 of the Management of Sick Leave Benefits at certain National and
While in the majority of instances, these are short-term absences, Provincial Departments”;2 “Evaluation of the Impact of the Policy
approximately 300 000 employees annually failed to return to work and procedure on Incapacity Leave and Ill-health Retirement (PILIR)
following long-term absences. According to this 2011 report, the on Sick Leave Trends in the Public Service”;16 “Incapacity leave
total cost of sickness absence to the UK public sector was estimated and ill-health retirement: briefing by Departments of Public Service
at £4.5 billion. and Administration, Health, Correctional Services. Committee
62 S A H R 20 1 6
Incapacity leave and sickness
minutes”;17 “KwaZulu-Natal Department of Health Annual Report in the workplace is a well-recorded presentation among South
– 2014/2015”;18 and “South African National Department of African HCWs leading to disability.4,6,25 The estimated prevalence
Health Annual Report 2013/2014.”19 The latter two documents are rate for latex allergy among HCWs is reported at 3%–12%.7,26–28
produced biennially by the national and provincial Departments of
The actual prevalence of blood-borne pathogens among HCWs is
Health and only the most recent reports were reviewed.
unknown but mimics that of the general population, with the risk
The authors also reviewed a small sample of employees from a single of occupational infection being the highest for hepatitis B (30%)
department within a healthcare institution. All employees who had and lowest for HIV (0.3%).29 Data for occupation-related infectious
made an application to the Human Resource Management (HRM) in disease prevalence among HCWs in Limpopo Province submitted
the previous cycle (January 2013 – December 2015) were reviewed. to the Compensation Commissioner between 2007 and 2009
Eighteen of 303 employees submitted 151 short-term incapacity included TB (83.9%), cholera (10.7%) and chicken-pox (5.4%).30
leave applications for short-term leave during the 2013/2015 leave
Lack of organisational support, job demands and nursing of patients
cycle. The authors reviewed all 151 applications.
lead to stress and burnout among HCWs.31–33 In the process of
The purpose of the document and patient review was to describe caring for patients, HCWs are often victims of physical violence,
and identify challenges with current disability management of which is an added stressor in the work environment.34 The burden of
PM
HCWs in the public health system with a view to proposing a model caring for terminally ill patients and those living with HIV and AIDS
for managing sickness absence at an institutional level. is also a source of stress among HCWs.35 These workplace factors
lead to psychosocial stress among HCWs, with the potential to
In the subsequent section based on a review of the existing literature,
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increase absenteeism in healthcare facilities.27 Absenteeism triggers
information is presented on the burden of disease among HCWs,
a vicious cycle as it leads to staff shortages, which contribute to
the legislative and policy framework for managing illness, and the
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increased organisational stress resulting in further absenteeism.
process for incapacity management of HCWs. Further information
is presented on secondary data analysis of clinical assessments of Despite the extensive body of literature on the relationship between
disability in HCWs.
Y T working conditions and ill-health, neither the NDoH’s Human
Resources of Health strategy document,1 nor the country’s National
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Development Plan 2030,37 nor the Lancet Special Issue on “Health
Burden of disease among healthcare workers
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public sector hospitals in Gauteng was reported as being 11.5%, facing the country. Furthermore, despite our knowledge about the
with the prevalence rate among nurses being 13.7%.5 A systematic prevalence of these diseases, our understanding of the disabling
review of the epidemiology of and programmatic response to TB chronicity among HCWs and its impact on their capacity to work is
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among HCWs in South Africa showed that the incidence of TB largely unknown.
among HCWs ranged from 138 per 100 000 population to 1 133
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to 84%.21 There was no consistent association between age and risk illness in the Department of Health
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category among the studies reviewed. The primary reason for HCW health status being obscured is the
The availability of antiretroviral treatment (ART) for persons living approach of the NDoH and the healthcare institutions, in that ill
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with HIV has resulted in an increased life expectancy,22 placing workers generally seek private health care, and no system exists
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them at risk of complications associated with chronic diseases of to monitor the health of the ill worker at the workplace. A national
lifestyle. The presence of HIV infection has been shown to increase guideline on medical surveillance is available,40 providing a
the incidence of TB infection among HCWs,8 while complicated detailed approach to the pre-placement of workers, ongoing medical
and uncomplicated TB among HCWs has resulted in considerable surveillance, and sickness absence management. However, these
morbidity within this population.20,23 Complications associated with guidelines have not been translated into actual policy at provincial
TB have resulted in HCWs experiencing pneumonectomies, hearing or institutional level. In some KZN institutions, medical surveillance
loss and neurological disorders,23 resulting in incapacity. programmes are managed by sessional doctors, mostly without
any specific training in occupational health, and in others there
Obesity, diabetes, hypertension, non-infective respiratory diseases,
is no medical doctor. Approximately four KZN hospitals employ
musculoskeletal disorders (MSDs), and dermatological diseases are
full-time doctors to manage their Employee Health Services (EHS).
non-communicable disease presentations typically found among
This under-resourcing of EHS implies that the health of HCWs is
HCWs.6,7,9,24 In a survey of 200 HCWs in a tertiary hospital in
inadequately monitored by health professionals with the appropriate
Pretoria, the prevalence rates for obesity, diabetes and hypertension
skills. Doctors without the necessary training are not able to assess
were reported as 37%, 10.5% and 19% respectively.9 The
hazards and the risks posed by such hazards, nor are they able to
prevalence rate of lower-back pain in South African HCWs has been
recommend interventions to control these hazards or to implement
reported to range from 25% to 58%,4,7 and a high number of HCWs
risk-based medical surveillance to detect workers who are likely to
seek medical help for their musculoskeletal-related pain.7 The natural
acquire work-related diseases.
complications associated with chronic diseases of lifestyle and
musculoskeletal disorders are likely to present within this population The World Health Organization/International Labour Organization
as HCWs age. Asthma and allergic dermatitis due to latex exposure Guidance Note on improving HCW access to TB and HIV
S A H R 20 1 6 63
management at their workplaces emphasises the need for employee does not pay annual levies to the Compensation Fund (exempted
health services for HCWs to be instituted at both national and employer status), and becomes responsible for all expenses arising
workplace level.41 The NDoH’s 2014 National TB Management from occupational injuries and diseases, including medical aid,
Guidelines specify that medical surveillance programmes for HCWs compensation for temporary and permanent disability, as well as
should be established and maintained.42 However, while these funeral expenses, as defined by the law. In terms of the law, it is the
policy documents are crucial for the detection of those likely to provincial Department of Health (DoH) that is directly registered as an
develop occupationally acquired diseases, and are important in the ‘employer individually liable’ – and not the provincial administration
management of those with acute illness, they make no reference to (Office of the Premier) or the NDoH. Thus, individual healthcare
those HCWs whose ailments develop into disability. institutions are not classified as ‘employers’ in their own capacity.
All institutional submissions must therefore be made through the
To address work-caused health outcomes, most institutions implement
provincial head office of the DoH. The latter is then responsible for
the legal requirements as set out in the Compensation for Occupational
onward submission of claims to the Compensation Commissioner.
Injuries and Diseases Amendment Act (130 of 1993) (COIDA).
The Commissioner will determine liability for the injury or disease,
Obtaining statistics at provincial or national level for HCW cases
and inform the DoH accordingly. If liability is accepted, the DoH
submitted to the Compensation Commissioner for compensation is
is then expected to cover the necessary costs (for medical aid,
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difficult, as this process occurs at institutional level and no official
compensation for temporary disability and funeral expenses).
reports are published at provincial or national level. Based on limited
Pension, lump-sum compensation and dependents’ payments are
research, approximately 18.35% of 583 known cases of TB among
paid through the National Treasury (Pensions Administration).52
HCWs were reported to the Compensation Commissioner between
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1999 and 2004 in hospitals in eThekwini, KwaZulu-Natal.43 In This ‘internalised’ liability in the compensation process leads to
Limpopo Province, only 56 cases of occupational disease among further complexities in the management of HCWs with chronic
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HCWs were reported to the Compensation Commissioner between incapacitating illnesses. During the period of temporary disability as
2007 and 2009.30 defined by COIDA, an injured or diseased worker is either provided
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These findings are in the context of generally low reporting of
with alternative work (generally without consultation of the EHS or
a doctor with occupational health training) or is placed on leave if
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occupational diseases to the Compensation Commissioner in South
no alternative work is available. In the case of the latter, this leave
Africa.44 In addition, the failure of COIDA to effectively address
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shortcoming.
rarely informed of this decision by the Commissioner. The employee
either continues with the alternative work indefinitely or remains
Legislative context for incapacity management on sick leave, without the option of challenging the decision of the
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of HCWs in the public sector Commissioner, as is provided for in law. It is unclear whether the
employee receives full pay throughout this period, or a portion as
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The employment, retirement and termination of services among stipulated by the Act.
HCWs in public sector facilities is governed by the Public Service
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leave is defined as additional sick leave granted at the discretion public sector hospitals
of the employer. This leave allocation is guided by the Policy and
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Procedure on Incapacity Leave for ill-health Retirement (PILIR).46 The In terms of the PILIR46 policy in public sector hospitals, HCWs
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PSA makes provision for the dismissal of an employee on the basis of who have exhausted their 36-day sick-leave cycle may apply for
ill-health or incapacity, with due observance of the Labour Relations temporary incapacity leave, which may be short-term (≤ 29 days)
Act (66 of 1995) (LRA).47 The Basic Conditions of Employment Act or long-term (≥ 30 days) incapacity leave. Up to the 36th day, the
(75 of 1997) (BCEA),48 the Employment Equity Act (55 of 1998) leave process is based on sick notes submitted by the employee to
(EEA),49 and the LRA47 provide a supporting framework to the the line manager who then submits the documentation to the Human
PSA. The Public Service Co-ordinating Bargaining Council (PSCBC) Resources Department. There is no discussion about the absence
Resolutions 7 of 200050 and 5 of 200151 provide further guidance from work between any member of the institution’s management and
on the management of incapacity among HCWs in the public sector. the employee up to this critical point, nor are any referrals to the
In terms of the BCEA, all employees are entitled to 36 days of paid EHS activated.
sick leave in a three-year cycle. The EEA allows for medical testing of The application to the Health Risk Manager (HRM) must be made
employees where needed,49 while the LRA47 allows for termination within five working days of the first day of absence (Figure 1). The
of services on the basis of ill-health after full investigation of the case HCW submits the requisite documentation together with all medical
and all potential alternatives have been considered.
reports and certificates to the Human Resource Department of the
COIDA makes provision for compensation of injuries and diseases facility. Within five days, the employer must verify all documentation
“arising out of and in the course of an employee’s employment”. and submit it together with a departmental report to the HRM while
The procedures for compensation applicable to HCWs (and public granting the employee conditional temporary incapacity sick leave
sector workers in general) differ somewhat from those workers in the for a maximum of 30 days. The HRM must acknowledge receipt of
private sector. Government departments, including the NDoH, are the documentation within two working days and confirm in writing
considered ‘employers individually liable’. As such, the Department that a response will be generated within 12 working days. The
64 S A H R 20 1 6
Incapacity leave and sickness
HRM reviews the application (primary assessment) and determines In terms of this process, the HRM essentially makes the decision
whether (1) the application is invalid and hence no incapacity leave based on third-party medical reports. The HCW is not seen in
will be granted, (2) the application is valid and incapacity leave person by the HRM prior to the HRM making this decision; hence if
must be granted, (3) the application is valid but the applicant must the documentation is incomplete or does not reflect the actual extent
undergo specified treatment, or (4) the application is valid but the of the HCW’s incapacity, inappropriate decisions can be made.
applicant must undergo a secondary assessment. The employer
must, within 30 days, make a decision on granting or refusing
the employee’s application and inform the HCW in writing of
Sickness absence among healthcare workers in
the decision. If incapacity leave is granted, the conditional leave the public sector
is converted to incapacity leave. However, if the application is According to a report by the Auditor-General, in the three-year
rejected, the employer must indicate whether the conditional leave period from 1 January 2001 to 31 December 2003, government
should be considered as annual leave or unpaid leave. employees accounted for 12.6 million days of sick leave, at a cost of
In the case of long-term incapacity leave, the HRM may request R3 527 million.2 HCWs in the Western Cape Province and KZN took
that the HCW be subjected to a full assessment, which entails a approximately 600 000 and 1.8 million days of sickness absence
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secondary or further medical assessment to determine functional respectively from January 2001 to December 2003, amounting
capacity. Based on this assessment, a decision is made as to whether to R127 million and R461 million in each province respectively.2
the HCW should continue with temporary incapacity leave and if so, It may be argued that this occurred before the introduction of the
PILIR strategy. The absence of data since implementation of the
the duration of the leave period.
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PILIR in 2006 does not permit proper evaluation of this system.
If the HCW’s condition is determined to be a permanent incapacity, The Department of Public Service and Administration (DPSA)
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the employer may grant permanent incapacity leave for a maximum presents data showing that in the period immediately following
of 30 days. During this period, the employer, based on the advice of implementation of the PILIR, the NDoH experienced a decrease of
the HRM, determines the feasibility of either alternative employment
Y T just 846 sick days from a total of approximately 18 000 sick leave
or duties or workplace adaptation to accommodate the HCW. If the days.16 Of all the workers taking sick leave during these two periods,
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permanent incapacity is such that the HCW cannot be effective at each worker took an average of 2.3 and 2.2 days respectively.
his/her rank, then a process to terminate the employee’s services on Clearly, the PILIR did not result in any meaningful improvement
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the basis of ill-health is commenced. in the early days of its implementation.17 The latter report states
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Figure 1: Process flow for temporary/permanent incapacity leave and/or ill-health retirement application when an employee has exhausted
36 days in a three-year leave cycle
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S A H R 20 1 6 65
that for the NDoH, the cost of sickness absence during these two The trends emerging from this data across the two periods suggest
periods (2004–2006 and 2007–2009) was R7.3m and R8.8m that the rate of absenteeism among senior levels of staff may be
respectively.16 At provincial level, the situation was substantially a cause for concern, with an almost 44% increase among senior
worse: KZN as the leading province recorded 786 934 and 871 management and a 47% increase among skilled supervisors,
227 days of sick leave in these periods, at a cost of R208m and compared to only a 7.6% increase among the lower categories of
R303m respectively (Tables 1 and 2).16 According to the recent KZN staff (Table 2). However, in terms of cost, it is the latter category that
DoH Annual Report, sick and disability leave cost approximately contributes the greatest (89%) loss to the Department.
R452m in 2014,18 compared with the NDoH’s bill of R15m in 2014
However, by 2014, these numbers had dramatically changed (data
(Table 3).19 In 2014, the average length of sick leave taken at a
not shown):18 in a single year, senior management had utilised 2 763
national level had substantially increased to 42 days19 compared to
days of sick leave, while skilled supervisors had taken 84 060 days
the 2010 DPSA Report.16
and the lower categories had taken 341 403 days. This resulted
in an average of seven days (among senior management), eight
Table 1: Total number of sick leave days taken in government days (among skilled supervisors) and eight days (among lower staff
health and education departments per province,
categories), of all those workers taking sick leave.
2004–2009
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Approximately 8.6% (n=16 234) of employees in the KZN public
January 2004 to January 2007
December 2006 to June 2009 sector applied for temporary incapacity leave to the HRM during
Total number of Total number the period November 2006 to December 2012, having exhausted
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Province Departments days taken of days taken their allocated 36 days over the three-year cycles. It is reported
Eastern Cape Education 550 819 585 217 that within the same period, 11.8% (n= 8 138) of the KZN DoH
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Health 463 793 446 633 employees had utilised all their allocated 36 leave days and had to
Free State Education 380 191 328 350 apply for temporary incapacity leave through the HRM.54
Health 231 323 218 513
Gauteng Education
Health
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679 734
631 144
675 642
607 378
Apart from the 2010 DPSA evaluation,16 no further recent evaluations
of the PILIR have been conducted, despite HRM’s concerns about
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KwaZulu-Natal Education 741 733 708 935 the delivery of services as expressed to Parliamentary oversight
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Health 786 934 871 227 structures.17 According to statements provided to Parliament, various
government departments indicated that there were delays on the
Source: Adapted from Public Service Commission; 2010.16
part of the HRM in responding to the submissions.17
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Table 2: Total number of sick leave days taken per level and cost for the period from January 2004 to June 2009, KwaZulu-Natal
Department of Health
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2006
Department of Health level No of days Cost in Rand No of days Cost in Rand
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Senior management (level 13–16) 808 891 634 1 468 1 918 008
Highly skilled supervisor (level 9–12) 23 648 15 903 822 44 755 38 697 036
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Table 3: Leave utilisation in the South African National Department of Health54 and the KwaZulu-Natal Department of Health,53 2014
Percentage
Percentage Number of of total Average Total number
Total of days with employees employees number of of days with
Government number of medical using sick/ using sick/ days per medical
sector days certification1 disability leave disability leave employee Estimated cost certification
National2
Sick leave 11 153 96 1 543 100 42 14 261 044 10 704
Disability leave4 1 054 100 62 100 17 1 295 844 1 054
Province3
Sick leave 438 812 86 55 117 100 8 399 457 000 378 562
Disability leave 57 151 100 1 933 100 30 52 135 000 56 982
Source: The South African National Department of Health19 and KwaZulu-Natal Department of Health.18
66 S A H R 20 1 6
Incapacity leave and sickness
The 2014 data represent the second year of the last leave cycle Box 1: Short-term sickness absence case study: Sick leave not
(2013–2015). It can be expected that the patterns of leave will vary approved and employee to return earnings for non-
sanctioned days off
across the three-year cycle, with a greater number of employees
utilising allocated sick leave in the final year of the cycle. In the last three-year leave cycle (1 January 2013–31 December 2015), a
HCW from a healthcare institution had exhausted the 36-day allocation
within the first year. Despite this extreme usage, the HCW was not referred
to the EHS. In the following year (2014), the HCW took a further 36 days,
Case study
once again with no review by an occupational medical practitioner. In line
The authors reviewed 151 submissions for short-term leave with the relevant policy, the HCW submitted sick notes on return to work
for each of the six spells of absence. On each occasion, applications were
applications, of which 58% had been decided upon by the HRM.
submitted to the HRM. Following review by the HRM, each of these six
These employees accounted for almost 1 200 days of leave. None
periods was declined. The HCW was informed that R13 669 was owed
of these employees was assessed by the institutional EHS prior to for these non-sanctioned days off. Thus, an employee who is likely to have
submission to the HRM, despite having already taken 36 days of some form of chronic ailment resulting in these above-average days of sick
sick leave in the previous three years. From this point forward, leave, is now facing economic stress, still with no appropriate management
of the underlying ill-health.
despite the policy requiring a 30-day turnaround time, the average
turnaround time within our sample was 110 days, with 29 days’
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delay from the date on which the employee had submitted the sick Box 2: Long-term sickness absence case study: Application still
under review and employee not at work
note (range of days: 1–170 days), and 28 days (range of days:
As in the previous case, a HCW had exhausted the 36-day sick leave
1–136 days) in the Human Resources Department submitting to the
allocation early in the cycle. Subsequent submissions to the HRM for
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HRM. For the cases on which the HRM had reached a decision,
short-term absences were approved. The HCW was not assessed by
this was done in an average of 53 days (range: 9–124 days). Our the EHS at the institution at any point. Subsequently, due to the chronic
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estimates of the cost in lost productivity, based exclusively on income ailment diagnosis by and related advice from her private doctors, the
(assuming Grade 1 levels) was approximately R613 000. HCW applied for long-term sickness absence. Three periods of long-term
Y T absence accounted for 185 days of sick leave. The HCW’s applications
In the event of the HRM rejecting the application, the management are still under review by the HRM. Even during this period of long-term
at the institution is faced with the dilemma of insisting that an ill absence applications, the HCW has not been assessed by the institution’s
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EHS. It is likely that during the period of repeated short-term absences, a
employee continue working. Should the employee accept this
proper clinical evaluation could have resulted in an earlier diagnosis of
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an individual on light duty results in that individual remaining in this The current management of ill HCWs at health institutions is almost
position until retirement, because there is no internal mechanism for non-existent and lacks a systematic approach. While workers will
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ill-health review. report to the EHS for follow-up of their chronic illnesses or to collect
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medication for chronic ailments, workers who fall ill or are chronically
ill are usually managed by private healthcare providers, with little or
Two scenarios of sickness management
no involvement of the EHS, until their prescribed sick leave (36 days)
The scenarios presented in Box 1 and Box 2 reflect the presentation usage over the three-year cycle is exhausted. Currently, a HCW
and management of two HCWs on short- and long-term sickness returning to work within two days has no obligation to present a
absence in the public health sector. These cases are representative medical certificate, while those taking more than two days leave
of the current situation in the sector. and taking leave on more than two occasions during an eight-week
period are required to present a medical certificate to their line
manager, who submits this to the Human Resources Department for
placement in the employee’s personal file.
S A H R 20 1 6 67
the HRM. In terms of appropriate service management, the ‘lost illness and determination of capacity to work, a one-third reduction
productivity’ paradigm is not inherently flawed. However, it enables in sickness absence is possible, and would result in a saving of
management of the problem only after an extended period of ill- approximately £555 million per year.13
health (36 days), and seeks redress from an external agent (the HRM)
The EHS-driven approach has been recognised in the UK, where an
thereafter. This persistent externalisation of ill-health management is
assessment of sickness absence concluded that “where occupational
certainly flawed, and in attempting to manage sickness absenteeism
health was provided, 39% of companies recorded a decline in
effectively, certain key assumptions are made. The current approach
short-term absence, whilst 28% experienced a reduction in long-term
assumes that:
absence”.10
➢➢ The private healthcare provider assessing a HCW has
As the roll-out of National Health Insurance (NHI) gathers pace, and
adequate training in occupational health.
a renewed vigour in the Human Resource for Health Strategy takes
➢➢ When declaring a HCW unfit to work, the private healthcare shape, the ‘health of the health workforce’ has to assume a central
provider understands the nature of the healthcare working position in the debate on restructuring our healthcare system. Failure
environment and the work demands, and is able to determine to recognise the impact of ill-health on the productivity of HCWs and
the level of incapacity of the worker in this context. failure to adopt an internalised, systematic approach will continue to
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➢➢ The line manager is able to determine the HCW’s level of result in inadequate service delivery.
fitness to return to work, and place him or her appropriately
In developing the model proposed by the authors, the NDoH in
within the working environment.
collaboration with the DPSA should adopt a multi-pronged strategy
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➢➢ The human resources officer monitors and intervenes relating to the health of the health workforce. A comprehensive
appropriately when there are long or repeated periods of systematic evaluation must be undertaken, and the full extent of
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absence. the problem of absence from work (and ‘under-work’ in the ‘light-
duty’ approach) should be documented, along with the impact on
➢➢ When making a decision on an application, the HRM,
Y T employees, service delivery and patient care, and the resulting
understands the nature of the working environment of the
costs. This requires multi-stakeholder participation undertaken by
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specific worker and the associated work demands.
appropriate experts. We suggest that consideration be given to the
Rather than adopting a systematic approach to the ill-health of
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most instances, when insisting that the worker returns to work, the
for confronting the problem. It argues for a work-focused approach
employee believes otherwise and seeks out the assistance of the
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that respects the right to sick leave, recognises that work is generally
EHS doctor. In both scenarios, the EHS doctor (who has not been
good for physical and mental health, and encourages management
involved in the prior management of the HCW, nor in making the
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In summary, these data support the concerns that sickness absence employee ill-health because “it focuses on what the employee can
in itself compromises healthcare service delivery through the do or might be capable of doing with reasonable help, rather than
numbers of days lost – in excess of 500 000 days in KZN at a what they cannot do due to illness or injury”.12
cost of about R452m in 2014 alone. This provides strong evidence
In the interim, a short-term strategy for managing ill employees at
that the strategies employed by the DPSA (the PILIR model) are not
healthcare institutions is essential. The management of these workers
effective. Ensuring the health of the health workforce requires a more
must be internalised at the institutional level, such that appropriate
focused, institutional intervention, driven by the appropriate experts
intervention can be implemented for individual workers well before
in occupational medicine.
the 36th day in a three-year cycle is reached. The externalised
approach currently in use in the public sector serves to exacerbate
Strategies for change
the problem, and undermines or even negates the health care of ill
In the UK, the NHS recognised the challenges resulting from sickness workers.
absence at its hospitals; it conducted a systematic analysis of the
Our proposal (Figure 2), while both simple and cost-effective,
problem13 and proposed institutional ‘evidence-based strategies’
does require the investment of resources. However, based on the
to address these. The philosophy adopted was not framed around
anticipated savings from lost productivity and improved patient
control of sickness absence, but rather around employee wellness
care, we argue that the return on investment may be substantial.
and health.12 The Boorman Review estimated that the NHS loses
approximately 10 million working days each year due to sickness It is proposed that workers who are absent from work for more than
absence.13 The Review estimated that through appropriate five days in a single sick-leave period or for 10 days collectively
intervention, early detection of ill-health, proper management of the over a two-month period, or those who are declared unfit to work
68 S A H R 20 1 6
Incapacity leave and sickness
by a medical practitioner outside the institution for similar periods by the required evidence. If the disease is aggravated by work, the
of time, must be referred to the institution’s EHS for an evaluation. occupational medical practitioner, together with the line manager,
Line managers and human resource practitioners should be trained must determine whether alternative placement is necessary or job
to recognise this requirement, and to make appropriate and timeous modification is possible.
referrals to the EHS. These workers must be assessed by a doctor
If the worker is assessed as being totally unfit for work, and job
with training in occupational health. The responsibility of the EHS
modification or alternative work are not feasible, the worker should
doctor is to determine whether the worker is fit for usual duties, fit for
be processed for medical boarding. Again, this should be an
alternative or adapted duties, or completely unfit to work. In the latter
internal process, without the involvement of the HRM. However, the
two cases, the doctor must determine the duration of the modified
Department and its stakeholders should define ‘total incapacity’ by
work duties. The period of review must also be specified. If the ill
stipulating whether this would pertain to ‘own’ or ‘any’ occupation,
worker is still at work, the line manager assumes responsibility for
and providing guidance to the medical doctors involved in the
ensuring review of the HCW by the EHS. If the worker is totally unfit
individual assessments. For example, in the case of a HCW employed
and no longer at the institution, the Human Resources Department
as an Intensive Care Unit nurse, who is no longer able to work in
assumes responsibility for maintaining contact with the employee.
such an environment but is able to perform basic nursing duties – i.e.
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In assessing the ill HCW, the EHS doctor is also expected to determine total incapacity for ‘own’ occupation, but capable of working in any
whether any work-related factors can be shown to have caused or other occupation – it should be determined whether this HCW should
exacerbated the illness. If so, the doctor must refer the worker to an be medically boarded or placed in another healthcare occupation in
occupational medicine specialist for further decision-making on the keeping with his/her capacity, but vacating the original post, such
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HCW’s ability to work. If, in the opinion of the specialist, the disease that service delivery is not compromised.
is caused by the HCW’s work environment, the procedure for
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reporting an occupational disease to COIDA must apply, supported
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Figure 2: Proposed institutional management of workers with ill-health and sickness absence
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S A H R 20 1 6 69
Clearly, institutional-level interventions that internalise the manage- Most of the available information from these agencies focuses on
ment of ill HCWs require additional human resources – particularly cost savings rather than on the effectiveness of promoting the health
in strengthening the EHS at hospitals and clinics in the public of HCWs. Generally, there is a lack of a systematic critique of the
sector. We propose that a network of health professionals with current PILIR system and the functioning of the HRM. We trust that this
varying levels of skills in occupational health be established. Ideally, chapter opens the debate on this system, with a view to fundamental
there should be at least one occupational medicine specialist for policy change.
3 000 HCWs. While this may not be immediately achievable, a
In presenting the information from these various government
decentralised approach integrated into the district health system
agencies, we focused on KZN, and to some extent on the national
model is more practical. At regional hospital level, an occupational
level. Although several of the national DPSA and PSC reports
medical specialist should be appointed to lead the EHS and to
contained information on the other provinces, we purposely chose
provide outreach to district hospitals. As is the practice in any other
to describe only KZN scenarios because of the size of the provincial
clinical service at healthcare institutions, this specialist should be
public health sector, and because the impacts in costs and average
assisted by one to four occupational medicine registrars, depending
days lost were substantial in this province.
on the numbers of HCWs within the catchment of district hospitals
and clinics served by the regional hospital. These registrars, Another key limitation is the use of a small sample size from the KZN
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under the supervision of the specialist, would provide the required institution, largely for illustrative reasons, and therefore the results
specialist support at district level. In addition, depending on the are likely to be biased in various ways. However, this research
employee population at the district hospital, the appointment of was not intended as an analytic investigation, but rather as an
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either a full-time or a sessional doctor with postgraduate training in exploration of the challenges. For reasons of confidentiality, we are
occupational health is required. unable to provide further descriptions of this sample.
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Currently, no healthcare institutions in the country have employed
occupational medicine specialists to manage their EHS. This limits Conclusion
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the availability of evidence in support of our proposed model being
successful. However, anecdotal evidence from KZN shows where The ill-health of South Africa’s health workforce is having a disabling
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occupational medicine registrars, working under the supervision effect on the health of the nation. Substantial numbers of HCWs are
either incapable of performing the tasks for which they have been
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or institutional level.
health of HCWs, ensure that more workers are at work, and improve
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Management of the EHS by an occupational medicine specialist productivity and patient care.
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Limitations
Apart from our generic description of the HRM process described,
we lacked access to information on the tendering process for the
issue of these contracts to the various HRMs. We also have no
information on the approaches adopted by the HRM in arriving at
various decisions on each case, the extent to which independent
specialists are used, and whether these specialists are trained in
occupational medicine. We submit that these gaps in information do
have an influence on the proposed model.
70 S A H R 20 1 6
Incapacity leave and sickness
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pdf 51 Public Service Co-ordinating Bargaining Council. Resolution 5
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72 S A H R 20 1 6
Language barriers in health: lessons from the
experiences of trained interpreters working in
7
public sector hospitals in the Western Cape
Authors:
Ereshia Benjamin i
Leslie Swartz ii
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Linda Hering iii
Bonginkosi Chiliza iv
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T 20 IL
here has been a longstanding call to employ trained interpreters to address The emerging themes suggest
language barriers in health care in South Africa. The international literature
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shows that while trained interpreters can be effective, the existing sophisticated that interpreters experience
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models of upper-income countries are expensive and contextually inappropriate for their work as challenging
low-resource settings like South Africa. In community interpreter models, members of
on practical and emotional
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the community are given brief training in interpreting; these models have a number
of potential advantages for our context, but have not been sufficiently reviewed in levels, and that there is
4 ED
from mentor sessions conducted with them over a three-year period. The emerging
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themes suggest that they experience their work as challenging on practical and
emotional levels, and that there is uncertainty about where they belong and fit into
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The experiences of the interpreters raise crucial questions about current language
issues in our hospitals, while offering important insights into the potential to develop
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a multilingual health service for South Africa’s culturally and linguistically diverse
population. We make recommendations for the promotion of language access in
health services, the professionalisation of health interpreters, and suggest areas for
further research.
i Department of Psychiatry and Mental Health, Facult y of Health Sciences, Universit y of Cape Town
ii Department of Psychology, Facult y of Arts and Social Sciences, Universit y of Stellenbosch
iii General Specialist Hospitals, Department of Health, Western Cape Government
iv Department of Psychiatry, Facult y of Medicine and Health Sciences, Universit y of Stellenbosch
73
Introduction
In the 2012/13 edition of the South African Health Review, Nadia of minority immigrants but the multilingual population at large.14
Hussey1 suggests that the ‘overlooked’ language barrier remains a The result is that South Africa essentially has “… monolingual health
crucial challenge to providing equitable and quality health care in services in a multilingual society”.7
South Africa. She makes an important contribution to a growing
There is extensive literature on strategies to manage linguistic
body of work on issues of language access in health care over the
diversity in health care in high-income countries with refugee
last three decades,2–29 and in her recommendations to improve the
populations. However, Swartz et al.24 have recently shown that
situation, echoes a longstanding call to employ trained interpreters
the issue of language diversity is in fact greater in many low- and
in health institutions across the country.
middle-income countries, due largely to high levels of external and
In this chapter, we describe an initiative to heed this call by the internal migration. However, affordable models for making health
Western Cape (WC) Department of Health (DoH), and highlight services available to a range of linguistic communities are scarce.
lessons learnt from the experiences of the trained community
In South Africa, common language practices to address barriers in
interpreters involved in the project. In introducing this work, we offer
health care include linguistic code-switching, the use of a few key
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a brief overview of language access issues in South Africa.
terms in the healthcare user’s language, and ad hoc arrangements5
involving the use of family members, hospital security guards, nurses
Language in South Africa
or household aides as informal interpreters.
South Africa is a multi-cultural and heteroglossic society with 44
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While South African researchers have demonstrated both the
living languages (11 of which have official status), and is home
complexity of informal, ad hoc interpreting, and the potential to
to a large number of African refugees. South Africa scores 18th
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improve communication and health care,2,19,25 the use of informal
highest worldwide on Greenberg’s language diversity index,30
or untrained interpreters is more often seen as “not suitable or
which means that the likelihood of two people meeting at random
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and sharing the same mother tongue is slim. Although language
trends are shifting, particularly with Afrikaans and English no longer
sustainable.”1,35,15 Informal interpreting has raised a number of
clinical, ethical and human rights concerns. Recent research has
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shown that in a relatively well-resourced tertiary mental health
being ‘white languages’,31 isiZulu remains the most common home
facility in the WC, where informal interpreting is conducted for
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or translator services “by choice regardless of their ability to Interpreting in healthcare settings is a highly complex process that
communicate in English” (emphasis added).a However, Williams aims to achieve “a workable interpretation which has use in the
and Bekker26 found that “knowledge about public-language policy clinical setting”21 and requires of the interpreter accomplishment
in the State health sector is vague and inadequate” resulting in “little in both languages as well as familiarity with the healthcare user’s
accommodation” for users who prefer using their mother tongue. culture, professional jargon,36,27 and emotional vocabularies.2
Words do not always translate easily or accurately, particularly
The situation in South Africa is such that medical interviews
medical terms,29 and cultural and other socio-political differences
are generally conducted in the healthcare user’s second or third
(e.g. educational levels) expressed in language through, for
language1 and it is therefore not surprising that the healthcare users
example, proverbs, emotional undertones and humour, can prove
in Levin’s study15 experienced language and culture as more of a
challenging for even highly trained interpreters.14
barrier than South Africa’s notorious structural and socio-economic
issues. This is in line with international findings where “… the Interpreters also act as “cultural broker(s)”27 or “mediators”1
language barrier is the primary challenge for meeting the healthcare providing a ‘bridge’ between clinicians and healthcare users24 –
needs of the immigrant population”,35 except that in South Africa which adds another level of complexity to the interpreter-mediated
the linguistically disadvantaged population is not made up solely clinical encounter. The concept of culture is easily reified,
ignoring important differences such as social class, religious
a The language rights of all citizens are enshrined in the Constitution,33
while the language rights of healthcare users are further elaborated in the beliefs, educational levels, degrees of acculturation, urbanisation
National Department of Health’s Policy on Language Services34 and the and explanatory models of illness between healthcare users and
Provincial Government of the Western Cape’s (PGWC) Language Policy.32
These policies also govern the establishment of the PGWC Language Unit interpreters, and both clinicians and interpreters may mistakenly
through which an external interpreter service (telephonic and face-to-face on
request) is made available to health establishments in the WC.
74 S A H R 20 1 6
Language barriers
assume that the interpreter ‘knows’ the healthcare user’s culture and available only for simultaneous or conference interpreting, and
is able to offer judgments about the user’s behaviour.24 Fulfilling this therefore not for community or health interpreting.
role requires a sophisticated ability on the part of interpreters to hold
It is in this context that the Interpreter Project was implemented. The
their own cultural constructions37 while fostering and foregrounding
project is part of a larger action research project exploring a range
the clinician–healthcare user relationship.14,19
of issues related to language and interpreting in health/mental
Adding to this complexity is the fact that the intepreter-mediated health care, including the experience of interpreters (both untrained
health encounter reflects deep historical and contemporary socio- and trained), clinicians and patients.8,10–13,21,24
political, cultural and economic divisions.1,16 The healthcare users
An action research method was adopted as such an approach
who require interpreter services in the health system are frequently
is best suited to a deep exploration of the subjectivities and lived
among the most marginalised socially and economically,14 and often
experiences of participants, particularly in research areas with a
have particularly traumatic histories. In public hospitals, untrained
limited knowledge base.46,47
interpreters often share the healthcare users’ cultural and socio-
economic background and may overidentify with them, and may
The Interpreter Project
be vulnerable to these unconscious and unspoken dynamics and
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alliances within the interpreter-mediated encounter, which heightens Following years of grappling with language access and motivating
the emotional impact of the work.38 for interpreter posts to be created in hospital establishments, the
WC DoH engaged in a collaborative project with the Provincial
Furthermore, language itself may be associated with traumatic Government of the Western Cape (PGWC), Extended Public Works
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memories and emotional meaning for interpreters, as suggested Programme (EPWP) and Stellenbosch University (SU) to train and
by Busch and Deumert.39 This is particularly relevant in the South place community interpreters in hospitals in the WC.
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African context where language continues to play a central role
in the political landscape and lived experience, particularly of In December 2011, 15 first-language isiXhosa speakers with formal
marginalisation, of ordinary people. Y T schooling to Matric level were recruited as health interpreters on a
contract basis by the EPWP. They underwent a three-day intensive
These issues are exacerbated in the context of mental health care,
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training course in Interpreting and Psychiatry by the Departments of
where assessment and treatment of all conditions are strongly Afrikaans and Nederlands, Psychology and Psychiatry at SU. The
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based on language. Disordered language and communication trained interpreters were then placed in six public hospitals in the
are commonly part of the symptomatology of serious mental WCb as interns and commenced duty in December 2011. However,
disorder; where this is the case, the question of communication and
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in March 2012, EPWP funding was reduced and the interns were
interpretation is not simply one of facilitating a discussion between re-appointed as administrative interns by the DoH for a period of
two people (clinician and healthcare user), each being able to 12 months from 1 May 2012. At this point, 12 interpreters were
communicate well, but in different languages. appointed due to attrition and resource constraints, with a further
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The international literature has shown that the use of trained interpreter resigning to take up another post shortly thereafter.
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interpreters raises the quality of care and levels of satisfaction for By May 2013, the DoH had successfully motivated for the creation
healthcare users with limited English proficiency to approximate of permanent posts and the remaining 11 interpreters were officially
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that of healthcare users without language barriers.40–43 Trained employed as interpreters on salary level 4 by the WC DoH. Two
interpreter services are therefore now widely viewed as an essential interpreters subsequently resigned to take up other posts in the
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part of quality health care, and service models in higher-income Department of Health, which currently leaves nine interpreters
countries include sophisticated professional interpreter services such
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S A H R 20 1 6 75
Emerging themes Nature of interpreting and interpreting challenges
The experiences of the interpreters in this project are consistent The interpreters distinguished between what they referred to as
with local and international literature on the subject where the ‘clinical’ and ‘general’ interpreting. Clinical interpreting involved
work is described as “complex, challenging, exhausting, and interpreting in a variety of clinical encounters, from individual
often invisible”.6,49,50 Additionally, the “negotiating of blurred role healthcare user–clinician interviews, to family and group sessions,
boundaries and competing, often conflicting, expectations was an ward rounds, healthcare user meetings in wards, and telephonic
additional work burden for health care interpreters and contributed consultations with healthcare users and family members. They
to feelings of being exploited, disrespected, misunderstood, or described the demands as differing in these contexts, from long and
excluded from membership on the health care team”.49 exhausting sessions in forensic wards, to shorter but high volumes of
sessions in busier admission units.
A key aspect of the experience of the interpreters in our project is the
question of where they ‘belong’, which is not unique to our project. ‘General’ interpreting involved patient care activities such as
In a similar local community interpreter projectc conducted more than helpdesk duties, assisting healthcare users to complete forms,
a decade ago, there was also “conflict and disagreement, overt and explaining rights and responsibilities, translating medication
covert, about where interpreters fit into the new order of things”.6 instructions, conducting healthcare user surveys, and managing
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Internationally, Rosenberg et al.51 also found that this “absence of a complaints and compliments. Helpdesks and queue marshalling
place for interpreters in the institution … [and] not [being] part of the in general hospital settings were often experienced as stressful,
healthcare or the administrative staff” was consistent with research because of the high number of healthcare users as well as having
16 6
findings. to deal with healthcare users who were frustrated after long hours
of waiting.
Another key aspect highlighted by this project is the underutilisation
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of trained interpreters, which is paradoxical given that the need for Administrative duties varied and included such tasks as data
such trained capacity is frequently expressed in the literature. While it capturing, filling out Review Board forms, recording admission and
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is possible that this is merely the result of logistical problems resulting
from a serendipitously introduced service, or of clinicians trying to
discharge statistics, delivering incident and periodical reports, and
updating the forensic service database.
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do their best in a pressurised, challenging service environment,13
The issue of where interpreters ‘belong’ in the system arose
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the hospital.
Discussions in the group were dominated by issues related to
conditions of service, particularly during the period when the At the same time, they noted that administrative duties ranged
interpreters were transferred to the Health Department. This was between 20% and over 80% of their job descriptions. Interpreters
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not surprising, given that this was the first time that most of the noted that while these functions presented an opportunity to
learn new skills and to be more competitive in the job market,
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group space to learn about procedures from each other, and to Additionally, this function required that interpreters stand in for
measure consistency of experience. absent administrative staff who are remunerated on a higher salary
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created under the authority of the quality assurance manager and Interpreters battled to reconcile the low utilisation of their services
the job description included an administrative function. It was clear in some areas with the appreciation they received from healthcare
that the system was ill-prepared for the interpreters, with no clear users for their services, which led to some questioning whether the
parameters on the administrative/interpretation split, no standards low utilisation was related to staff rather than healthcare user need:
for performance evaluation and the absence of career-pathing,
The patients do need us, but do the staff?
leading the interpreters to say frequently “… we don’t know where
we belong in the system”. The staff … do not treat me as an interpreter … they treat
me as a clerk.
76 S A H R 20 1 6
Language barriers
This was juxtaposed with less frequent experiences of feeling valued interpreter who used the employee assistance agency following a
and respected by clinicians, as in instances of being called to traumatic incident found it unhelpful, but with the encouragement of
interpret despite the presence of isiXhosa-speaking staff members, the group, returned to the agency and worked successfully with a
or in linguistically challenging encounters (e.g. Setswana/English- different counsellor.
speaking clinician; isiZulu/isiXhosa-speaking client and isiXhosa/
Feelings of vulnerability were linked to feeling poorly trained
English/isiZulu-speaking interpreter).
to work in hospitals generally, and in psychiatry in particular for
Lack of in-hospital transport was one of the resources frequently cited those in such settings. Because they entered the hospital system
by interpreters as an obstacle to meeting their job requirements. initially as administrative interns, and were later transferred to
Others included access to computers to complete administrative permanent posts, the interpreters did not undergo the standard
tasks such as minute-taking, and the absence of isiXhosa–English induction and orientation programme for new appointees. Despite
dictionaries to aid them in the translation of more technical terms ongoing requests, only one interpreter underwent the Introduction to
and difficult concepts. Furthermore, interpreters frequently discussed Psychiatry course offered in the hospitals.
the lack of on-site supervision, and a lack of referral pathways to
Interpreters also felt ill-prepared for the effects of listening to the
interpreters with more experience or better training in scenarios
traumatic experiences of healthcare users, and felt that training in
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where engagements were difficult to interpret for clients.
counselling skills could help them contain the difficult emotions they
A further challenge was that of the interpreters finding themselves were left having to process.
in compromising positions between clinicians and healthcare users.
Furthermore, their experiences of different cultural practices led one
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These ranged from experiences of healthcare users saying to the
interpreter to the realisation that “We are all Xhosa, but we are all
interpreter “Don’t tell the doctor … ” to a clinician reportedly telling
different”. The interpreters felt that they needed “a course on culture”
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the interpreter “Don’t worry about it, he’s talking nonsense” when a
to help them fulfill their role as cultural broker, the complexity of
healthcare user disclosed sexual assault by another healthcare user
which became clearer during the discussions in the group.
during an interpreted session. Y T As interpreters were exposed to various physical and emotional
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Emotional experiences of the work risks, the question was raised of indemnity and protection by their
employer. Such risks included exposure to healthcare users who
Much of the emotional experience of the work was initially linked
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by the lower salary level assigned to interpreters, and their while another was concerned about the effect on relatioships
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perception that their administrative functions were more valued with other staff members:
than their interpretation services. Some interpreters experienced the
… because they’ll feel like I’m spying.
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For one of the interpreters, this was particularly painful after she was of authors to question whether the South African healthcare system
unsuccessful in her application for an administrative post: ‘silences’ non-English healthcare user voices1,3,23 and benefits from
constructing them “as voiceless, dependent, powerless, healthcare
I am working as a clerk … but I didn’t get the job … I’m the
users.”10 Elkington and Talbot7 add that the healthcare system’s
joke of the hospital.
‘reluctance’ may result from conflating language and race, and thus
The interpreters frequently expressed that the hospital system does not “ironically further entrenching the notion that indigenous languages
understand their role as interpreter and had unrealistic expectations do not deserve recognition and conveying to indigenous language
in this regard, e.g. the focus on patient numbers, and availability. speakers that this aspect of their need is unimportant”.
They also felt unsupported by the lack of access to resources, and the Regardless of the factors that may be at play in mitigating the
lack of on-site supervision related to their interpreter function. Very promotion of language access, the question is: who is responsible
few clinicians offered them the opportunity for debriefing following for the service? The interpreter-mediated session is traditionally
interpreted sessions, and with the mentorship group meeting less viewed as having three main players: interpreter, healthcare user
frequently, they were often left to find their own supports. They and clinician. Zimanyi52 suggests that “in reality, there are usually
could appreciate the longer-term value in this, but sometimes found more participants, although not always physically present, whose
acute periods of distress difficult to manage. One interpreter who contributions (or non-contribution as the case may be) also greatly
found a session with a child rapist to be “too close to home” as affect the outcome of such sessions”. These ‘institutional participants’
the child victim was the same age as his daughter, sought support include health services, the State and the community. Our project
from a fellow interpreter, in addition to the mentor group. Another suggests that these levels, particularly those of the health services and
S A H R 20 1 6 77
the State, have a direct impact on the provision of quality interpreter policy is implemented, hospitals must ensure that all staff are familiar
services, and dialectically, on the experiences of interpreters. with national and provincial language policies and the role that
interpreters play in complying with these.
At State level, the lack of policy guidelines and standards for quality
interpreting services, as well as lack of regulation of the language Hospitals should also ensure that healthcare users are informed of
professions7 impacts negatively on service development. This is their right to express themselves in their mother tongue, and to use
compounded by the lack of recognition of health interpreters by interpreter services. In order to improve the interpreting services
professional bodies and the lack of accredited training programmes provided, healthcare users should be invited to provide feedback on
available for community interpreters in general, and health the quality of these services.
interpreters in particular. This leaves community interpreters without
Utilisation of interpreter services should be closely monitored, with
the protection of ethical standards and practice guidelines.
appropriate responses in the case of both under- and over-utilisation.
At the level of health services, the WC DoH has gone a long way Here, practical responses such as integrated booking systems57 or
towards operationalising national and provincial policy directives, the use of interpreters across centres7 could be considered. More
such as the National Development Plan 2030 (NDP 2030),53 by importantly, the possible drivers of utilisation patterns should be
creating interpreter posts in the Health Department. The project given adequate consideration at institutional level, keeping in
PM
demonstrates what can be achieved through cross-sectoral mind the institutional dynamics that may be at play. Courageous
collaboration and decisive and innovative leadership. conversations of this nature may need to be had, and may benefit
from external facilitation.
However, as pointed out by Swartz et al.,24 the challenge in
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growing this fledgling service lies in examining the organisational Supervision and debriefing are crucial for interpreters to function
as well as the linguistic dimensions of the service. This requires a at optimal levels. On-site supervision is also more likely to support
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meaningful engagement with questions of how language issues, ‘team functions’ rather than ‘profession-specific functions’,6 thus
and interpreters, are viewed at the institutional level, and what the facilitating integration while responding to the unique dynamics at
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institutional responsibility is for supporting and growing the service.
In practice, this means that institutions must take full responsibility for
institutional level. Our intervention has also highlighted the value of
peer supervision, and occasional joint supervision with members of
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the utilisation of interpreter services, and provide structural support the clinical team may also be necessary.
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78 S A H R 20 1 6
Language barriers
acknowledgement of officially trained medical interpreters as a Research is needed to gain a deeper understanding of the
‘related profession’ in health services. Such acknowledgement interpreter’s role, and how to support the integration of interpreters
ought to be equal to the status of social worker, psychologist or into low-resourced, linguistically limited health systems such as ours.
physiotherapist.
This has implications for the salary levels of interpreters. There have Acknowledgements
been attempts to address the question of appropriate remuneration
levels and utilisation (for example, appointing interpreters as The Language Project is supported by a grant from the National
administrative clerks with interpreting as a key job output). While Research Foundation. We express our appreciation to the interpreters
such proposals may be expedient in addressing the issue of salary in this project for their generous willingness to help us learn about
level, the risk of entrenching the invisibility of language issues would providing better health services.
remain.
Policy
All policies should be reviewed in terms of language access issues.
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For example, the NDP 2030,53 and a number of other key policy
documents, do not consider the impact of language barriers on
health outcomes.
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The accreditation of health interpreters should be addressed, as
well as guidelines for practice and ethical standards. In this regard,
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registration as a ‘language practitioner’ under the South African
Language Practitioners’ Council Act61 may present an opportunity
for professionalisation. Y T
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Training
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Research
EM
The vast majority of studies in this area have been conducted in high-
income countries,62,56 and while there is a burgeoning body of work
in South Africa dating from the 1980s,1–29 there is a clear gap in the
literature on the careful description and appraisal of innovative and
low-cost ways of attempting to address these issues in South Africa.
S A H R 20 1 6 79
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19 Penn C, Watermeyer J. When asides become central: small
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inpatients across a language barrier. Glob Health Action.
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33 Republic of South Africa. The Constitution of the Republic of
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35 Kale E, Kumar B. Challenges in Healthcare in Multi-Ethnic 52 Zimanyi K. Narrative Enquiry into Mental Health Interpreting
Societies: Communication as a Barrier to Achieving Health in Ireland: The responsibilities of quality service provision.
Equity. In: Maddock J, editor. Public Health – Social and Critical Link 5 Conference; 2007, April 11–15. Parramatta,
Behavioral Health. 2012. p.295. [Internet]. [cited 22 March Sydney, Australia. [Internet]. [cited 22 March 2016].
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social-and-behavioral-health/communication-and-dialog-in-a-
multiethnic-population 53 The Presidency of the Republic of South Africa. National
Planning Commission. National Development Plan: Vision for
36 Paone T, Malott K. Using interpreters in mental health 2030: 2011. [Internet]. [cited 22 March 2016].
counselling: A literature review and recommendations. J URL: http://www.gov.za/sites/www.gov.za/files/devplan_2.
Multicult Couns Devel. 2008;36(3):130–42. pdf
37 Tribe R, Lane P. Working with interpreters across language 54 Norstrom E, Fioretos I, Gustafsson K. Working conditions
and culture in mental health. J Ment Health. 2009;18(3):233– of community interpreters in Sweden. Interpreting.
41. 2012;14(2):242–60.
38 Splevins KA, Cohen K, Joseph S, Bowley, CM. Vicarious 55 Busch B. The Linguistic Repertoire Revisited. Appl Linguist.
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56 Brisset C, Leanza Y, Laforest K. Working with interpreters in
39 Busch B, Deumert A. Multilingualism, traumatic experience health care: a systematic review and meta-ethnography of
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University of Cape Town; 2012.
57 Granhagen Jungner J, Lutzen K, Pergert P. Creating a
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40 Jacobs E, Chen AH, Karliner LS, Agger-Gupta N, Mutha meeting point of understanding: Interpreters’ experiences
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health care: a proposed research agenda. Milbank Q. 2015;33(2):1–9.
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58 Cambridge J, Singh SP, Johnson M. The need for measurable
41 Karliner L, Jacobs E, Chen A, Mutha S. Do professional
Y T standards in mental health interpreting: a neglected area.
interpreters improve clinical care for patients with limited Psychiatrist. 2012;36:121–4.
english proficiency? A systematic review of the literature.
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Health Serv Res. 2007;42(2):727–54. 59 Butow PN, Lobb E, Jefford M, Goldstein D, Eisenbruch M,
Girgis A, et al. A bridge between cultures: interpreters’
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42 Ribera J, Hausman-Muela S, Peeters K, Toomer E. Is the use of perspectives of consultations with migrant oncology patients.
interpreters in medical consultations justified? A critical review Support Care Cancer. 2012;20:235–44.
of the literature. PASS Int v.z.w. 2008. [Internet]. [cited 22
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2014.
44 Costa B. Interpreting in mental health contexts via skype. 4th
62 Bauer A, Alegria M. Impact of patient language proficiency
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Bridging the gap between biomedical and
traditional health practitioners in South Africa
8
Authors:
Mosa Moshabela i,ii,iii
Thembelihle Zuma iv
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Bernhard Gaede iii,v
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raditional health practitioners (THPs) in South Africa are increasingly The merging of biomedical
acknowledged as essential providers of health care and the National Department
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of Health is taking firm steps towards the formal regulation of THPs. However, and traditional healing
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tensions continue to dominate the landscape of research and policy debates on the paradigms provides for a
role and practices of THPs, particularly with respect to historical injustices, gaps in
complementary system of
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In this chapter, we report on the findings of a study of peer reviewed and grey could offer patients a truly
literature related to THPs up to 2015 and argue that the world view of the biomedical holistic and comprehensive
paradigm is very different from that of the healing paradigm as the former uses a
form of care.
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scientific knowledge lens while the latter uses an indigenous knowledge lens.
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of plural health care, which could offer patients a truly holistic and comprehensive
form of care.
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The current body of evidence demonstrates much progress in the way that traditional
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83
Introduction Discussion
The National Department of Health (NDoH) in South Africa has taken Four main themes arose from our review. Firstly, we found strong
firm steps towards the official recognition and institutionalisation evidence of the existence of medical pluralism in South Africa where
of Traditional Healing and Medicine.1 These steps include the there are multiple forms of understanding, explaining and treating
establishment of a directorate of Traditional Medicine within the illness.8,12,13 Secondly, there is evidence of conflicting paradigms of
National Department of Health, as well as the enactment of the knowledge, and of polarisation between the ‘biomedical paradigm’
Traditional Health Practitioners Act (22 of 2007), which founded based on scientific knowledge and the ‘healing paradigm’ based
the Interim Traditional Health Practitioners Council.2 In November on indigenous knowledge.14–16 Thirdly, work has been conducted
2015, the Minister of Health published the Regulations for on the current understanding of traditional healing as it occurs in
Traditional Health Practitioners in Government Gazette No. 39358, the context of indigenous knowledge systems, and in close relation
Notice No 1052 in terms of Section 47,3 read with Section 21 of to religious knowledge systems.17–19 Lastly, the collaboration
the Traditional Health Practitioners Act,2 reportedly after consultation between traditional healing and biomedical systems occurs against
with the Council. Consultation meetings are currently taking place a backdrop of mistrust, tensions and unresolved issues.16,20,21 The
across the country, with the aim of clarifying the legislation and latter area of research is located within the discourse of medical
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regulations, and to obtain support from different sectors, including syncretism, which represents the evolution of combining, blending or
traditional health practitioners (THPs).4 merging different medical approaches and systems.22
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into two major areas: THPs as providers, and traditional medicines
(TMs) as their medicinal products. Therefore, policies and regulatory South Africa is arguably one of the few countries in Africa regarded
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processes have to treat these two as related, but distinctly different in as being unanimous in diversity, yet the rich diversity of culture,
order to facilitate progress. There is an urgent need for a regulatory race, language, ethnicity and religion presents challenges for the
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council of THPs as practitioners of health care,5 much like the Health country’s social dynamics, including its healthcare system.23–25 These
Professions Council of South Africa, and for a regulatory council for multiple forms of diversity represent different world views, and as a
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TMs,6 either though the Medicines Control Council or through a new result, many fellow South Africans become aware of or experience
similar structure. While there are many debates on TMs including in characteristic differences, which may at times result in tension or
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a previous edition of this Review, 7 in this chapter we focus on THPs conflict.26 In visiting a health provider, patients take with them a
rather than TMs. certain world view relevant to health and wellbeing which is likely
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challenges of managing people living with HIV. While most of this pluralism can also be seen in the co-existence of multiple medical
literature paints a negative picture of the role of THPs, there is also systems, which manifest in the way patients engage with health
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a growing body of evidence generated for the purposes of building care, or their care-seeking behaviour.8
bridges between traditional and biomedical (allopathic, Western,
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84 S A H R 20 1 6
Traditional health practitioners
this, the use of THPs remains highly prevalent, with rates of 20% equating to biomedicine if THPs are to be allowed to manage
among patients on antiretroviral treatment (ART).12,40 patients and treat illness.47 These standards are unlikely to be met by
traditional healing and we argue that this is due to comparing two
The plural healthcare system in South Africa offers a multiplicity of
different paradigms using a one-sided biomedical paradigm.15,16,48
options for healthcare seekers and it is in the best interest of South
Africans that their healthcare providers function together in harmony Several authors make reference to the problem of examining
so as to best serve the people first, before serving their professions, traditional healing from a purely biological point of view, since
their trades or themselves.8,32,41,42 Historically, biomedical structures traditional healing is not founded on the science of biology.15,37,49
have been used by missionaries as a vehicle to convert people, Wreford for example,20,50 has argued that any true exchange
many of whom held traditional world views, to Christian world relevant to collaboration is dependent on THPs acknowledging
views.43,44 Ultimately, the conflict of values and interests between the perceived supremacy of the biomedical paradigm. Therefore,
patients and health practitioners, both biomedical and traditional, the challenge of establishing collaboration between biomedicine
exists as a result of co-existing world views, but the disproportionate and traditional healing exists in part as a result of the hierarchical
social power of practitioners may serve to compromise patients’ classification of knowledge,47 whereby the scientific knowledge of
views and values. There is a need to recognise and acknowledge biomedicine is located above other forms of knowledge. Likewise,
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the co-existence of plural healthcare systems, and to optimise these most of what constitutes religious knowledge locates itself above
in ways that can most benefit the patient. indigenous knowledge, in which case indigenous knowledge is
driven underground and lost to society.14,51–54 It has thus been
Conflicting paradigms
argued that the study of Indigenous Knowledge Systems is not
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The relationship between traditional healing and biomedical systems simply a scientific endeavour but an opportunity to reclaim Africa’s
is characterised by mistrust, tension and conflict, which constitutes a ‘scientific’ and sociocultural heritage.
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major setback for the current effort to forge collaboration between
Biomedicine promotes what is thought of as ‘culture-free
the two systems.15 On the one hand, providers of biomedicine
Y T representations of disease’16 that are seen to be neutral and
are vocal in their criticism of traditional healing and the fact that
realistic, while traditional healing is considered rife with ‘dangerous
traditional healing lacks a body of evidence to substantiate its
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and ultimately mistaken metaphors’; yet biomedicine tends to
practice through a scientific knowledge lens;27 on the other hand,
operate along quasi-missionary lines seeking to liberate people from
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are almost always informed about engagement with the biomedical standardisation and training are mostly clear-cut, and attempting
system. It has been observed that “to acknowledge a practice does to assess traditional healing in comparable terms is perhaps nigh
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not necessarily mean to endorse it”,46 and if collaboration between on impossible, which renders the notion of establishing equivalence
traditional healing and biomedical systems is to succeed, both largely meaningless.16 The primarily biological worldview of
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systems must reach some degree of mutual understanding based on biomedical science and its interventions has led to attempts by allied
respect and an equal footing.7,21,26 Much of the current literature professionals, psychotherapists and social workers to incorporate
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refers to the need for traditional healing to achieve standards the psychosocial aspects of illness and wellbeing into biomedical
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HEALING PARADIGM
S A H R 20 1 6 85
science.51 The shift resulted in what is now seen as bio-psychosocial against the background of a largely uninterested universe.16 In this
medicine, with the relatively new field of family medicine being the respect, a ‘healing paradigm’ offers a degree of solace to patients;
case in point.55 their suffering can be seen to have been caused by malevolent forces
deployed against them, sometimes out of jealousy or turbulence in the
The recognition of synergistic possibilities between the two systems,
spirit world, rather than having simply come about through random
shown in Figure 1, is likely to cultivate common ground for a more
infections and mutations. Jealousy-as-causation is a recurring theme
progressive and constructive form of mutual understanding.
within the majority of the discussions on witchcraft that arise, with
Approaches to illness both patients and healers in broad agreement on this aspect.16 At
the same time, within such a world view, it must be emphasised that
The strength of biomedicine lies in its biological curative approach,
for every victim of witchcraft there must be a perpetrator, and if not
while traditional healing dominates in terms of a spiritual approach
adequately handled, unnecessary harm may ensue.62–64
with the two modalities representing potentially opposing world
views.16 Curing is a largely biological process that results in the According to Kale,65 there are three key principles of traditional
clearing of disease from the body.37 In traditional healing, illness healing relevant to this debate, and the extent to which THPs form an
is generally viewed as a more psychosocial condition involving integral part of their people and community. Firstly, THPs endeavour
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spiritual or mental health aspects in need of healing. to ensure that patients are satisfied that they, as individuals, and
their symptoms are taken seriously, and that patients are given
Current evidence suggests that the hitherto mutually exclusive debates
enough time to express their fears. Secondly, THPs study the
regarding the existence of ancestors or God can both be located in
patient as a whole and deserve credit for not splitting the body
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the realm of the spirit world and that people with indigenous beliefs
and mind into two entirely separate entities. Thirdly, THPs do not
have a natural ability to merge ancestral reverence with worship
consider the patient as an isolated individual, but as an integral
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for God.18,56 The ancestors are conceptualised as the ‘living dead’
component of a family and a community, and members of the
– compassionate spirits who are blood-related to the people who
patient’s family participate in the treatment process. Therefore, the
hold indigenous beliefs and who show an interest in the daily lives
Y T services of traditional healers go far beyond the uses of herbs for
of the living.18,56,57 This belief is a source of comfort when family
physical illnesses.66 THPs serve many roles, including but not limited
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members die or when people are faced with their own imminent
to custodianship of the traditional African traditions and customs,
death. Ancestors are not worshipped, but remembered and revered
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often found in the so-called African Christian Churches, are for all
traditional healing has also adopted tools and practices from
intents and purposes classified here under the religious sector of
biomedicine, as well as other modern inventions in order to
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THPs; they are currently not classified under THPs by law and may
appropriate itself in modern society.67 Therefore, medical systems
constitute an independent sector of healers.60,61
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evolve over time and through this evolution, adopt and incorporate
unlike biomedicine, traditional healing, is often communal rather new ways of functioning suited to the time and place of their
than individualistic or private.37 In all cases, patients are asked to practice, thus generating another form of medical syncretism. Much
be part of the process in the interests of contributing to their own can be learned from medical syncretism in relation to the need for
healing. Furthermore, due to the ways in which the spirit world is biomedicine to work alongside traditional healing. However, a
perceived to impact on people’s health, treatments and ceremonies number of pertinent issues should be addressed urgently for the new
are tailored to the requirements of individuals and their families, change to gain traction.
as is any prescribed traditional medicine. Traditional healing is
Firstly, South Africa needs to resolve ‘old wounds’ inflicted upon
therefore a highly personalised and interactive experience for
traditional healing by colonisation, missionaries and apartheid.52
patients, in which healers are facilitators.37 This differs substantially
Secondly, the country must resolve current threats, including the
from the expert-driven and standardised approaches that are central
prevailing atmosphere of mistrust between traditional healing and
to biomedicine.
biomedicine, the potential harm of traditional medicines and in
As with biomedical practitioners, traditional healers identify what some cases bogus THPs.15 Lastly, discussions on the action plan
is wrong with their patients – naming the presenting illness is and next steps must shift from barriers to opportunities; these may
viewed as a significant aspect of the treatment process. Where the include the potential complementary nature of biomedicine and
systems diverge is that traditional healing places significance on the traditional healing,68 incorporation of traditional healing into the
patient’s personal experiences surrounding ill health.16 In contrast, education curriculum,11 the role of dual practitioners of biomedicine
biomedicine has little to offer patients in terms of explanations for and traditional healing,69 and the contemporary landscape of HIV
their misfortune – diseases are seen to be contracted randomly and AIDS.8,70
86 S A H R 20 1 6
Traditional health practitioners
Redressing injustices Wreford,50 herself both an anthropologist and a THP, has argued
that the first step towards meaningful accommodation would be a
One argument put forth in policy debates around the need for the
change in the biomedical mind-set, for the biomedical establishment
institutionalisation of traditional healing is that of a social justice
to view THPs as allies.16 However, through a biomedical lens, the
imperative to redress past injustices. Ingle for example recounts how
perceived weaknesses of the traditional healing system include
attempts by traditional healers to regulate themselves in the seventies
harmful treatment regimens.11
were met with opposition and their name of choice, ‘Traditional
Medical Practitioners Association’, was disputed by the then Walwyn and Maitshotlo36 showed that 88% of THPs prepared their
Department of National Health and Population, which preferred own medication, mostly from plant material, and sold their products
the term ‘traditional healers’ and not ‘medical practitioners’.52 Ingle as aqueous extracts in labelled bottles. None of these products had
also recounts how traditional healing was simplistically reduced to been systematically evaluated, and there was generally no record-
herbalism and was associated with other herbal practices, including keeping, either of the patient or of the medicine itself. Quality control
those of Whites, Coloureds and Indians, to the detriment of the depth practices such as expiry dates, controlled storage conditions and
of knowledge normally associated with being a THP. These efforts batch records were totally unknown in our sample. The revenue
to co-opt traditional healing into a narrow biomedical framework associated with this production of medicines is large, which has led
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of herbalist practices were specifically aimed at undermining some to manufacture and produce TMs for the treatment of HIV and
the socio-cultural practices that maintained the social fabric and AIDS, and to make claims for marketing purposes such as the ability
coherence of the colonised populations.71 THPs were criminalised to cure HIV.16
under the Witchcraft Suppression Act (3 of 1957),72 and labelled
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As with many medicines, traditional or otherwise, ingredients utilised
as witchdoctors.26 The derogatory language describing traditional
by traditional practitioners can be toxic – at times, fatally so. For
practices as backward, barbaric and primitive was meant to label
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the most part, traditional remedies are based on directives outlined
and stigmatise THPs as inferior. Culturally and socially traditional
in practitioners’ dream-conversations with ancestors rather than
healers had a much greater role, including governance, advising,
Y T the pharmaceutical properties of the ingredients concerned.14,16
and responsibility for the social wellbeing of the community;
One may therefore wonder how a biomedical practitioner could
however, these roles were eroded in the re-emerging definitions of
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consider THPs as allies and treat them with respect when their
culture.73,74
practices do not meet the standards of biomedicine and their
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Beyond these deep old wounds, there exist several current threats beyond the scope of this chapter, although some authors have
to the intended institutionalisation of traditional healing. Also, both already begun framing the discussion in constructive ways.7,38,79
groups need to engage mutually to understand each other’s world A scientific biomedical lens is unlikely to yield positive answers,
and work so as to alleviate existing tensions.75 Overall, biomedical and expecting traditional medicines to meet the standards of
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practitioners have limited knowledge and experience of traditional biomedicine will endorse a position of supremacy for biomedicine.
healing, and should be encouraged to engage in activities that
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Any insistence on following this path will yet again lead to a cul-de-
would enhance their knowledge and experiences in this sphere.27,76 sac. However, THPs must resolve outstanding controversial issues
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Wreford77 maintains that among themselves,79 address the question of identifying bogus
if the communication that does take place insists on scientific THPs who should be excluded from platforms of engagement with
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supremacy and refuses reciprocity, the effort is likely to biomedical practitioners to enable more genuine partnerships, and
perhaps be prevented from conducting any harmful practices in the
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intellectually with the ideas that underline traditional practice. and witch-hunts continue to threaten the integrity of engagement
with biomedical practitioners, and the THP community should
Most THPs are willing to learn and refer patients to clinics address them.11,64,80,81 These engagements would help to address
and hospitals, while this deference is not true of biomedical challenges of delayed appropriate health care when traditional
practitioners.10,39,78 Mokgobi76 showed how certain sub-groups of remedies fail to produce the desired effect,8,11,82 as well as
biomedical practitioners, such as XiTsonga- and Sesotho-speaking catastrophic healthcare expenditure associated with the nature of
biomedical practitioners, expressed clear intentions to work with out-of-pocket payments for THPs.31,32 Currently, the care economy of
THPs in the future. Similarly, biomedical practitioners working THPs functions more like a private sector, largely because clients pay
with psychiatric conditions had more positive opinions of the out-of-pocket, and there is no State subsidy of their care economy.
envisaged involvement of THPs in primary health care than did However, THPs also function more like community health workers
general physicians and general nurses, who could logically form given their community-embeddedness and the informal nature of
part of the initial platforms of engagement.21,34,35,78 Therefore, in their indigenous health sector. Tshehla83 and Mbatha et al.84 argue
order to build bridges between the two systems, two-way in-service that although the law allows THPs to issue sick certificates, the
exchanges and trainings between THPs and biomedical providers current legal and policy landscape is not conducive to this practice,
are necessary and important.75 Pre-service training is needed for and there are still inconsistencies and gaps within these legal and
students to become acquainted with traditional healing at an early policy documents. For example, employers may not be obligated to
stage of their careers, and traditional healing should be included accept such sick certificates for as long as regulatory structures are
in the higher education curriculum for nursing, medicine and not in place. Therefore, the new THP regulations3 constitute a step in
pharmacy.33 this direction; otherwise, the lack of a conducive policy environment
will continue to threaten efforts to recognise THPs.
S A H R 20 1 6 87
Harnessing Opportunities George et al. show that THPs are enthusiastic about the prospect of
collaborating with biomedical practitioners in the prevention and
Rudolph et al.85 argue that THPs constitute an untapped resource
care of HIV and AIDS.87 Flint16 presents the mission statement of
with enormous potential. Traditional healers are often seen as a
the Traditional Healers Organisation (THO) as unambiguous in its
solution to the growing human resource crisis in healthcare services,
assertion that “while modern medicine is needed for the accurate
particularly to assist with the extension of the health services at
diagnosis of HIV and AIDS, it is the THPs who would probably be
community level.65 However, a valuable bridge should be built to link
the primary care providers and in the front line in the prevention
traditional healing with modern medicine, particularly in the struggle
and control of the spread of this disease”. This notion resonates
against HIV and AIDS.70,77,86 The current policy efforts pertaining
with the findings of Schuster et al.45 and Davids et al.88 that THPs
to THP regulation1,3 offer a window of opportunity to adopt a more
tend to deal with the ultimate or distal causes of ill-health, whereas
informed direction. We further argue that HIV and AIDS creates a biomedicine deals with the more immediate and proximal causes.
more practical window of opportunity for the creation of linkages
between THPs and biomedical practitioners. Although claims by This progressive view lends itself to a more collaborative approach
certain THPs to cure HIV and AIDS have been disputed, much harm between traditional healing and biomedicine for people who
has been caused due to such money-making schemes and practices hold indigenous belief systems. Dual practitioners of biomedicine
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that are considered to have tainted the traditional health sector. and traditional healing, such as nurse-Sangomas and Sangoma-
Literature shows that THPs often negotiate payment according to the physicians, could offer further wisdom on how to reconcile
ability of the user to pay, and the treatment also includes all other differences between the two systems.11,69,89
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Conceptually, it is possible for biomedicine to adopt a scientific
THPs tend to accept payment at the end of the treatment rather than biological approach to attend largely to the biological aspects of
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at the outset. In fact, THPs who demand payment upfront are often disease, while indigenous and religious approaches could be used
suspected of being charlatans, which means payment should be mainly to address the socio-cultural and spiritual aspects, while
made when the healer and the client are satisfied with the care
Y T we resolve tensions regarding biological therapies. In this way, as
provided.16,37 A distinction should also be made between payments shown in Figure 1, the combination of biomedicine and traditional
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made as part of the treatment course, and for therapeutic purposes or religious healing could afford patients a more complete and
for the benefit of the client, as opposed to payment made as healer’s holistic form of care that would synergise biological, psychological,
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charge for consultation and care. social and spiritual approaches. Instead of a culture-free healthcare
system, South Africa could boast, at the least, a culture-sensitive, and
4 ED
Culture Free
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Culture Neutral
BIOMEDICAL HEALING
PARADIGM PARADIGM
Culture Sensitive
Culture Appropriate
88 S A H R 20 1 6
Traditional health practitioners
Conclusion
A radical shift towards integrating traditional healing in South
Africa’s healthcare system is imminent. The challenge of collaboration
between traditional healing and biomedical systems is now going
beyond ‘calls and talks’, and reaching a level of planning for
action. Currently, there are still more questions than answers, and
little is known about how the regulation of THPs will unfold, and
more importantly, what implications this will have for the country’s
healthcare system. The current body of evidence demonstrates much
progress in the way that traditional healing is perceived in South
Africa, having shifted from a derogatory ‘witchcraft paradigm’
supported by the Witchcraft Suppression Act (3 of 1957), to a
more tolerant, and in some instances reconciliatory, discourse of
a ‘healing paradigm’ now protected under the Traditional Health
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Practitioners Act (22 of 2007). However, the progress to date does
not represent a success story, but only the beginning of a long
journey ahead. A number of issues still need to be resolved, the
main one being the atmosphere of animosity between THPs and
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biomedical practitioners, which is compounded by the perceived
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supremacy of biomedicine. Traditional healing is regarded as being
based on unregulated, unscientific and dangerous practices that
lend themselves to delayed access, high healthcare costs, herbal
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toxicity, bogus practitioners, ‘muti’ murders and witch-hunts. There
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is a real threat to the future of the health system in South Africa
if the details of the issues raised in this chapter are not carefully
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is very different from that of the healing paradigm; the former uses
a scientific knowledge lens while the latter uses an indigenous
knowledge lens. The two systems, therefore, neither exist nor
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S A H R 20 1 6 89
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strategies in South Africa. Soc Dynamics. 2005;31(2):126–
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Achieving universal access to sexual and
reproductive health services: the potential and
9
pitfalls for contraceptive services in South Africa
Authors:
Naomi Lince-Deroche i Melanie Pleaner ii
Jane Harries iii Chelsea Morroni ii,iii,iv
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Saiqa Mullick ii Cindy Firnhaberv,vi
Masangu Mulongo v Pearl Holele vii
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Edina Sinanovic viii
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niversal access to sexual and reproductive health services was included in South Africa’s laws,
the Millennium Development Goals and has been carried forward in the
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new Sustainable Development Goals (SDGs). Access to contraception is policies and guidelines
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highlighted in the Family Planning 2020 (FP2020) initiative. Given South Africa’s on contraceptive service
ongoing commitment to the SDGs and FP2020, this chapter explores the potential
provision in the public
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for achieving universal access to contraceptive services in South Africa against the
backdrop of the country’s domestic policies, current implementation efforts and HIV sector are progressive and
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The chapter begins with a description of South Africa’s enabling policy environment
with regard to sexual and reproductive health and rights generally, and contraception
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specifically. Service delivery norms and approaches for budgeting and expenditure
tracking are described, and national and provincial contraceptive statistics are
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presented.
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Public sector delivery of contraceptive services nationally faces both similar and
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Finally, key recommendations are provided for contraceptive service delivery in the
future in light of ongoing research and changes on the horizon – such as National
Health Insurance, national-level efforts to integrate HIV and primary care services,
and efforts under-way as part of the National Development Plan.
i Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine,
Facult y of Health Sciences, Universit y of the Wit watersrand, Johannesburg
ii Wits Reproductive Health and HIV Research Institute, Universit y of the Wit watersrand, Johannesburg
iii Women’s Health Research Unit, School of Public Health and Family Medicine, Universit y of Cape Town
iv EGA Institute for Women’s Health and Institute for Global Health, Universit y College London
v Right To Care
vi Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Facult y of Health Sciences,
Universit y of the Wit watersrand, Johannesburg
vii South African National Department of Health
viii Health Economics Unit, School of Public Health and Family Medicine, Universit y of Cape Town
95
Introduction
The Millennium Development Goals (MDGs) were established the changing landscape of South Africa’s HIV epidemic, which
in 2000, and 2015 marked the deadline for taking stock of permeates virtually all aspects of service delivery and presents
achievements. Large strides were made in some areas; however, particular challenges for contraceptive service delivery.
much remains to be addressed on a global scale.1 MDG 5b called
for “universal access to sexual and reproductive health services.”2
In sub-Saharan Africa, use of contraception among women aged
South Africa’s contraception laws, policies, and
15 to 49, married or in a union, more than doubled from 1990 guidelines
to 2015, yet 24% of these women still have an unmet need for South Africa’s excellent laws, policies and guidelines provide a
contraception.1 Recognising the need for further action, the new supportive, rights-based framework for delivery of sexual and
Sustainable Development Goals (SDGs) were established in 2015, reproductive health services. Access to health care is valued at
and these again include universal access to sexual and reproductive the highest levels. The country’s Constitution guarantees the right
health.3 to access healthcare services, including sexual and reproductive
health services, for all,6 and the National Development Plan
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Family Planning 2020 is a global initiative founded in London in
2012 with the aim of making modern contraceptives accessible to considers “providing affordable access to quality health care while
an additional 120 million women by 2020.4 Individual countries are promoting health and wellbeing” as central to achieving its domestic
expected to make their own, locally applicable commitments, which development goals.7 The National Health Act (61 of 2003)
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are then made public and tracked through various mechanisms. acknowledges the particular health needs of vulnerable groups,
including women, and provides for free health care for pregnant
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South Africa adopted both sets of development commitments
women, including women undergoing termination of pregnancy.8
– the MDGs and the SDGs – and has also established domestic
The new National Adolescent Sexual and Reproductive Health and
commitments for FP2020. These commitments are aligned to the
Y T Rights Framework Strategy (2014–2019)9 and the Strategic Plan for
country’s laws, policies and guidelines on health. However, looking
Maternal, Newborn, Child, and Women’s Health and Nutrition in
back, the country has struggled to make progress on health-related
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South Africa (2012–2016)10 are broadly supportive of adolescents’
MDGs for various reasons. In this chapter, we explore the potential
and women’s rights and access to health services and specifically
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birth spacing. This is not meant to minimise the importance of access The National Contraceptive Policy Guidelines released in 2001
to other essential sexual and reproductive health services such as contained a focus on the right of all women to choose a method and
screening and treatment for reproductive cancers, maternity services, stressed quality of care.11 This was a significant departure from the
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safe termination of pregnancy services, and care and recourse for perceived coercive, population control-focused policies that targeted
survivors of gender-based violence. Indeed, we acknowledge that Black women under apartheid.12 The 2001 guidelines were updated
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too much attention on one indicator can work to the detriment of in 2012 and released as the National Contraception and Fertility
Planning Policy and Service Delivery Guidelines and the National
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health services within the global SDG framework and therefore as ‘the guidelines’ or the ‘CFP policy and guidelines’).13 The revised
warrants special attention. CFP policy and guidelines acknowledge the role of contraception
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96 S A H R 20 1 6
Contraceptive services
(not listed in Table 1), are available in the private sector, but at a in 2010 to be 63.7%, suggesting a possible gain of 3.8% for this
cost. According to the CFP guidelines, methods should be offered in group since 2003.17 This estimated rate for women married or in
the public sector in a comprehensive, integrated manner and include a union in South Africa is similar to the rate estimated for Southern
discussion of fertility plans, offer of voluntary HIV counselling, Africa in 2010 (62.2%), and is much higher than the estimated CPR
screening for sexually transmitted infections and TB, and education for Africa as a whole (30.9%). However, South Africa’s CPR is lower
on breast and cervical cancer screening.13 than that of other upper-middle-income countries (Mexico 72.1%,
Russia 78.6%, Brazil 79.5%), and lower than rates in the United
States (77.1%) and Europe (72.0%).17
High knowledge and uptake of contraceptive
The most popular method of contraception in the 2003 SADHS
methods
was the injectable; 26.7% of all women aged 15 to 49 used this
The Contraceptive Prevalence Rate (CPR) is used to represent current method at the time of the survey (Figure 1). Among women who
use of contraception. It is defined as the proportion of women aged were currently using a contraceptive method at the time of the
15 to 49 who are ‘currently’ using a contraceptive method. The survey, 53.2% were using an injectable method (data not shown).16
CPR has traditionally been reported for women who are married Use of long-acting and permanent methods such as the intrauterine
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or ‘in a union’, although more recently the data are also available contraceptive device (IUCD) or sterilisation was much lower at 0.6%
for women who are sexually active and for all women combined.15 and 7.3% of all women aged 15 to 49.
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last SADHS in the country was conducted in 2003 – well over a
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decade ago.16 Considering use of modern contraceptive methods,
the CPRs for all women, married or in a union, and sexually
active women aged 15 to 49 were 50.1%, 59.8% and 64.6%
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respectively.17 A more recent analysis, which used modelling,
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estimated the CPR for South African women (married or in a union)
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Table 1: Modern contraceptive methods that should be available in the public sector based on national guidelines
Female sterilisation (tubal ligation) Typical use: 0.5% Permanent Limited current availability; guidelines emphasise
Perfect use: 0.5% creating one service point per district.
Male sterilisation (vasectomy) Typical use: 0.15% Permanent Limited facilities.
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intrauterine system (LNG-IUS) Perfect use: 0.2% as second-line option for select women.
Copper intrauterine contraceptive Typical use: 0.8% 5 years**** All service levels
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S A H R 20 1 6 97
Figure 1: Knowledge of, ever use and current use of modern contraceptive methods by all women aged 15 to 49 in South Africa, by
method
100%
93.4
90%
84.5
79.9
80% 78.1
70.5
70%
60%
53.2
50.1
50% 47.2
45.1
39.7
40%
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7.3 7.3 6.0
3.7 2.6
0.3 0.3 0.6 0.2 0.0 0.1 0.5 0.0
0%
Any modern Female Male Pill IUCD Injectables Implants Male Female Emergency
method sterilization sterilization condoms condoms contraception
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Knowledge of Ever use Current use
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Note: The implant was not available in South Africa in 2003. Also, condom use represents only those women who used condoms exclusively (i.e. the condom
data exclude women who used condoms plus another method).
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Reported use of methods is higher if one considers sexually active
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women only, rather than all women. Figure 2 presents ‘ever use’ and
‘current use’ of contraceptive methods in 2003 for sexually active
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Figure 2: Ever use and current use of contraceptive methods by sexually active women aged 15 to 49 in South Africa, by method (2003)12*
100%
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90% 85.2
80%
G
70%
64.8
R
60% 56.0
BA
50%
38.4
40%
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32.8
29.2
30%
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20%
12.2
10.110.1
7.8
10%
5.0 3.0
0.6 0.5 0.8 0.2 0.0 0.9 0.5 0.0
0%
Any modern Female Male Pill IUCD Injectables Implants Male Female Emergency
method sterilization sterilization condoms condoms contraception
More up-to-date information on the CPR and patterns of contraceptive Rate (CYP). The CYP measures the level of protection from pregnancy
use is urgently needed in South Africa in order to understand the over one year given the amount of contraceptives dispensed.18 The
impact of recent policy and service delivery changes. Fortunately, denominator is the total ‘couple-years’ in which there is an assumed
data collection for the next SADHS will be initiated in 2016. To track risk of pregnancy at the national level. The numerator is the number of
progress on contraceptive services on a more current and routine couple-years in which protection from pregnancy is assumed based
basis, dispensing data are collected in health facilities. These data on the number of contraceptives dispensed and a conversion factor
are collated at the national level in the District Health Information which allows for standardisation of effectiveness duration across
System (DHIS) and used to calculate a Couple Years of Protection methods. The CYP allows for comparison of methods in terms of their
98 S A H R 20 1 6
Contraceptive services
Figure 3: Couple-Years of Protection Rate for South Africa for financial years 2000, 2005, 2010 and 2014, by province
70%
60.0
60% 57.8
49.2
50% 46.8
44.9
43.7 42.7
39.4 38.7 39.8
40%
32.1 32.7
30.7 30.1
29.5
30%
25.5 25.3
24.2
10%
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0%
EC FS GP KZN GP MP NC NW WC SA
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Source: Massyn et al., 2015.19
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contributions to the total CYP; however, it is impossible to know how ‘Unmet need for family planning’ is used to measure progress on
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many or the proportion of individuals who have accepted a method.
For these reasons, the CYP is considered an imperfect metric, but it
contraceptive access. The term is defined as the proportion of
women, married or in a union, who are fecund and who do not want
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is widely used and can be useful for comparing statistics within a any more children or who want to postpone childbearing to beyond
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particular country over time or for cross-country comparisons. the next two years, but who are not currently using a contraceptive
method.23,24 In South Africa, unmet need was estimated at 12.7%
The DHIS database provides CYP information based on financial
for 2010.17
4 ED
year DHIS data.19 Figure 3 indicates that for the financial year
ending in 2000, the CYP for the country was 25.3%. Growth in Addressing unmet need is important, especially for countries like
CYP was slow and even declined in some provinces between 2000 South Africa, given the important role of contraception in the
O
and 2010; however, it increased for the country to 46.8% in 2014.a armamentarium of HIV prevention strategies. However, some
A significant portion of the increase occurred in 2014 as a result of researchers have suggested that this indicator alone is insufficient
G
the introduction of the implant, which as a long-acting method, offers for assessing progress with contraceptive access, in that it is a
2.5 couple-years of protection for each insertion (for Implanon-NXT) time-dependent, variable indicator and may not address unintended
R
according to the internationally accepted conversion factor for this pregnancy among self-reported ‘current’ contraceptive users.24 In
method.20 It is worth noting that the official CYP data for South Africa fact, research has shown that in countries where the proportion
BA
represent method provision in the public sector only. It is generally of women using a contraceptive method greatly outweighs the
accepted that 20% of the population receives health care in the proportion with unmet need, the greatest number of unintended
O
private sector,21 and in the 2003 SADHS, 13% of women reported pregnancies may actually come from current contraceptive users as
EM
obtaining their contraceptive method there.16 a result of incorrect or inconsistent use.24–26 Some women who are
late in refilling methods or who take a ‘break’ from use may be
counted as continuous users in routine data collection or surveys,
Existing challenges masking their risk of pregnancy.27
South Africa is arguably doing well with contraception considering In South Africa, Baumgartner et al.28 found that among women in
its laws, policies and guidelines on service provision, and need of continuation of their injectable contraceptive in the Western
comparing its CPR with to that of other African nations. Indeed, Cape and Eastern Cape Provinces, 25% were between two and
almost all women in the country (93.4%) have heard of modern 12 weeks late for reinjection. Of those who were late, 2% in
contraceptive methods, and close to three-quarters (70.5%) have the Western Cape and 36% in the Eastern Cape were refused a
ever used one (Figure 1). However, these figures mask problems reinjection by the nursing staff.28 In Gauteng Province, in a cohort
with service delivery; equitable access; and correct, consistent, and of 189 new injectable users, 78 (41.3%) discontinued use before
continuous use of methods, especially among certain groups such as one year.29They reported that they were “taking a break”; the
young or rural women.22 mean length of the break was seven months during which no other
contraceptive method was used.29
a South Africa has historically used conversion factors for the CYP that
are slightly different from today’s internationally harmonised conversion
factors. The CYP could be higher if South Africa shifted to the international
conversion factors.
S A H R 20 1 6 99
Drug-drug interactions may also put current contraceptive users at risk Method availability through forecasting, budgeting, and
of pregnancy due to reduced contraceptive efficacy. For example, a supply chain management
particular antibiotic may interfere with oral contraceptive efficacy.30
A multi-country study of global DHS data found that “perfect
Some epilepsy medications may also reduce hormonal contraceptive
efficacy,31 and new research (discussed further hereafter) suggests availability” of contraceptives would reduce method discontinuation
that use of certain ARV, or TB drugs may also reduce the efficacy of and increase the CPR by 1–2 percentage points. This analysis
some hormonal methods. concluded that, looking across countries, for every additional
method “fully available”, the CPR increases by 5–8 percentage
Understanding the gaps in South Africa in terms of contraceptive points.33
use and how to intervene requires a broad understanding of
contraceptive delivery, uptake, and usage. Many women are Few methods are “fully available” in South Africa. Despite guidance
already using contraception, but generally, use is limited to a from the CFP guidelines on what should be offered and where
few, relatively shorter-acting methods, such as the injectable, oral (Table 1), in practice, some higher-level facilities or special facilities,
contraceptive pills, and condoms. Access to a range of methods, such as HIV or TB clinics, do not offer contraceptive services, and
including information about them, is lacking for many women. what is available in primary-level facilities varies. Requests for
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Figure 4 offers a conceptual framework to bring together the many sterilisation, and sometimes also IUCD insertion, are often referred
factors contributing to contraceptive use or non-use. It illustrates to higher-level facilities, and in some districts access to these services
the importance of a strong health system, including financing for is extremely limited at any level.13 Finally, for some methods, the
services and the pivotal role of healthcare providers, and the role of commodity may be in stock at the facility, but due to lack of clear
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community-focused outreach and education in generating demand messaging about drug–drug interactions or concerns about the
for services. The following sections refer to this figure and provide appropriateness of some methods for particular women, the method
20 IL
discussion on areas requiring special attention. may not be offered or discussed.
Y T
A N
Figure 4: Understanding contraceptive supply and demand – A conceptual framework
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N
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Follow-up after
Ability to choose
method choice
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Comprehensive
Affordability
counselling
Methods available
(number, type, and geographic proximity)
Forecasting/tendering
Source: Shaded items represent indicators of service quality according to the framework put forward by Bruce.32
Note: ‘Providers’ can be broadly interpreted as all healthcare providers involved in service delivery, including nurses, doctors, pharmacists, financial
managers and administrators.
100 S A H R 20 1 6
Contraceptive services
Budget allocations for provision of contraceptive services, like all to purchase or access contraceptive methods. In South Africa, nurses
sexual and reproductive health services, fall within the primary health in primary health care services play a major role in contraceptive
care budget. This budget is allotted from the ‘Provincial Equitable provision. Research from South Africa shows that nurses have
Share’ provided to provinces as a lump sum meant to accommodate strong preferences about which methods are appropriate for
service delivery for all sectors, including health.34,35 Because the women – especially those who are HIV-positive, unmarried, and/
Provincial Equitable Share is not linked to a particular service or or young.39,40
specific service targets, planning for and tracking expenditure on
Nurses can also influence method choice and/or continuation of
sexual and reproductive health services can be challenging. In
methods – intentionally or unintentionally – through sub-standard or
contrast, HIV and TB services are supported through a separate
biased counselling. Almost all of the issues identified through research
fund, called the ‘HIV and TB conditional grant’.36 Although the
that are said to be barriers to contraceptive use or continuation
conditional grant allows for greater accountability on HIV and TB,
could be addressed through improved counselling and support
the separation of funds for HIV- and TB-related care and treatment
from healthcare providers. Misinformation about methods, health
complicates provision of integrated services, such as the provision of
concerns, language challenges, and provider biases are significant
contraception within HIV care and treatment facilities.
barriers to initial uptake,41 and reasons for discontinuation among
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The contraceptive method mix available in facilities is heavily ‘current’ contraceptive users include desire for pregnancy, method
dependent on systems for procurement and supply chain failure and method side-effects.27 Counselling on all of these issues
management, which are in turn influenced by healthcare providers, could help to prepare women for use, to choose the methods that
administrators and pharmacists. Commodities are purchased are best for them, and to assist them with method switching when
16 6
through tendering, which involves forecasting by provinces based necessary.
on anticipated demand. Prospective provincial estimates are often
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Improvements to counselling services must include consideration of
based on historical ordering and dispensing records, which are
the approach and environment in which counselling is provided.
unfortunately prone to data errors and misinterpretation in terms of
Y T A brief face-to-face counselling session in a busy clinic may not
their potential to represent future demand. Once the tender is in
be sufficient to convey all the information a woman needs on the
place, timely ordering from suppliers and distribution to facilities is
A N
reproductive cycle, return to fertility after method discontinuation,
another hurdle. Problems with supply chain management have been
potential drug–drug interactions, the need for dual protection,
M U
Forecasting and supply chain management for contraceptive services information, text message reminders for renewal, pamphlets, etc.
are uniquely complicated by the desire to provide women with in improving women’s understanding of how methods work and
multiple choices. Budgeting for choice is complicated by variations method uptake and continuation.42–44
in method duration and the tendency of some women to stop early
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This shifting and scale-up are precisely what is called for in the
ever-increasing demands on their time. Efforts to improve access
CFP policy and guidelines. There is an expressed aim of increasing
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S A H R 20 1 6 101
affordability.53–55 There are many documented problems with healthcare providers, if they have the information and agency to
contraceptive service accessibility in South Africa. The CFP do so. The 2003 SADHS showed that educated women were more
guidelines state that contraceptives should be available at all likely to be using a contraceptive method at the time of the survey,16
levels of care. However, many facilities do not offer the full method and qualitative research from Soweto revealed that tenacious,
mix – sometimes even when the commodities are in stock – and highly motivated young women can sometimes obtain contraceptive
some offer no contraceptives at all. Personnel shortages, lack of methods from disapproving healthcare providers despite the odds.39
training on method provision, and lack of equipment are sometimes Demand-creation activities, such as awareness-raising campaigns
to blame. Counselling is often limited to one to two methods (if and education on reproduction and contraception in schools,
given at all), and stigma and/or discrimination by healthcare have been shown to be cost-effective strategies for increasing
providers is commonplace. HIV-positive, unmarried, and young contraceptive uptake;58 however, the importance of offering a high-
women are particularly at risk of discrimination by healthcare quality service should not be underestimated.
providers.39,40,56,57
Finally, women’s access to contraceptive services must be considered
Given these barriers, women with the financial means may choose within the larger social context. Despite progressive laws and
to access their contraceptive method in the private sector. For women policies, strong power differentials in heterosexual relationships and
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who cannot afford private sector access, contraceptives, including social and structural barriers to educational, economic and political
long-acting and permanent methods, are offered free of charge in advancement strongly disadvantage women.66 South Africa’s
the public sector, but women may still incur costs. These include: rates of interpersonal and gender-based violence are exceedingly
the costs associated with searching for information about methods high,67 and attitudes about young women’s sexuality are generally
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and where to obtain them; the time and travel costs associated disapproving, with the dominant discourse presenting young
with obtaining them; costs associated with managing side-effects mothers as promiscuous and representative of the degradation of
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associated with use; and psychological costs associated with not cultural and social mores.40,68,69 All of these factors undoubtedly
obtaining one’s desired method or managing the stigma associated impact on women’s ability to access services and their prioritisation
with use.58,59
Y T of contraceptive access in terms of their day-to-day needs.
A N
The user perspective The implant in South Africa
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According to South African law, anyone aged 12 and older has Introduction of the implant in South Africa in 2014 was relatively
the right to receive contraception without parental consent.60 late compared with other countries on the continent; however,
4 ED
Unfortunately, this legal right to access services is not reflected in the it is an example of a step taken towards improving the quality of
rates of adolescent pregnancy in the country. This is in part because contraceptive services through expanding women’s options and
healthcare providers’ opinions often differ from the law. Holt et al.40 increasing access to long-acting reversible contraception, and
reported that many of the healthcare providers at three public health raising awareness regarding method availability nationally. The
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facilities in Soweto thought that young women should not have sex implant is registered for use in over 100 countries globally, including
G
before marriage and therefore should not access contraceptives. countries in the Southern African region.70 It consists of matchstick-
When probed about what methods were most appropriate for sized rods filled with progestogen, which are inserted under the skin
R
young women if used, the majority of the providers responded that of a woman’s upper arm. The implant is effective for three to five
young women should use injectables. Pills were not seen to be an years depending on the implant type.70 Both Jadelle and Implanon-
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option due to the reported inability of young women to remember NXT have been approved for use in South Africa, but distribution
to take them every day, and IUCDs were also not recommended.40 has focused on Implanon-NXT.
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All women, regardless of HIV status or age, could benefit from Interestingly, in parallel with the success of the campaign and
additional information on contraception. Although challenging distribution thereafter, introduction of the implant has highlighted
and not the ideal solution, some women can overcome barriers existing challenges with South Africa’s contraceptive service delivery.
to access, particularly those posed by unhelpful or discriminatory The implant is a temporary or ‘reversible’ method of contraception,
1 02 S A H R 20 1 6
Contraceptive services
but unlike the pill and injections, which are also temporary, the HIV-positive women in Kenya.82 Women using the implant and EFV-
implant requires that a woman see a healthcare provider to have it based ART were three times more likely to become pregnant than
removed. This forces women to re-engage with the healthcare system women using nevirapine-based ART. However, the risk of pregnancy
if they are not satisfied with the method or if they have changed their for women using all other forms of contraception – except for IUCDs
mind about its use. or sterilisation – was higher than for women using the implant and
EFV-based ART regimens. This is further supported by Pyra et al.83
There has been growing concern about the number of women
The authors combined data from seven African countries. They
returning for early removal of the implant, some within a few
found decreased effectiveness among women using EFV-based ART
months of insertion. Establishment of formal monitoring systems for
and the implant; however, women using EFV-based ART and the
the implant lagged behind roll-out of the method, which has posed
implant still benefited from lower pregnancy risk than did women
a challenge in determining the true extent of removals. However,
using EFV-based ART and other contraceptive methods.
estimates and preliminary data collection from the provinces suggest
that as of December 2014, 820 implants were removed, suggesting This kind of situation – where technical, nuanced information needs
a possible 0.1% removal rate in the early part of the roll-out.71 to be filtered to the public through healthcare providers – is not
More refined data collection and careful observation over time are new in the contraceptive field. There is an ongoing yet unanswered
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needed. The removal rate is likely to have increased in 2015 as scientific debate regarding the potential for use of progestogen-only
access to removal services increased; however, the rate for 2014 injectables (DMPA/Depo and Net-EN) to elevate women’s risk of
is lower than anecdotally reported in South Africa and compares HIV acquisition.84 To date, there is no consensus on this question.
favourably with removal rates from other countries. A study from the Research currently under way (the ‘ECHO study’) aims to answer this
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Netherlands showed that 8% of women who chose to use Implanon question directly. In the meantime, the World Health Organization
had discontinued its use within 12 months.73 In a study in the US, has issued a cautionary statement advising women at risk of HIV to
20 IL
31% of women and adolescents who chose an implant discontinued use dual protection.85 This issue is discussed in the CFP guidelines,
using that method before 24 months,74 and in a study in Australia, and is cited as one of the reasons for the aim of reducing the
Y T
47% of women discontinued the implant during a follow-up period
of three years.75
country’s heavy reliance on injectable contraceptives. This issue,
as well as the new research on the implant and ARVs, highlights
A N
the need for careful messaging on contraceptive use and ongoing
Despite South Africa’s implant removal rate being both expected and
M U
called into question the quality and safety of the method.76 Concerns
have also been raised in academic publications and reported Conclusions
by the media about the efficacy of the method for HIV-positive
South Africa’s laws, policies and guidelines on contraceptive service
women taking ARVs.76 Implants contain synthetic progesterone:
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the implant, thus potentially reducing blood concentrations in some In this environment, achieving the SDGs and National Development
women.78,79 Research conducted prior to the introduction of the Plan goals on universal access to sexual and reproductive health
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implant in South Africa showed that women may respond differently services and the FP2020 goals on scaling up contraceptive access
EM
to reduced etonogestrel or levonorgestrel concentrations; there were specifically, will require careful consideration of existing service
conflicting study results on the potential for the reductions caused by delivery and opportunities for incremental progress. Improvements
EFV to lead to increased risk of pregnancy.79–81 should build on existing infrastructure, policies and service delivery
successes.
Based on evidence available at the time, in October 2014, the
HIV has been a game-changer for health care in South Africa. It
National Department of Health released a circular to the provinces
has forced discussion on equitable access to care and demanded
indicating that women taking EFV-based ART or certain epilepsy- and
innovation in the context of limited resources. The National
TB-related drugs (which work similarly to EFV in the body) should
Department of Health has responded to the HIV epidemic and
not be given the subdermal implant, and that women taking these
other health-related challenges with considered solutions, which
medications who had already received the implant should be given
will benefit the population as a whole. Today, the environment with
the option of having the implant removed and taking up another
regard to healthcare provision in South Africa is rapidly evolving. A
method. Regrettably, the circular did not indicate that the implant
plan for National Health Insurance (NHI) has recently been released
was safe to continue using if a woman chose to do so and that, in
and outlines a phased approach for bringing together the public
fact, the method would still offer protection from pregnancy albeit
and private sectors under a single-payer system.86 Ongoing pilots
with reduced efficacy.
for NHI have included public-private partnerships for delivery of
Since then, newly published work has underscored the idea that the contraception, to increase access by making affordable contraception
subdermal implant may still be a good option for some HIV-positive available in more geographic locations. The NHI initiative also
women taking EFV-based ART. Patel et al. conducted a retrospective, presents opportunities for the merging of quality control and data
longitudinal cohort analysis based on data from roughly 25 000 collection and management systems – potentially allowing a more
S A H R 20 1 6 1 03
complete picture of access and uptake in the country. Primary health Address the role of the healthcare provider and access to
care re-engineering is also under way and could further increase information
access to contraception through community-based distribution via ➢➢ Acknowledge the role of healthcare providers as “street-
Ward-based Primary Health Care Outreach Teams, School Health level bureaucrats”.91 Engage them from the point of policy
Services, and District Clinical Specialist Teams.87 development, ensuring buy-in before implementation.
Given this shifting landscape, goals for shifting and scale-up of ➢➢ Recognise the role of healthcare personnel in data collection,
contraceptive use in South Africa present unique challenges for the budgeting and planning for services.
road ahead. Fortunately there is renewed attention on contraceptive
➢➢ Prioritise training on contraceptive counselling. High-quality
services globally, and plenty of available evidence on effective and
counselling should include discussion of the availability of a
cost-effective strategies for intervention. Accountability at every
range of methods, the potential for side-effects including how
stage – from budgeting for methods to dispensing to women – is
they may lessen over time, how to use each method correctly,
critical. CYP and unmet need for family planning will be important
and the option to switch methods if necessary.
to assess over time; however, women who report ‘current use’ of
contraceptives will require as much support as women who may ➢➢ Develop and promote innovative approaches for information-
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not be currently using a method, and certain key groups, such as sharing on reproduction and contraception, such as websites,
unmarried women, young women and HIV-positive women, require social media, mobile phone applications, and interactive
special attention. All women will require counselling, education and learning platforms.
supportive interactions with the healthcare system throughout the ➢➢ Provide healthcare workers with clear guidance on effective
16 6
continuum of their reproductive lives – focusing on both conception messaging for complicated, technical issues and the tools
and contraception – in order for South Africa to reap the benefits of
20 IL
required to convey messages to diverse audiences.
improved contraceptive uptake.
➢➢ Recognise the severe scarcity of resources in the public sector.
Y T Strive to improve working conditions and improve throughput
Recommendations in the country’s clinical and nursing training institutions.
A N
The following are specific recommendations to meet the goals of the ➢➢ Given existing resources and possible limitations on improving
M U
CFP guidelines and address South Africa’s commitment to FP2020 all health facilities overnight, consider the creation of ‘centres
and achieving universal access to sexual and reproductive health, of excellence’ that could allow for focused development
measured here through contraceptive access and uptake: of expertise, establishment of best practice, and provision
4 ED
responsibility for implementation, and capacity-building to communities so that they address more than the availability of
enable policymakers and planners to develop, monitor and methods. Provide information on topics such as reproductive
R
accountability – possibly a conditional grant for sexual and ➢➢ Target key groups with ethical and appropriate information
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104 S A H R 20 1 6
Contraceptive services
Research Acknowledgments
➢➢ Engage the research community to determine the best ways to This work was made possible by the generous support of the
improve healthcare provider attitudes and counselling quality. American people through the United States Agency for International
➢➢ Develop and test messages for providers and communities Development (USAID). The contents are the responsibility of the
regarding complex technical information on contraception. authors and do not necessarily reflect the views of USAID or the
United States Government. This work was funded through the South
➢➢ Elicit women’s input on when, where and how to engage them
Africa Mission of the US Agency for International Development
with regard to contraceptive use.
(USAID) under the terms of Cooperative Agreement 674-A-12-
➢➢ Support continued exploration of the complex interactions 00029 to the Health Economics and Epidemiology Research Office
between HIV, ARVs and other medications, including hormonal (HE2RO), a Division of the Wits Health Consortium (Pty) Ltd.
contraceptives.
Monitoring progress
➢➢ In addition to unmet need, the CPR and CYP, consider other
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indicators to measure progress over time, including:
-- Percentage of facilities offering a mixture of short-acting
and long-acting modern contraceptive methods
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-- Percentage of facilities offering a permanent method of
family planning
20 IL
-- Number of health providers trained in long-acting and
permanent services
Y T
-- Percentage of facilities meeting minimum standards with
regard to essential supplies and equipment to support
A N
provision of long-acting and permanent services
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intercourse
-- Percentage of family planning clients who received HIV
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family planning.
S A H R 20 1 6 105
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45 Jain A, Bruce J, Kumar S. Quality of services programme V. “Life is still going on”: reproductive intentions among
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Clarendon Press; 1992. p. 202–21.
65 Barron P, Pillay Y, Doherty T, Sherman G, Jackson D,
46 Jain A, Bruce J, Mensch B. Setting standards of quality in Bhardwaj S, et al. Eliminating mother-to-child HIV transmission
family planning programs. Stud Fam Plann. 1992;23(6):392– in South Africa. Bull World Heal Organ. 2013;91:70–4.
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66 Jewkes R, Morrell R. Gender and sexuality: emerging
47 Mwaikambo L, Speizer IS, Schurmann A, Morgan G, Fikree perspectives from the heterosexual epidemic in South Africa
F. What works in family planning interventions: a systematic and implications for HIV risk and prevention. J Int AIDS Soc.
review. Stud Fam Plann. 2011 Jun;42(2):67–82. 2010;13(6):1–11.
48 Miller K, Miller R, Askew I, Horn MC, Ndhlovu L. Clinic- 67 Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic
Based Family Planning and Reproductive Health Services in violence: Findings from a South African cross-sectional study.
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Assistance Project; 1998. 68 South African Press Association (SAPA). Zuma: Send teenage
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49 Mensch B, Arends-Kuenning M, Jain A. The impact of the
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50 Koenig M, Hossain M, Whittaker M. The influence of quality [cited 16 March 2016].
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73 Teunissen AM, Grimm B, Roumen FJME. Continuation rates URL: https://www.phasa.org.za/the-implementation-of-phc-re-
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Acquir Immune Defic Syndr. 2014;66(4):378–85. indicator-summary
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108 S A H R 20 1 6
Breastfeeding in South Africa: are we
making progress?
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Authors:
Lisanne du Plessis i
Nazia Peer ii
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Simone Honikman iii
René English ii
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R 20 IL
ecent global evidence shows that breastfeeding benefits both mothers Creating an enabling
and babies in rich and poor nations. Furthermore, evidence suggests that
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concerted national efforts to scale up breastfeeding interventions, policies environment to practise
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and programmes can bring about rapid change, and that creating an enabling breastfeeding has huge
environment to practise breastfeeding has huge potential as an investment in the
potential as an investment in
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future health of mothers and the healthy life course of their children.
the future health of mothers
In South Africa, available national data suggest that most mothers initiate
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breastfeeding after birth. However, it has been observed that very few babies are and the healthy life course of
exclusively breastfed during the first six months of life. Many babies also receive their children.
complementary foods between two and three months of age, and in some cases, even
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within a few days of birth. This suboptimal early nutrition profile predisposes South
Africans to poor health outcomes in both their infant and young child years as well
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as in adulthood.
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This chapter interrogates whether we are making progress in our country to improve
breastfeeding practices. A review was done of breastfeeding progress globally, and
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child feeding (IYCF) over the past few years. The chapter determines what has been
done to promote breastfeeding, including which policy changes have imminently
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i Division of Human Nutrition, Facult y of Medicine and Health Sciences, Stellenbosch Universit y
ii Health Systems Trust
iii Perinatal Mental Health Project, Alan J Flisher Centre for Public Mental Health, Psychiatry and
Mental Mental Health Universit y of Cape Town
1 09
Introduction
It is now well established that breastfeeding holds substantial benefits Table 1: World Health Assembly Nutrition Targets 2025
for both mothers and babies in rich and poor nations. Estimates
World Health Assembly Baseline Baseline Target
indicate that improved global breastfeeding rates can prevent target year/s status for 2025
breast cancer deaths in 20 000 mothers and prevent mortality in 40% reduction in the number 2012 162 million ~100
823 000 infants annually.1 Promotion, protection and support of of children under five who are million
stunted
breastfeeding can therefore contribute substantially to achieving the
50% reduction of anaemia in 2011 29% 15%
Sustainable Development Goals (SDGs).2 women of reproductive age
(pregnant and non-pregnant)
Evidence suggests that concerted national efforts to scale up 30% reduction in low birth 2008–2011 15% 10%
breastfeeding interventions, policies and programmes can bring weight
about ‘rapid’ change, and that creating an enabling environment No increase in childhood 2012 7% 7%
overweight
to practise breastfeeding has huge potential as an investment in the
Increase the rate of exclusive 2008–2012 38% 50%
future health of mothers and the healthy life course of their children.1 breastfeeding in the first six
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months up to at least 50%
In South Africa, available national data show that most mothers
Reduce and maintain childhood 2012 8% <5%
initiate breastfeeding after birth.3,4 However, it has been observed wasting to less than 5%
that very few babies are exclusively breastfed during the first six
Source: World Health Organization, 2015.10
months of life.3–5 Many babies also receive complementary foods
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between two and three months of age, and in some cases, even
A review by Rollins et al. in the Lancet 2016 Breastfeeding Series
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within a few days of birth.5 This suboptimal early nutrition profile
drew on data from countries1 that report on the World Health
predisposes South Africans to poor health outcomes in both their
Organization (WHO) IYCF indicators. The review showed that
infant and young child years as well as in adulthood. Within this
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context, the chapter interrogates whether we are making progress in
our country to improve breastfeeding practices.
early initiation and EBF are compromised in all countries, regardless
of their economic status,1 and only 37% of infants are exclusively
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breastfed for the first six months in low- and middle-income countries
A review was done of breastfeeding progress globally, followed (LMICs).1 It has been noted that as a country’s national wealth
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by a review of South Africa’s commitment to breastfeeding as a increases, so breastfeeding practices decline and the breastfeeding
component of infant and young child feeding (IYCF) over the period shortens.1 Notably, in countries where rapid improvement
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past few years. We highlight what has been done to promote in EBF rates have been reported, such as in Bangladesh, Brazil,
breastfeeding in general (for both HIV-infected and non-infected Cuba and Togo, collaboration among the stakeholders and sectors
mothers), including which policy changes have imminently promoted in addressing the contributing factors correlated directly with the
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breastfeeding. We also reflect on the findings of evaluations done overall success of nutritional interventions.2
in South Africa that assess how we have progressed as a country,
According to the Lancet 2016 Breastfeeding Series, the
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are unpacked and detailed, together with a review of proven in sub-Saharan Africa, South Asia and parts of Latin America, with
interventions at different levels of society. Finally, the chapter makes EBF of infants younger than than six months estimated at 35.04% in
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practical recommendations to restore breastfeeding as the ‘new’ sub-Saharan Africa in 2012.12 Countries in East and southern Africa
norm for infant nutrition within all sectors of South African society. tend on average to have lower rates of continued breastfeeding but
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11 0 S A H R 20 1 6
Breastfeeding
widespread reality of mother-to-child transmission (MTCT) of HIV breastfeeding until their infants are one year of age.26 Furthermore,
led to the introduction of numerous policies that resulted in a swift, Regulation 991, which governs the Code of Marketing of Breast-
sweeping move away from breastfeeding and a dramatic shift milk Substitutes and other foodstuffs for infants and young children,
towards the use of breast-milk substitutes. was legislated in December 2012,27 with gradual implementation
of these Regulations over a three-year period, culminating in full
Thus interventions to prevent MTCT – implemented since 2001 in
implementation in 2015.
South Africa and updated in 2008, 2010,15 201316 and 201517,18
– have been accompanied by evidence-based transitions in IYCF The promotion, protection and support of breastfeeding has also
recommendations for HIV-positive women. Recommendations ranged been prioritised in a number of policy documents, including the
from avoiding breastfeeding and the provision of free commercial NDoH Roadmap for Nutrition in South Africa 2013–2017;28
infant formula,19 to avoiding breastfeeding if certain conditions the National Strategic Plan for Maternal, Newborn, Child and
were met (affordability, feasibility, acceptability, sustainability and Women’s Health and Nutrition 2012–2016;29 and the National
safety), to breastfeeding under antiretroviral therapy (ART) cover.18 Health Promotion Policy and Strategy 2015–2019.30 Nutrition
also featured in the National Development Plan (NDP), focusing on
In the very first set of recommendations, women were counselled to
the wellbeing of women and children and on interventions during
choose either EBF with early weaning at 4–6 months, or exclusive
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the first 1 000 days of life, with breastfeeding as key to attaining
formula feeding with free formula provided until six months. As
development outcomes in the country.31
a result, breastfeeding practices were compromised, not only for
babies born to HIV-infected mothers, but also for HIV-unexposed
Some lessons learned
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babies born to HIV-negative mothers, as a consequence of the
spill-over effects of mixed messaging, which caused HIV-negative The benefits of breastfeeding are increasingly emphasized
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mothers also to opt for alternatives to breastfeeding. Particular harm throughout the world in scientific literature. During pregnancy
to breastfeeding in South Africa stemmed from the following: most women express the desire to breastfeed. It has to be
Y T established what influences women to not breastfeed or to stop
➢➢ Healthcare provider confusion about infant feeding and the
breastfeeding in the early postpartum period. Factors affecting
risks of HIV transmission through breastfeeding
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breastfeeding are economic factors; advertising and commercial
➢➢ Poor support for infant-feeding counsellors printing; the example set by the higher socio-economic group;
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➢➢ Poor counselling skills changing values and status symbols; competing ideologies;
perceived milk insufficiency; cultural preference for fat babies;
➢➢ A disconnect between feeding recommendations and the
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work was done in South Africa by various researchers who focused The above quotation could have appeared in a 2016 publication
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specifically on breastfeeding in HIV-infected mothers.19–21,23 on breastfeeding in South Africa, but this summary was published in
1984 in an article titled “Breastfeeding in South Africa: Social and
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S A H R 20 1 6 111
principles inherent in the country’s health system.37 Inadequate health services, and the State authority or local government in charge
capacity was identified as a key factor contributing to the poor of policies.39 These different role-players can assist in creating an
implementation of such nutrition services. Insufficient capacity was enabling environment for successful breastfeeding. Accordingly,
found at various essential levels, such as information-management, we reviewed the existing literature to identify documented local
programme, strategic, technical and operational levels, and was determinants and interventions in an attempt to understand what
identified as having directly hindered progress in IYCN. Swart et hinders or facilitates South African breastfeeding practices. We also
al. recommended that capacity be developed among trained staff drew on the evidence from the Lancet Breastfeeding Series (2016)1
across a range of various specialities or roles, using both pre- and to supplement our findings.
in-service training. The report further recommended the prioritisation
The mother, family and community
of certain key nutritional interventions in order to facilitate greater
impact through a more focused and unified approach, rather than A woman’s breastfeeding behaviour is influenced by personal
diluting the pool of resources in an attempt to focus on too wide a attributes (age, weight, education level, confidence, baby’s gender,
range of interventions.37 baby’s wellbeing, and baby’s temperament).1 Breastfeeding
involves an intimate relationship between mother and baby, as the
In 2009, a landscape analysis was undertaken in South Africa to
two interact constantly. The mother internalises her influence on the
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identify primary problem areas in the progress towards effective
baby, notably whether the baby is satisfied and content with breast
implementation of nutritional intervention strategies.38 The findings
milk.1
were encouraging, suggesting that South Africa does in fact possess
the ability and resources to implement pivotal nutritional interventions A study by Sibeko et al.40 showed that women choose to breastfeed
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targeting maternal and child under-nutrition. However, challenges because they believe it is better for infant growth and health. Reasons
to operationalising these resources were found to lie in ineffective that women do not breastfeed exclusively include fears about milk
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policy and programme implementation. The report specifically insufficiency and reduced milk production, due to the perception that
identified policy and implementation inadequacies in terms of the infant is hungry41–43 or that the infant is not receiving optimal
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budget allocations, human resources, inter-sector collaboration, and
nutritional surveillance systems to monitor and evaluate interventions
nutrition. Bland et al. noted that the overarching concern of mothers
was the infant not being adequately fed and therefore remaining
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and influence decision-making. In terms of implementation, there unsatisfied when drinking breast milk only.42
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The findings of an independent report prepared for the Department months of life highlighted the influence of the community and elders,
of Performance Monitoring and Evaluation (DPME) in 2014, especially grandmothers, in this regard.a The reasons for women
“Evaluation of Nutrition Interventions for Children from Conception not breastfeeding were explored in another series of community
to Age 5 in South Africa”,36 supported the national reports and dialogues, also conducted in 2013, which aimed to identify barriers
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evaluations previously discussed. These findings indicate that there is to the uptake of antenatal care and prevention of mother-to-child
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still a poor rate of progress regarding nutritional outcomes, which has transmission (PMTCT) in three rural provinces in South Africa.b The
led to a lack of progress in improving child mortality and morbidity findings revealed a negative perception of breastfeeding among
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in the country. As a result, South Africa showed delayed progress younger women and girls. Lack of knowledge, desire for social
in achieving its Millennium Development Goals (MDGs) by 2015 acceptance, and pressure to maintain an ideal body shape, fuelled
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(specifically MDGs 4 and 5 relating to child mortality and maternal negative attitudes and perceptions in this age group. According to
health), and ultimately failed to achieve them. Although there are the participants, women lacked information and therefore did not
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policies, strategies and regulations within the relevant individual understand the benefits and importance of breastfeeding.b In the
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departmental portfolios regarding nutrition intervention (i.e. within North West Province, young female participants spoke about the
the Departments of Health; Social Development; Agriculture, possibility of breastfeeding damaging their bodies, making them
Forestry and Fisheries; and Rural Development and Land Reform), “too slim” and flattening their breasts. Some women wanted to
there is an indication of uneven commitment to nutrition across these breastfeed in order to lose weight. Others did not want to breastfeed
departments, evidenced in differing degrees of investment in the so that they would not lose weight. Evidence from a study by Shah et
allocation of budget, staff, planning, management and leadership.36 al.44 also highlights concerns about body shape. Women who had
The core finding of the DPME report also indicates that there is an not achieved their desired weight loss from breastfeeding chose not
overall lack of capacity, including systemic, organisational and to breastfeed.41 Across all age groups, women also claimed to have
individual capacity, to address the IYCN problems adequately in insufficient breast milk to breastfeed exclusively for six months.41,42
the country.
Traditional and cultural factors are strong determinants of
breastfeeding in South Africa. In the Northern Cape, traditional
Key determinants of breastfeeding in South medicines are believed to prepare the baby for dentition and to
protect against witchcraft. In Limpopo Province, a traditional dish
Africa called tshiunza, made from maize and roots, and fermented to form
Existing evidence suggests that numerous factors play a role in a soft sour porridge, is given immediately after birth and promoted
determining choices that women make regarding breastfeeding. by grandparents. This food is believed to provide babies with energy
Kent’s39 ‘nested rings of responsibility’ indicate these levels of
a Personal communication: Lenore Spies, Integrated Nutrition Programme,
influence, which include the mother, the family, the community, Department of Health, KwaZulu-Natal.
hospitals, work-places, employers, business, industry, the media, b Personal communication: Elise Levendal, Researcher, Health Systems Trust,
26 March 2016.
112 S A H R 20 1 6
Breastfeeding
to grow well and to assist them in passing stools since breast milk reluctant to breastfeed in public because of fear of being mocked
is believed to be insufficient for infants.45 In some cultural settings and shamed. Breastfeeding in public is not seen as ‘normal’; this has
in South Africa, mixed feeding, including complementary foods, resulted in incidents where women have been escorted out of shops
begins within one month of birth.41,42 for breastfeeding in public.61
Poor breastfeeding technique (poor latching/attachment and The community dialogues conducted in 2013 revealed that there
positioning) are known to predispose women to breast health was some confusion with regard to breastfeeding recommendations
problems, namely mastitis, sore or cracked nipples and breast for HIV-positive mothers.b Participants spoke about their difficulty
engorgement.41 These conditions interfere with the success and in determining the risks and rewards of practising breastfeeding if
duration of breastfeeding practice during the first six months, they were HIV-positive. In Mpumalanga Province, all participants,
especially among women with sub-clinical mastitis. The conditions including women of childbearing age, men and family members,
can also increase the risk of postnatal HIV transmission in HIV- reported that breastfeeding posed a dilemma for HIV-positive
infected women.46 One study showed that if women had sore mothers. They often adopted mixed feeding patterns, specifically
nipples they felt less confident in their ability to breastfeed, and were formula milk in private and breastfeeding in public, to avoid
therefore less likely to choose breastfeeding.41,47 embarrassment when people asked if they were not breastfeeding
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because they were HIV-positive.62 Furthermore, for women
Other factors related to the individual are also reported. Women
regardless of HIV status, the practice of expressing breast milk and
who had increased exposure to media messages41 were more likely
storing it for the baby to feed on when the mother was absent was
to stop breastfeeding, and women who had completed schooling
uncommon, as grandmothers, mothers and nannies were assigned
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were more likely not to breastfeed.40 Bland et al.41 reported on the
to look after the babies.b,40,45 These caregivers determined their
use of trained lay counsellors in their study, which was designed
own methods of formula feeding. Some of the participants also
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to improve breastfeeding practices in HIV-positive and -negative
reported mixed feeding and giving babies solid food earlier than
women living in a high HIV-prevalent area with previously low EBF
the recommended age.
rates. The study showed that women with better socio-economic
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status were more likely to stop breastfeeding at 16 weeks, and
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single women were also more likely to stop breastfeeding.48 Prior Health systems and services
breastfeeding experience has also been found to impact on current
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practices; women who did not have a positive experience with their
Human resources: numbers and capacity
first baby were less likely to breastfeed their second child.40 Studies show that pregnant women are given advice on infant-
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The mental health of the mother also plays a part in breastfeeding. feeding choices mostly by healthcare staff, which emphasises the
Stress and anxiety can contribute to depression.49,50 Perinatal important role that healthcare workers play in influencing mothers’
depression is associated with infant under-nutrition, which may be decisions.40–43 Fathers, mothers-in-law, aunts and other family
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mediated through several separate or concurrent mechanisms.51 members are also mentioned as providing IYCF advice.40–43 In a
Depressive symptoms, such as poor concentration, lethargy, sleep study by Davies that investigated how informed literate mothers were
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disturbance and low mood, can play a role in initiating and about their infant-feeding options, 80% of mothers made decisions
maintaining EBF for the first six months.51 A study in Pakistan based on information provided to them by healthcare workers.48
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demonstrated that depressed mothers were more likely to perceive A notable obstacle hindering breastfeeding progress is the lack of
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were more like to initiate early cessation of breastfeeding. These members were stationed at PMTCT sites, and only 53% had been
findings are particularly pertinent for South Africa, given the high
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S A H R 20 1 6 11 3
them. Ninety-eight per cent of these respondents agreed that mothers in South Africa; it also facilitates UNICEF-designed lactation-
had the right to make informed decisions, and 80% agreed that management training workshops and a peer-counselling programme
mothers were able to make such decisions. Between 49% and 82% for volunteers largely from disadvantaged communities to work as
of the healthcare workers knew the correct answers to knowledge breastfeeding counsellors.70 This organisation acts on step 10 of
questions relating to breastfeeding, and between 37% and 56% the BFHI, which has been described as one of the most difficult and
knew the correct answers to knowledge questions relating to formula neglected steps, namely: “to foster the establishment of breastfeeding
feeding. Not one healthcare worker participating in the study knew support groups and refer mothers to them on discharge from the
all the steps involved in preparing a formula feed. In the same study, hospital or clinic”.70
14% of the healthcare workers indicated that what was expected
of them was not achievable in their working environment.47 These
findings underscore the need for ongoing training and retraining
Workplace and employment
of healthcare workers,43 including specific HIV and breastfeeding Low-cost interventions in the workplace, including lactation rooms
training and supervision.65 and nursing breaks, have been shown to reduce absenteeism and
improve work performance, commitment and retention among
Tuthill et al. offer qualitative evidence of health workers claiming
female staff, and paid maternity leave can increase EBF practice
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that the transition from the prior policy of warning HIV-infected
substantially.1
mothers against breastfeeding and the subsequent promotion of
breastfeeding with ART coverage was difficult because of the Specific legislation in South Africa’s Constitution,71 Labour Relations
conflicting messages. They felt that as a result of these changes, Act,72 Employment Equity Act,73 and Basic Conditions of Employment
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patients no longer trusted the health workers’ guidance.62 Act74 protect women from discrimination related to pregnancy and
hazardous working circumstances, and regulate maternity leave.
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Insufficient and poor counselling by health professionals and lack
Women in South Africa are entitled to maternity leave of up to four
of health worker knowledge regarding the impact of HIV were also
months, but with the exception of government service and some
contributory factors for early cessation of breastfeeding.65 One study
Y T large companies this is mostly unpaid leave, making babies of
reported poor health worker knowledge and gaps in knowledge,
women working in other sectors vulnerable to suboptimal feeding
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which were evident because health workers recommended that
and care practices.
mothers feed their babies with water, formula and solids rather than
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encouraging the women to practise EBF.44 The Tshwane Declaration specifically resolved that legislation be
reviewed to protect and extend maternity leave for all workers,
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Baby-Friendly Hospital Initiative and to include an enabling workplace. This resolution is yet to be
The Baby-Friendly Hospital Initiative (BFHI) was launched by the addressed, leaving a void in the protection of economically active
World Health Organization and the United Nations Children’s Fund mothers and their babies.
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also to shift the focus from the sole context of the hospital setting.68
put in place. The Code of Marketing of Breast-milk Substitutes and
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11 4 S A H R 20 1 6
Breastfeeding
There is also considerable potential benefit in promoting and Antenatal and postnatal combined counselling was more effective
supporting breastfeeding through social media. Examples are the than targeted counselling during one period only. Community-
La Leche League Facebook page where mothers can pose questions based interventions consisting of counselling or education and
and be supported, and MomConnect.75 social mobilisation, with or without mass media, increased timely
breastfeeding initiation by 86% (95% CI:33–159) and EBF by 20%
(95% CI:3–39).1,59,76
The State authority or local government in
In the workplace setting, the minimal data available suggest that
charge of policies
maternity leave policies are effective in increasing EBF by 52%
Evidence from South African studies show that it is very difficult (RR=1.52; 95% CI:1.03–2.23). A global study did a multivariate
for mothers to sustain EFB because of various factors, alone or analysis on the relationship between national policies and EBF
combined, that may obstruct this practice. rates.77 In multivariate models, national policies guaranteeing paid
Less than 0.3% of the national health budget is allocated to nutrition, breastfeeding breaks until the child was at least six months old were
including breastfeeding interventions. Priority nutrition interventions associated with significantly higher rates of EBF. This guarantee
are not necessarily receiving an appropriate proportion of the generated an increase of 8.9% in the rate of EBF of infants younger
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nutrition budget; this has prompted a call to evaluate the proportion than six months (P<0.05) in the full model. Also, lactation rooms and
of funds actually spent on high-priority interventions of this kind in breaks to express breast milk increased breastfeeding until the child
terms of returns on the nutrition-funding investment.28 was six months old by 25% (95% CI:9–43).1,59,76
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What is clear from this and other related systematic reviews76,78 is
that multiple interventions are more effective than single interventions,
Interventions targeting breastfeeding
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and that two or more actions (a mixture of interventions) were most
In this section we interrogate evidence on interventions to improve effective in improving any breastfeeding and EBF rates.
breastfeeding and reflect on the extent to which interventions with
Y T A literature review79 was done on public health interventions in
a strong evidence base are prioritised within local strategies,
LMICs that improve maternal, neonatal and child morbidity and
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guidelines and policies. The section is structured to present findings
mortality outcomes within the first 1 000 days of life in order to
from studies that compiled evidence from systematic reviews drawn
identify a range of interventions. The objectives were to assess the
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Findings were presented according to the following categories: policies and guidelines, and if so, to determine the degree to
health systems and services; family and community; and workplace which these interventions were incorporated into local documents
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and employment. In the health systems setting, several interventions and promoted in practice. A systematic five-phased process was
were included in the Baby-Friendly Hospital Initiative (BFHI), namely followed, including an exhaustive search strategy covering a wide
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individual counselling or group education, immediate breastfeeding range of databases, the application of rigorous quality-assessment
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support at delivery, and lactation management affecting criteria, and assessment of applicability in South Africa through
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breastfeeding rates. These interventions increased EBF by 49% studying key local strategies, policies and guidelines. With
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(relative risk (RR)=1.49; 95% confidence interval (CI):1.33–1.68), regard to breastfeeding, the relevant LMIC interventions were: (1)
and any breastfeeding by 66% (RR=1.66; 95% CI:1.3–2.07). antenatal breastfeeding education; (2) breastfeeding support; (3)
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Counselling and education increased EBF by 66% (RR=1.66; 95% breastfeeding promotion; and (4) Kangaroo Mother Care (KMC).
CI:1.43–1.92), and any breastfeeding by 47% (RR=1.47, 95% These are detailed in the following section.
CI:1.29–1.68).1,59,76
While interrogating existing strategies, policies and guidelines, it
In the family and community setting, the Lancet series presents a became clear that despite widespread commitment to promoting
meta-analysis of interventions providing both antenatal and postnatal appropriate breastfeeding practices, South Africa has failed to
support to mothers, fathers and other family members at home; these incorporate specific evidence-based interventions in our strategies.
included community health workers and peer-to-peer counsellors. The No document exists that lists the various options ‘in one place’,
latter refers to counselling by a nurse, trained lactation counsellor, or presents the ‘how’ of implementation, or provides options that
other health provider. This support was extended to post-discharge enable multiple approaches to be adopted by nurses. Such failures
telephone calls combined with home visits. Fathers were specifically could exacerbate the incapacity of staff in terms of breastfeeding
targeted individually and also in group counselling sessions. The promotion and support at the coalface. Furthermore, understanding
results showed that home and family-based interventions were of local determinants, such as cultural and traditional practices, is
effective in improving EBF (RR=1.48; 95% CI:1.32–1.66), continued not explicitly incorporated into these guidelines.
breastfeeding (RR=1.26; 95% CI:1.05–1.50), any breastfeeding
(RR=1.16; 95% CI:1.07–1.25), and improved early initiation of
breastfeeding (RR=1.74; 95% CI:0.97–3.12).1,59,76
S A H R 20 1 6 11 5
Evidence from a review of breastfeeding of hospital stay. At follow-up, they found that KMC was associated
with a decreased risk of mortality and severe infection/sepsis.
interventions in low- and middle-income
Lastly, KMC was found to increase some measures of infant growth,
countries breastfeeding, and mother–infant attachment.
Antenatal breastfeeding education In 2012, Moore et al.83 did a systematic review of 34 RCTs and
showed that early skin-to-skin contact in KMC produced a significant
In 2011, Lumbiganon et al.80 did a systematic review to explore
(27%) increase in breastfeeding at 1–4 months of age (RR=1.27;
the effectiveness of antenatal breastfeeding education in increasing
95% CI:1.06–1.53), and increased duration of breastfeeding
breastfeeding initiation and duration. One study in the review
(mean difference (MD) 42.55 days; 95% CI:−1.69–86.79), which
compared peer counselling with routine care (that was not defined)
had borderline significance.
and showed a significant increase in the initiation of breastfeeding
in the intervention group (RR=1.82; 95% CI:1.13–2.93). Evaluation of the nutrition interventions cited in this chapter showed
that KwaZulu-Natal and the Western Cape were the leading
Another study compared a breastfeeding booklet–plus–video–plus–
provinces in terms of improved breastfeeding rates and nutritional
lactation consultation versus a breastfeeding booklet–plus–video.
outcomes in South Africa.36 Central success factors were the
PM
The results at six months showed a significant increase in EBF in the
interventions being province-led, and intentional key stakeholder
group receiving a booklet–plus–video–plus–lactation consultation
engagement. The success factors are presented in Table 2.
compared with the other group (RR=2.23; 95% CI:1.01–4.92).
This study also measured a programme involving multiple methods
16 6
Table 2: Progress in improved breastfeeding rates and nutritional
versus no formal education, namely a breastfeeding booklet–plus– outcomes in South Africa – central success factors for
video–plus–lactation consultation versus no formal breastfeeding KwaZulu-Natal and Western Cape Provinces
20 IL
education. The results showed a significant increase in EBF at three
KwaZulu-Natal process – initiative for breastfeeding
months in the group that received a breastfeeding booklet–plus– support36,84
effectiveness of support for breastfeeding mothers. The target group has a more balanced budget allocation for nutrition in proportion to the
province’s prevalence of child stunting.
consisted of pregnant women who intended to breastfeed. The results
Nutrition indicators
showed that all forms of extra support analysed together gave an
A monitoring and evaluation (M&E) reporting system has been
O
increase in duration of ‘any breastfeeding’ (RR=0.91 for cessation of established in all departments, resulting in more nutrition indicators
any breastfeeding before six months; 95% CI:0.86–0.96). All forms being reported on than in other provinces. Two indicators were added
to the District Health Information System (DHIS) in April 2011: early
G
of extra support had a greater effect on the duration of EBF than breastfeeding initiation (one hour of birth) and EBF at 14 weeks.
on any other form of breastfeeding (RR=0.81; 95% CI:0.74–0.89). Nutrition advisors
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Joint lay and professional support extended the duration of any form The University of KwaZulu-Natal (UKZN) is currently training former
of breastfeeding significantly (RR=0.65 for cessation before 4–6 community caregivers (CCGs) in nutrition and skills to provide nutrition
BA
WHO/UNICEF training (RR=0.69; 95% CI:0.52–0.91). District management advocacy has been facilitated for policy support
EM
A 2013 systematic review by Haroon et al.78 reported on A breastfeeding culture has been created through the communication
strategy, including radio and print messaging and participation in the
breastfeeding promotion interventions and breastfeeding practices annual World Breastfeeding Week.
by comparing breastfeeding education or support with routine care. Capacity-building for breastfeeding has been instituted at all levels
The effect of interventions was observed for exclusive, predominant, within the health care system, including community caregivers and
employment of nutrition advisors at all PHC facilities.
partial and no breastfeeding rates. Statistically significant increases
Results:
in EBF rates as a result of breastfeeding promotion interventions
In 2012, the EBF rate was 34.3% at 14 weeks.
were observed: 43% at day 1, 30% at <1 month, and 90% at 1–5 Early initiation of breastfeeding increased from 26% in 2011/12 to
months. Rates of no breastfeeding reduced by 32% at day 1, by 81.60% in 2014/15.
30% at <1 month, and by 18% at 1–5 months. The rate of ‘Infant exclusively breastfed at Hep B 3rd dose’ increased
from 34% to 49.8%.86
Ongoing strategies to improve IYCF include:
Kangaroo Mother Care
• Extension of the Mother-Baby-Friendly Initiative to community health
The 2012 systematic review by Conde-Agudelo et al.82 covered centres (CHCs) and PHC centres
11 6 S A H R 20 1 6
Breastfeeding
Western Cape process85 – breastfeeding support, promotion assigned to recruit pregnant women at their sites to participate in
and programmes the study. Prevalence of EBF at 12 weeks in the intervention cluster
The Mother-Baby-Friendly Initiative (MBFI) has been implemented in was about twice that in the control cluster, whether based on a 24-
94% of the public birthing units in the Western Cape Province.
hour (PR=1.72; 95% CI:1.12–2.63) or seven-day (PR=1.98; 95%
Implementation of the MBFI requires that practices in the birthing
unit be reviewed to remove obstacles hindering the establishment CI:1.30–3.02) recall of feeding practices. The prevalence of EBF
of breastfeeding. This includes setting standards (the national was lower at 24 weeks of age than at 12 weeks, but the differences
standardised training package for clinical staff), educating mothers
(provincial infant-feeding education package), and standardising
(prevalence ratios) were higher for 24-hour (PR=5.70; 95%
practices (comprehensive infant-feeding policy available in all CI:1.33–24.26) and seven-day (PR=9.83; 95% CI:1.40–69.14)
accredited units).
recall of feeding practices.
The Western Cape Provincial DoH has created sentinel sites for the
breast-milk banks and drafted guidelines for the management of
expressed breast milk (to be submitted this year for approval). Lay counsellors trained to conduct home visits 41
Implementation of guidelines and policies:
Lay counsellors visited women to support EBF four times antenatally,
• Mother-Baby-Friendly Initiative implementation in public health
birthing facilities four times in the first two weeks postpartum, and then fortnightly
• Infant feeding counselling guidelines to guide counsellors (or up to six months. Daily feeding practices were recorded at weekly
PM
healthcare workers) in supporting mothers to make informed infant- intervals by separate field workers. Counsellors were trained on
feeding choices
the WHO/UNICEF HIV and Infant Feeding Counselling Course
• Infant formula on prescription according to set criteria. This has
worked to reduce the use of infant formula through strengthening the and supervised for quality control. Using 24-hour recall, EBF rates
criteria and supporting informed decision-making. at three and five months were 83.1% and 76.5% respectively in
16 6
Breastfeeding Peer-Counselling Programme (BPCP) HIV-negative women and 72.5 and 66.7% respectively in HIV-
• Non-profit organisations are funded by sub-districts to place
positive women. Counselling visits were strongly associated with
20 IL
breastfeeding peer counsellors (BFPCs) at midwife obstetric units
and basic antenatal care sites in the Metropole district. BFPCs are adherence to cumulative EBF at four months. Women who had
capacitated to deliver peer-to-peer counselling and are trained in a received the scheduled number of visits were more than twice as
20-hour or updated national breastfeeding course.
Y T likely to maintain EBF than those who had not (HIV-negative women:
• The BFPCs are tasked with educating pregnant women on the infant-
feeding education package, supporting mothers without companions odds ratio (OR)=2.07; 95% CI:1.56–2.74), HIV-infected women:
A N
(when they can) and supporting (and educating) postnatal women on adjusted OR: 2.86; 95%; CI:2.13–3.83).
breastfeeding and its management.
M U
Media messages: (IMCI), lactation counselling, and newborn care guidelines. Women
• The Western Cape has standardised key messages through in the intervention arm were scheduled to receive seven home-based
R
provincial documents, initiatives and policies. The First 1 000 Days visits: two during pregnancy and one within 48 hours of delivery,
campaign will incorporate a communication strategy.
during days 3–4 and 10–14, and during weeks 3–4 and 7–8. The
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Lactation consultants:
N
The Western Cape Department of Health’s breastfeeding policy has 95% CI:1.59–2.33). The intervention appeared to have a slightly
EM
been published and advocates for maternity legislation for women. more significant effect among HIV-negative mothers (RR=2.16; 95%
The policy is in the process of being implemented. Health facilities are
voluntarily establishing ‘comfort rooms’ for staff members that can be CI:1.71–2.73).
utilised as a space to express breast milk.85
Key recommendations
Notable local studies
The evidence presented in this chapter indicates that successful
The following community-level projects providing various forms of protection, promotion and support of breastfeeding requires a
breastfeeding support have yielded promising results. multi-layered, multipronged approach across the various levels
of government and society.1,2,12 In order to create an enabling
PROMISE-EBF86 – Individual home-based exclusive environment for breastfeeding in South Africa, the different strata in
breastfeeding peer counselling society that influence breastfeeding practices should be considered
Peer counsellors provided breastfeeding support in intervention within the definition of an enabling environment for nutrition
clusters. They provided one antenatal breastfeeding peer-counselling interventions. Three linked elements of an enabling environment,
visit and four post-delivery visits. The intervention involved mothers namely knowledge and evidence; politics and governance; and
receiving infant-feeding peer counselling, while in the control group, capacity and resources,88 should be the main focus at all levels
peer counsellors assisted mothers with obtaining social grants. The of impact1 and should be addressed in South Africa as a matter
focus of the intervention was to provide community-level support. of urgency. This approach was also proposed in the Lancet Series
Women from the respective communities were selected and trained on Breastfeeding,1 and our recommendations are modelled to align
to provide counselling, and were supervised. Peer counsellors were with the action points in the Series.
S A H R 20 1 6 117
Knowledge and evidence should be addressed through policy, legislation and systems of
accountability in order to support breastfeeding in the workplace
Dissemination of evidence and to create an enabling environment for breastfeeding in general
Evidence on breastfeeding and its significant impact on national (as workplace policies will not impact mothers who are informally
health and development should be vigorously disseminated. There and self-employed). Furthermore, all maternity health services must
is often a lack of understanding among programme managers, be compliant with Regulation 27 and the MBFI.
policy-makers, scientists, healthcare workers and communities about
the significance of good national breastfeeding practices in the Regulation of the breast-milk substitute industry
achievement of the SDGs, as well as the benefits for both women Breast-milk substitutes are a multi-billion dollar industry, and without
and children. Therefore, broad promulgation of such evidence is stringent enforcement, the legislated regulations will continue to be
necessary for the successful promotion, protection and support of violated. Even ‘subtle’ marketing of breast-milk substitutes directly
breastfeeding. subverts the promotion of breastfeeding as the best possible IYCF
practice. State commitment in enforcing regulations is a significant
Promotion of a culture of breastfeeding way in which the government can fulfil its obligations to the
PM
A positive attitude towards breastfeeding in society should be International Convention on the Rights of the Child, particularly in
engendered, with specific focus on addressing local beliefs and terms of ensuring “the survival and development of the child”.
practices that are contrary to the promotion of good practices. The Although breastfeeding is not expressly mentioned in the SDGs,
move to promote breastfeeding as a high-value practice should be
16 6
the improvement of breastfeeding interventions will contribute
achievable in today’s milieu of mass social marketing and innovative extensively to the achievement of the health, food security, education,
communication formats. Also, existing resources should be used and
20 IL
equity, development and environmental SDG targets.91 However,
shared, for example the well-packaged information in the documents robust commitment and investment on a multi-sector scale, including
developed for the launch of the Lancet Series on Breastfeeding.89 all relevant nutrition stakeholders, must be established.
Y T
A N
Politics and governance Capacity and resources
M U
need to understand and appreciate the role that breastfeeding plays level are crucial in considering what is needed to scale up efforts
in reducing mortality and saving money on a national scale. National for breastfeeding. Adequate numbers of trained breastfeeding
commodity-based interventions such as the promotion and use of supporters (all healthcare staff, community health workers and
O
drugs and vaccines tend to secure official support because they are volunteers) should be strategically placed and supervised in health
comparatively easy to monitor and evaluate, and they dovetail with facilities and communities for highest impact. The success stories from
G
the interests of the commercial sector, whereas the promotion of at least two provinces in South Africa, reported earlier, should be
breastfeeding does not. However, breastfeeding has considerable used as examples to build on. Existing policies and guidelines should
R
positive impact in economic terms, including increased intelligence be reviewed to determine the extent to which the recommendations:
and thriving in children, which contributes to the country’s gross
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11 8 S A H R 20 1 6
Breastfeeding
Conclusion
A review of the literature on breastfeeding in South Africa over the Some progress has been made, albeit slow and fraught with
past few decades suggests that EBF practices have stagnated at challenges. However, much still needs to be done to improve
around 8% for age six months. Since 2011, a display of high-level exclusive and continued breastfeeding rates in the country. Three
political commitment to promote, protect and support breastfeeding linked elements of an enabling environment, namely knowledge and
has resulted in important policy changes, including in the context evidence; politics and governance; and capacity and resources,88
of HIV, as well as legislation of the Code of Marketing of Breast- should be the main focus at all levels of impact across society1 and
milk Substitutes in the form of Regulation 991. A number of policy should be addressed in South Africa as a matter of urgency. Despite
documents have highlighted breastfeeding as a key child-survival the fact that almost two decades of democracy have passed, the
strategy and also as an intervention that can substantially impact battle to attain good nutrition and breastfeeding outcomes continues.
future health. There are now indications that over the past four years
these commitments have had a positive effect on early (4–8 weeks)
EBF rates in the country.
PM
Multiple layers in society can impact IYCF and more specifically
breastfeeding; these include the mother, the family, the community,
hospitals, work-places, employers, business, industry, the media,
health services, and the State authority or local government in
16 6
charge of policies. Determinants of breastfeeding across these
layers, and interventions internationally, in LMICs and locally that
20 IL
have been proven to work, were reviewed in order to establish
which interventions with a strong evidence base are prioritised
Y T
within local strategies, guidelines and policies and in different
settings (i.e. the health systems and services, family and community,
A N
and workplace and employment). It is important to note that multiple
interventions are more effective than single interventions, with a
M U
S A H R 20 1 6 11 9
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MomConnect: an exemplar implementation
of the Health Normative Standards Framework
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in South Africa
Authors:
Christopher Seebregts i,ii Peter Barron iii
Gaurang Tanna iv Peter Benjamin v
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Thomas Fogwill vi
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n August 2014, the National Department of Health implemented MomConnect MomConnect has drawn
as a national digital maternal health program that implements the South African
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mobile health (mHealth) strategy and the National Health Normative Standards global attention due to its
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Framework for Interoperability in electronic health (eHealth). As the first digital health innovative features and
program communicating with people at scale, MomConnect enrolled more than
its avoidance of many of
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half a million women from all regions of the country in the first year of operation,
representing approximately half the number of pregnancies in the public health sector. the common pitfalls when
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MomConnect uses a mobile phone application to support a pregnancy registration implementing digital
system in antenatal care facilities, allowing pregnant women to receive stage-based health projects at scale in
messages to help them improve their health and that of their babies. Women can
low-resource settings.
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Used throughout the health system at facility level, MomConnect has generated a
national register of pregnant individuals and set up a national feedback system to
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MomConnect has drawn global attention due to its innovative features and its
avoidance of many of the common pitfalls when implementing digital health projects
at scale in low-resource settings. This chapter focuses on the design and development
of the technical infrastructure supporting MomConnect.
125
Introduction
Reduction in maternal and child mortality is a global health priority ➢➢ subscription to stage-appropriate SMS messaging from the
that featured prominently in the Millennium Development Goals as date of registration, through delivery, until the baby’s first
Goals 4 and 5, with targets given to each country.1 Like many other birthday;
middle- and low-income countries, South Africa is implementing
➢➢ a virtual help-desk allowing pregnant women to ask additional
various programmes to improve maternal health.2–4 In 2014, the
questions, and submit compliments and complaints; and
Minister of Health, Dr Aaron Motsoaledi, launched an initiative
to use mobile phone technology as part of a suite of interventions ➢➢ a service to allow mothers to rate the quality of care received
(e.g. increased access to contraception, improved coverage of at the facility.
breastfeeding) to address the relatively high maternal mortality ratio Despite the existence of a number of mobile health applications
(MMR), child mortality rate and perinatal mortality rate (PNMR) in including websites, mobi-sites, social networks and smartphone
South Africa.5,6 The Medical Research Council estimated the MMR applications, these services were for the most part small in scale,
in South Africa to be 155 deaths per 100 000 live births in 2013,7 clustered mainly in urban areas, and required the use of smart
down from 281 deaths per 100 000 live births in 2008. South phones and internet access. This limited the usefulness of the
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Africa is targeting 100 deaths (or less) per 100 000 live births by technology in rural areas and in poorer communities, which were
2020.8 among the target populations identified by the NDoH in addressing
Mobile health (mHealth) is recognised as having significant potential maternal and child health.
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to address health issues in developing countries, notably maternal
Policy framework
and child health.9–13
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In 2014, the NDoH published the HNSF,14 which augments previous
This chapter describes the development of the technical infrastructure
South African government policies dealing with interoperability,
for the MomConnect system, and the alignment of its information-
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management component with the Health Normative Standards
Framework for Interoperability in electronic health (eHealth) in South
enterprise architecture and standards.19,20 The framework was
designed to address some of the issues and initiatives identified
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in the National eHealth Strategy17,21 and sub-outcome 10 of the
Africa (HNSF).14 The emphasis in this chapter is on describing the
Medium-term Strategic Framework 2014–2019 (under Outcome
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implementation of the HNSF that is relevant for digital health solution A mobile maternal health (mMH) task team comprising representatives
developers in South Africa and in other countries in low-resource
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In developing this chapter we have been guided by the recently was convened under the auspices of the NDoH. This task team
subsequently developed a concept proposal for using mobile
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a http://www.southafrica.info/services/health/momconnect.htm#.VsR-aBji7EE
126 S A H R 20 1 6
MomConnect
System components
for maximum access, Unstructured Supplementary Service Datab Edge devices
(USSD) and Short Message Service (SMS) systems were chosen as In the case of MomConnect, mobile phone handsets are used as
the protocols because they do not require sophisticated phones to be the edge devices. A constraint on the system is that it had to be
operational, and every cell-phone in South Africa has the capacity compatible with the majority of handsets, namely basic, low-end
to support these two services. handsets with support for only voice, USSD and SMS services. The
initial registration process in public health ANC facilities uses either
Data elements the client’s handset or a handset provided by the clinic.
Table 1 provides a list of the data collected as part of the MomConnect
Consumer application
registration process at facilities as well as through self-subscriptions
and CHW enrolments. These data elements are collected for each For the purpose of the initial project, a single mobile health
transaction; each mother can conduct multiple transactions of each application was selected to serve as the consumer application.
type and the system can capture a subset of these 16 elements per The application is an open-source, custom-made mobile messaging
transaction. Some transactions can be activated only once within a platform, programmed to interact with individual mobile phone
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specified period (to avoid duplicate entries for the same transaction), handsets using USSD and to send messages via SMS. The USSD
while others can be activated a number of times. application supports the collection of data from handsets using data-
collection screens as well as the messages sent back to the handsets
These core data elements were later supplemented with additional
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by SMS. The same toll-free USSD short-codes are made available
data elements relating to service ratings, a help-desk, and a system
on all four mobile networks in South Africa.27 SMS messages to the
for feedback on services received (compliments and complaints). A
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central system for opt-outs and help-desk questions are reverse-billed
separate but complementary program, NurseConnect, collects data
to the NDoH-funded MomConnect project. The cost was subsidised
elements from nurses in order to provide them with support and
Y T by all four mobile network operators in South Africa (Cell C, MTN,
clinical updates, and to facilitate interaction with managers.
Telkom Mobile and Vodacom). A separate system was integrated
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with the consumer application to provide help-desk functionality.
System architecture
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connects consumer applications and edge devicesc (through an It was programmed to validate and orchestrate messages received
interoperability layer) to demographic registries and clinical in a standard format, as specified by the HNSF,14 also making it a
repositories complemented with security and audit services.14 reference implementation of the interoperability layer component as
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Description Function
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1 Mobile health application ID Unique identifier specifying the application provider. In the current version of
MomConnect, there is only one Application ID.
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2 Software type ID Unique identifier specifying the application software type. In the current version of
MomConnect, there are two types: (SMS) and (USSD).
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3 Device telephone number Unique number of the SIM card interacting with the server by USSD or SMS
4 Client telephone number Unique mobile phone number of the client to which SMS messages will be sent
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5 Client identifier Unique client identifier – this is the South African National ID Number, if available;
alternatively the client mobile phone number is used.
6 Message type Unique code specifying the source of the data, viz. a public subscription, identification
by a community health worker, a clinic registration, an opt-out message, a message of
baby loss, service-rating data, help-desk data
7 Language Unique two-digit code indicating the preferred language for message correspondence in
one of the 11 official languages in South Africa
8 Event date Date of the event
9 Facility code Unique six-digit facility code
10 Date of birth Date of birth of the client (optional)
11 Opt-out reason code Unique code specifying the reason for opting out of the MomConnect service:
Miscarriage, Stillborn, Baby Loss, Not useful, Other, Unknown
12 Estimated due date The date of estimated delivery of the baby, validated by a nurse
13 Question-answer pairs Data containing the service rating and help-desk questions and answers
14 Reply date Date of the reply to the help-desk message
15 Class of help desk interaction Compliment, complaint or question
16 Help desk operator ID Unique code assigned to operators of the help-desk service
S A H R 20 1 6 127
Demographic Registry and Clinical Repository Standards and profiles
The Demographic Registry and Clinical Repository used by Mom- As specified in the HNSF, the connection between layers in the
Connect is a module of the open-source District Health Information health information exchange should be implemented using one or
System (DHIS) – the official routine information system used to more interoperability standards. The main interaction considered
monitor the performance of various health programmes in the for standardisation was that occurring between the consumer
national health systems. It serves three main functions: application and the HIE.
➢➢ The tracker module stores individual records in the form of a The MomConnect implementation team initially chose the Clinical
national pregnancy registry and acts as a patient registry and Document Architectured (CDA) as the content standard. The Mobile
shared health record (SHR). Access to Health Documente (MHD) profile was implemented from
➢➢ The data warehousing capability facilitates aggregation the consumer application to the HIE for further processing. At the
and therefore reports core indicators aggregated from the same time, non-clinical data were captured in JavaScript Object
individual records. Notationf (a text-based data exchange format) (JSON). Due to the
limited clinical content captured in MomConnect and in the interests
➢➢ The module stores an organisation unit hierarchy and thereby
of simplification, the JSON document became the primary source
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maintains the list of unique facility codes, acting as a master
for transaction data populating the pregnancy registry. In future,
facility list and registry in the HNSF implementation.
the team plans to replace the JSON document with a document
In the early stages of the project, additional components, such as formatted using Fast Healthcare Interoperability Resourcesg (FHIR), a
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a dedicated client registry with master patient index (MPI) and a relatively new lightweight Health Level Seven (HL7) standard. FIHR
shared health record (SHR) were tested and although these were is not mentioned explicitly in the HNSF as it did not exist at the time
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technically successful, they were removed because a significant of writing the HNSF, but it is an emerging standard that is expected
portion of records did not have personal identifier data (see Table 2) to be incorporated in future.
and maintaining a separate system that was not serving a practical
Y T The selection, customisation and implementation of standards
function introduced additional and unnecessary overheads. In
prescribed by the HNSF is complex but achievable by a team with
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addition, the client registry system’s patient-matching algorithms
knowledge of interoperability and international standards. In future,
were not utilised, as the dataset captured would have been too
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Other identification 16 748 3% ➢➢ During the USSD session, if a facility code is entered it is
validated against the central Facility Registry.
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One of the important requirements for MomConnect was to adhere The number of MomConnect registrations and subscriptions has
to the principles and architecture elaborated in the HNSF. The grown steadily over the 17-month period of the MomConnect
technical implementation team was able to meet this requirement project, as shown in Figure 2.
using existing software tools combined with the standards and
profiles listed in the HNSF specification.
d http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7
The initial infrastructure was developed and deployed within the e http://wiki.ihe.net/index.php/Mobile_access_to_Health_
first few months and then evolved iteratively over the course of the Documents_%28MHD%29
f JavaScript Object Notation is a lightweight data-interchange format that is
project. Changes to the infrastructure were implemented without any
easy for humans to read and write.
breaks in service. g https://www.hl7.org/fhir/overview.html
128 S A H R 20 1 6
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USSD/SMS
SMS
Facility check
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Registration message
Message validation
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Accepted
Validate client
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Add event to tracker
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Aggregate reporting
613 791
550 000
500 000
450 000
400 000
Number of Individuals
350 000
300 000
250 000
200 000
150 000
100 000
50 000
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06-09-2014 03-11-2014 31-12-2014 27-02-2015 26-04-2015 22-06-2015 19-08-2015 16-10-2015 13-12-2015 09-02-2016
Time
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As a successful national mobile health application, MomConnect Technological systems
is one of only a few known standards-based implementations in
➢➢ Usability: The MomConnect technology platform was designed
Africa and serves as positive proof that South Africa can succeed in
to maximise usability at several levels. At an end-user level,
implementing the HNSF and make health applications interoperable.
phones made use of simple USSD functionality that is familiar
to end-users and ubiquitously available across cell-phone
Discussion types throughout the country. The backend infrastructure was
optimised to use the fewest possible components and simplest
In view of the operational success of the MomConnect technical possible standards, and user-friendly administration tools were
implementation, and ongoing challenges faced when attempting developed to assist with long-term maintenance.
to mainstream digital health technical solutions, it is useful to align
some of the key features of the technical architecture with factors that ➢➢ Interoperability: MomConnect’s technical infrastructure
have been found by others to be important to success. In this section, makes use of the architecture provided by the HNSF, which
we consider the MomConnect infrastructure in the context of two implements interoperability standards and profiles across
digital health systems frameworks. The recently published guidelines different applications that may also be extended to support
for reporting health interventions18 were also useful for guiding both additional health services.
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the content of this chapter and the recommendations for future work. ➢➢ Privacy and security: The MomConnect technical infrastructure
makes use of industry-standard methods for ensuring privacy
The MomConnect program and its technical features are reviewed
and implementing security.
from four health system dimensions as recommended by Leon et
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al.28 Financial systems
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Government stewardship ➢➢ Sustainable funding: The MomConnect technical infrastructure
uses entirely open-source systems and software that minimises
➢➢ Strategic leadership: This is arguably the single most important
Y T licensing and support costs and is consistent with South African
criterion for success, and the MomConnect infrastructure scores
government policy.29 As such, it is relatively more sustainable
highly in this dimension in that it was launched and supported
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and less reliant on ongoing funding than other commercial
by the Minister of Health and led by senior officials in the
systems. The system is being improved continuously and the
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➢➢ Capacity for implementation: The MomConnect infrastructure Another framework for evaluating the MomConnect technical
development was undertaken by the NDoH in collaboration architecture is the Principles for Digital Development (PDD),31
with private sector partners mobilised through the mMH Task generally considered by many donors and implementing partners to
Team. This proved to be an effective mechanism for ensuring represent best practice in the development of digital health solutions.
that the MomConnect infrastructure contributes directly to the Evaluation of the MomConnect technical implementation against the
development of the public health system, while leveraging PDD is detailed in Table 3.
some of the innovation and implementation skills available in
the private and academic sectors.
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MomConnect
Table 3: Evaluation of MomConnect technical implementation against the Principles for Digital Development (PDD) framework
Design with the • This was adapted using the input of local experts to make it compatible with the local South African context, ensuring that the
user system was accessible to and equitable for marginalised populations where the need is greatest (rather than where technical
access is easiest). The South African Mobile Alliance for Maternal Actionh (MAMA) project had extensively tested the system
used by MomConnect and its initial messages with South African women.
• The messaging system used has been found to be effective in other low-resource settings.
• The task team comprised people with varied backgrounds and experience, from which the project benefited.
• Technical infrastructure made use of general, pre-developed eHealth and mHealth system components that had been
successfully implemented in low-resource settings and shown to be effective and reliable. This meant that the focus could
be on satisfying the end-user’s requirements. The task of developing the MomConnect infrastructure was largely one of
configuring the systems for the mobile maternal use case and integrating the working systems using the NDoH standards-
based framework, rather than attempting to develop new systems.
Understand the • The process followed in the development of the technical infrastructure was initiated and led at the highest level by the NDoH
ecosystem and made use of an mMH Task team that included experienced private sector mHealth practitioners.
• A survey of all mHealth services and projects was conducted at the start of the initiative, and all active partners were invited to
the first meeting that led to the establishment of the Task Team.
• Technical implementation was aligned with technological, legal and regulatory policies, both in South Africa and internationally.
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Design for scale • A systems approach was followed in the development of the technical infrastructure to ensure that the system fitted into the
wider NDoH architecture.
• Open standards were selected and implemented to ensure that the application could be scaled to include other mHealth
applications and extended to include additional services.
• The system was designed to be used in thousands of facilities, with training and support designed accordingly.
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Build for • The technical infrastructure was designed around considerations of long-term sustainability, including the use of open-source
sustainability software and alignment with NDoH systems.
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• Use of the program has been institutionalised through the operating practices of clinical staff, ensuring a level of organisational
sustainability.
• MomConnect was designed to be a zero-cost service for the client.
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Be data-driven • Technical infrastructure was largely developed to manage data, including the data for registering and subscribing clients,
messages sent to clients to promote antenatal care, and data for monitoring and evaluating the program.
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• A simpler minimal solution would have been merely to register women and provide messages. However, the technical backend
infrastructure provides much more data for effective management of the program.
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• Usage data from MomConnect are collated weekly and circulated to the MomConnect Task Team and other stakeholders
ensuring that management decisions are informed by data on the development of the system.
Use open data, • Technical infrastructure has a number of features illustrating the principles of an open mHealth architecture32 and open eHealth
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standards. Both the IHE profiles and the HL7 CDA specification used by the MomConnect technical infrastructure are openly
available to users from low- and middle-income countries. The standards were also adapted to the specific requirements of
MomConnect. The standards will be used to define a common means of connecting mHealth consumer applications to the
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HIE.
- Open source: All applications used by the MomConnect technical infrastructure are open source.
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- Open innovation: Development of the technical infrastructure was conducted in an open environment and with transparency,
allowing open innovation to occur.
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Re-use and • The NDoH and mMH Task Team elected to use open-source software that had already been implemented in South Africa
improve and other countries. In this way, the MomConnect technical infrastructure was built based on existing initiatives, and its
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development has benefited from the considerable software development effort and investment that has generated existing
software tools and standards. This has certainly lowered the costs and risk associated with software systems development.
In addition, by using existing tools, MomConnect has contributed to the continued growth and development of these tools as a
global good of open architecture health informatics tools that can be deployed in other low-resource settings.33
• The message structure and the content of many of the messages were adapted from the MAMA South Africa project. While the
NDoH took full ownership of the MomConnect project, the existing building blocks were used rather than re-invented.
• The South African MomConnect technical infrastructure has now become a model for other initiatives, such as FamilyConnect
in Uganda.
Address privacy • MomConnect is one of the first projects in South Africa collecting individual-level data using a unique patient identifier. Privacy
and security and security are of primary concern. The MomConnect HIE and monitoring systems protect client data at several levels,
including physical access to the hardware, encryption of data and the use of certificates. A security policy has been developed
and implemented by the NDoH
Be collaborative • The MomConnect technical infrastructure project has been collaborative on several different levels. The mMH Task Team was
initiated as a collaborative forum with representatives from a range of South African organisations. As the system develops,
additional partners may be included to contribute to the integrated system. The development of the technical architecture was
a productive collaboration between public health professionals and software engineers. The use of open-source software
components and communities has the potential to contribute to the notion of a “broader commons of resource, action and
knowledge” through the development of similar projects and initiative in Africa.33,34
Key: MAMA – Mobile Alliance for Maternal Action mMH – mobile Maternal Health
NDoH – National Department of Health HNSF – Health Normative Standards Framework
IHE – Integrating the Healthcare Enterprise HL7 – Health Level Seven
CDA – Clinical Document Architecture HIE – health information exchange
h MAMA South Africa provides access to information on pregnancy using different channels and a variety of formats and protocols (see http://www.askmama.
co.za/)
S A H R 20 1 6 131
Conclusion
Aligning MomConnect with international best practices resulted in a ➢➢ Extend to other health services: An opportunity exists to
number of conclusions: extend the MomConnect implementation to other health
➢➢ Ensure government stewardship: Government stewardship is the services where digital data are collected. The NDoH plans
most fundamental precondition for building health information to expand the program to include additional maternal,
technology infrastructure at national level. MomConnect has newborn and child health (MNCH) services and mobile health
also shown that projects with strong government leadership applications. The application currently being considered is
can effectively leverage private sector innovation to best the mobile health application implemented by CHWs as part
advantage and have the strongest chance of creating systems of the primary health care stream of Ward-based Outreach
that are sustainable beyond the initial development phase. Teams (WBOTs). MomConnect can be developed to include
and integrate with other services, such as child health and
➢➢ Adopt an open architecture approach: The open architecture immunisation programmes supporting a continuum of care
approach adopted in the HNSF14 has significant advantages through pregnancy and early childhood and linking to the
for large-scale systems development, allowing multiple requirements for universal health coverage.35
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applications to be integrated into a single system through
loosely coupled components. Open standards and open ➢➢ Include other mobile health applications: A particular advantage
application programming interfaces (APIs) are fundamental of the HNSF architecture is that it enables interoperability
enablers of the open architecture approach. Combining a between different applications using the same interoperability
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flexible front-end consumer application with a standardised standard. This opens up the possibility of leveraging digital
platform proved to be a powerful platform for MomConnect. health applications used in other programmes to contribute
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to data collection and potentially interact with MomConnect
➢➢ Adopt the Principles for Digital Development:31 These principles to create more extended data sets. The ability to facilitate
can assist system developers in avoiding common pitfalls and
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help them to develop systems that contribute to strengthening solve the vexing problem of the proliferation of small pilot
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public health systems rather than consuming scarce resources projects (‘pilotitis’) in mHealth that has plagued many low- and
with limited outcome. middle-income countries, including South Africa, struggling
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➢➢ Re-use and integrate: Software and system development is to use information and communication technologies (ICTs) to
expensive and risky, with a high failure rate. Within this context improve efficiencies.13,36 The NDoH is already working with
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many working components can be re-used and integrated into other mobile health application providers to explore such
a working system. This effectively lowers the cost and risk incorporation into the MomConnect technical infrastructure.
associated with system development. However, it is necessary ➢➢ Extend the national architecture based on the HNSF: The South
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to avoid the hazards of fitting the requirement to a particular African HNSF is an advanced legislative framework for
software tool. digital health that can be used effectively to realise digital
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➢➢ Design a roadmap: Restricting scope and creating a roadmap health benefits such as interoperability, standardisation and
for implementation are critical to the success of system re-use of existing infrastructure. The architecture itself could
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development projects. It is important to understand which be used effectively by the NDoH to guide the implementation
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functionality is important at which stage of development of the of other digital health programs in South Africa in the
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project. In the case of MomConnect, it was possible to limit interests of strengthening the public health information system
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functionality, e.g. the number of data elements, in order to more generally. There are many advantages in integrating
focus on the elements essential to its success. MomConnect into the eHealth reference implementation
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MomConnect
Acknowledgments
The authors acknowledge the leadership of the South African Minister
of Health who initiated and leads the MomConnect project, as well
as the direction and contribution of the South African National
Department of Health, especially Dr Yogan Pillay who convened and
led the mMH Task Team, and the MomConnect project managers.
The mobile phone and mobile health application components were
implemented and managed by a group from Praekelt Foundation.
The interoperability components were implemented and managed
by a group from Jembi Health Systems. The registry and data
warehouse components were implemented and managed by a group
from the Health Information Systems Programme, South Africa (HISP-
SA). Additional inputs for the technical design and implementation
of MomConnect were provided by the Council for Scientific and
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Industrial Research (CSIR) Meraka Institute and Inner City Fund
(ICF) International. Regular inputs and feedback were provided
by all members of the mMH Task Team. Local and international
funders, including the United States President’s Emergency Plan for
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AIDS Relief (PEPFAR), the Johnson & Johnson Foundation and Elma
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Philanthropies, support MomConnect. The mobile operators in South
Africa – Cell C, MTN, Telkom Mobile and Vodacom – afforded
generous discounts on the commercial cost of SMS messages.
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3 Chola L, Pillay Y, Barron P, Tugendhaft A, Kerber K, Hofman 15 Wolmarans M, Solomon W, Tanna G, Chetty M, Dombo M,
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24 South African Government. Act No. 4 of 2013: Protection of 34 Moodley D, Pillay AW, Seebregts CJ. Position Paper:
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from: Health Information Systems in Developing African Countries.
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view/113893
35 Mehl G, Labrique A. Prioritizing integrated mHealth
26 South African National Department of Health. MomConnect. strategies for universal health coverage. Science. 2014;
One Year of Operation: A Case Study. August 2014 – August 345(6202):1284–7. [Internet]. [cited 6 April 2016].
2015. Pretoria: National Department of Health; 2015. p. URL: http://dx.doi.org/10.1126/science.1258926
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URL: http://www.healthenabled.org/resources/momconnect_ 36 Wilson K, Gertz B, Arenth B, Salisbury N. The Journey to
case_study.pdf Scale. Moving together past digital health pilots. December
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source-software-use-south-african-government
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The contribution of congenital disorders to
child mortality in South Africa
12
Authors:
Helen L. Malherbe i
Colleen Aldous ii
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David Woods iii
Arnold Christianson iv
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R 20 IL
eduction in child mortality has been a priority issue in South Africa leading up In South Africa many
to the Millennium Development Goals. However, the contribution of congenital
Y T
disorders (CDs) to child mortality is yet to be recognised and acted upon. congenital disorders
A N
Rapid reductions in child mortality have resulted largely from comprehensive HIV and
go undiagnosed or are
misdiagnosed resulting in
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issues other than those currently being addressed may require long-term prioritisation. death being reported and
In 2013, congenital anomalies (excluding many CDs) overtook infection as the third in an underestimation
leading cause of early neonatal deaths, which account for one-third of all under-five
of the true burden of
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deaths.
congenital disorders
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previously hidden disease burden of CDs. In South Africa, many CDs go undiagnosed
or are misdiagnosed, resulting in the incorrect cause of death being reported. These
BA
inaccurate data result in an underestimation of the true disease burden of CDs in the
O
country.
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This chapter argues for recognition of the role of CDs in child mortality and morbidity
and the potential advantages of medical and genetic services for the prevention and
care of CDs.
i Genetic Alliance South Africa; School of Clinical Medicine, College of Health Sciences, Universit y of KwaZulu- Natal
ii School of Clinical Medicine, College of Health Sciences, Universit y of KwaZulu- Natal
iii Newborn Care, School of Child and Adolescent Health, Universit y of Cape Town
iv Wits Centre for Ethics (WiCE), Universit y of the Wit watersrand, Johannesburg
137
Introduction
Since the Millennium Development Goals (MDGs) were set in was higher than the 1990 MDG baseline due to the negative
2000, there has been a global drive to reduce child mortality.1 In epidemiological impact of HIV and AIDS and concomitant TB.7
order to achieve the MDG 4 target of cutting under-five mortality Significant reductions were then seen in child mortality until 2011
by two-thirds by the end of 2015, countries rapidly incorporated due to a number of factors. These included scaled-up prevention of
measures relevant to their specific healthcare challenges. As the mother-to-child transmission of HIV, expanded roll-out of antiretroviral
MDG deadline loomed, South Africa focused on responding to therapy, and the addition of the rotavirus and pneumococcal
the HIV and AIDS and concomitant tuberculosis (TB) epidemics, re- conjugate vaccines to the childhood Expanded Programme of
engineering primary health care and developing a strategic plan for Immunisation (EPI).7–9 Despite the rate of reduction tripling since
Maternal, Newborn, Child and Women’s Health (MNCWH) and 2000, the U5MR decreased by one-third only, to 39 per1 000
Nutrition. Several ministerial committees were established to address live births,8 falling short of the South African MDG 4 target of 2
underlying issues, including the National Perinatal Mortality and per1 000 live births.
Morbidity Committee (NaPeMMCo) and the Committee on Mortality
However, according to the Rapid Mortality Surveillance Report there
and Morbidity in Children (CoMMiC). The topic of newborn and
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has been no further decrease in infant and child mortality in South
child mortality and survival has also been examined in detail in
Africa since 2011.8 This stagnation indicates the need to address
previous editions of the South African Health Review.2,3
other health issues contributing to infant and child mortality, whilst
None of these policies or initiatives has comprehensively recognised continuing with ongoing efforts.5,7,8 Many issues related to social
16 6
the contribution of congenital disorders (CDs) to neonatal, infant determinants of health and childhood illnesses are already being
and child mortality and morbidity. This is despite the fact that in addressed, including malnutrition and infectious diseases associated
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industrialised countries around the world, CDs are the leading with poverty such as measles, diarrhoea and malaria. A 2013 study
cause of death in infants and children, contributing up to 28% of identified 15 key interventions that were scaled up in South Africa
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under-five deaths in high-income countries.4 Like many other middle-
and low-income countries (MLICs), South Africa is following this
for maximum impact on maternal and child mortality during the
final two years of the MGDs.10 Preliminary measures to target non-
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epidemiological trend and the proportion of deaths and disability communicable diseases (NCDs), now a component of South Africa’s
resulting from CDs is rising, especially as communicable diseases quadruple burden of disease, are also under way.11 However, CDs,
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are better controlled.5 which are the first NCD experienced by infants and children,5,12 are
yet to be recognised for their contribution to stillbirths, and neonatal,
This chapter provides an overview of the health issue of CDs and
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infant and child mortality in South Africa. This is despite the global
their unappreciated role in child mortality and morbidity in South
call to action by the World Health Assembly (WHA) in 2010 through
Africa. Epidemiological transition is described in relation to CDs
Resolution 63.17,13 which recognised the importance of CDs as
and an outline is given of the growing role of CDs in the burden
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mortality and morbidity through medical genetic services for the CDs are a common, costly and critical health issue. According to
prevention and care of CDs. The current status of these services the 2006 March of Dimes report,14 serious CDs result in the death
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is reviewed and compared with what is required to address this of 3.3 million children under the age of five globally every year.
growing health need. Where relevant, secondary data have been Although CDs are found in all populations throughout the world,
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sourced from peer-reviewed literature and globally recognised data over 90% occur in MLICs where 95% of CD-related deaths occur.14
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138 S A H R 20 1 6
Congenital disorders
and radiation) or abnormalities of the fetal environment that deform transition of countries has been described extensively using
or disrupt the developing fetus (e.g. constraint and amniotic band Omran’s model,18 which defines three stages of disease. As
disorder). Teratogens – fetal environmental factors that cause CDs – mortality rates decrease and longevity increases, countries move
may be chemical substances, physical agents or infections, and are from Stage 1 ‘the age of pestilence and famine’ to Stage 2, ‘the
more common in MLICs where the potential for exposure is higher age of receding pandemics’ and into the third stage, ‘the age
and there are fewer preventative measures in place.14 of degenerative and man-made diseases’ characterised by low
mortality rates and high life expectancy at birth (over 50 years). It
The global lack of consensus on terminology related to CDs has
is in this third stage that communicable diseases are well controlled
plagued the medical genetics sector and resulted in lower priority
or eradicated, and NCDs and degenerative diseases emerge.18
being given to this healthcare issue. In 2006, after decades of
uncertainty, agreement was reached by international experts on Like many MLICs, South Africa is not following Omran’s classic
the use of basic terminology at a joint World Health Organization model18 of epidemiological transition that was completed by
(WHO) and March of Dimes meeting.15 Participants recommended industrialised, high-income nations decades ago.19 From 1960 to
that the terms ‘CDs’ and ‘birth defects’a be used synonymously. Use the early 1990s, infant and child mortality in South Africa declined
of the term ‘congenital anomaly’ was not advised, since it excludes steadily and longevity increased.5 Figure 1 plots the U5MR,20 infant
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around 40% of functional CDs including non-syndromic congenital mortality rate (IMR)20 and life expectancy at birth (longevity) data,21
disabilities, common single gene disorders and inborn errors of and the HIV epidemic (indicated by the percentage of HIV-positive
metabolism.b,12,15 pregnant women)22 for South Africa for the last 25 years. Life
expectancy at birth peaked at 62.33 years in 1992, and in 1993
16 6
The limited uptake of this agreed terminology and the copious use of
both the U5MR and the IMR were at an all-time low of 58.2 per
non-equivalent terms has led to confusion, fragmentation of effort and
1 000 live births and 45.1 per 1 000 live births respectively.20,21 All
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an inability to compare data sets.b This has diluted the visibility of the
indications were that South Africa was approaching the early phases
significant contribution of CDs to neonatal, infant and child mortality,
of transition from Stage 2 (the ‘age of receding pandemics’) to Stage
and prevented CD data from being evaluated comprehensively. CDs Y T 3, the ‘age of degenerative and man-made diseases’ and was set to
are often undiagnosed or misdiagnosed and the cause of death
follow the classical model of epidemiological transition.5,18
A N
is wrongly attributed, contributing to under-reporting.16 The lack of
accurate data on CDs has led to an underestimation of the true However, in the mid-1990s, epidemiological transition was
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contribution of CDs to the disease burden.14,16,17 interrupted and reversed by the HIV and AIDS and concomitant TB
epidemics (Figure 1). As a result of these epidemics, South Africa
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population health statistics and pattern of disease in a region or dramatically in response, peaking at 80.8 per 1 000 live births
country, resulting from changes in socio-economic, educational, in 2003 and the IMR at 53.2 per 1 000 live births in 2002.20
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infrastructural and healthcare development.14 The epidemiological In 2005, longevity dropped to its lowest level since the 1960s at
R
Figure 1: Epidemiological transition in South Africa over the past 25 years, as demonstrated by data for childhood mortality,20 longevity,21
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90 35
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80
30
Total number of deaths per 1 000 live births
70
Percentage of HIV infected women
25
60
20
50
40 15
30
10
20
5
10
0 0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
MDG set U5MR IMR Longevity HIV prevalence (% pregnant women infected) ARV roll-out
S A H R 20 1 6 1 39
51.56 years.21 The combination of a newly emerged communicable these CDs became proportionately greater in overall neonatal,
disease (HIV and AIDS) and the re-emergence of an old infection infant and child mortality as deaths from communicable diseases
(TB) with an increasing burden of NCDs has resulted in an additional reduced. As industrialised countries completed the second stage
stage being added to Omran’s original concept, called the ‘age of of epidemiological transition, CDs emerged and have remained a
emergent and re-emergent infections’.19,23,24 leading cause of child death in these nations today.29,30
Following the roll-out of comprehensive HIV and AIDS interventions CDs attained public health significance in these industrialised
in 2004, the HIV and AIDS prevalence rate plateaued at around nations in the early 1960s when they moved into the third stage
30% in the early part of the current decade (see Figure 1).22 The of epidemiological transition.14,18 This was demonstrated in a
rapid reductions achieved in infant and child mortality between comparative study undertaken by McKeown30 of death rates in
2005 and 2011 have resulted in both the IMR and U5MR being England and Wales for 1901 and 1971, shown in Table 1. An
lower today than prior to the HIV and AIDS epidemic, at 28 overall reduction of 68% was seen in the death rate for all diseases
per1 000 and 39 per1 000 live births respectively.8 South Africa over the 70-year study, including a 90% reduction in infectious
is now back in positive epidemiological transition. However, both diseases. Death rates for NCDs decreased by 45% overall, but the
the IMR and U5MR have stagnated since 2011, and the neonatal number of CD deaths remained the same.30 This was due to the
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mortality rate (NMR) has stagnated since 2009 despite the continued mainly genetic cause of CDs, which cannot be changed, resulting in
implementation of HIV and AIDS interventions.8 CDs contributing a greater proportion of deaths as overall mortality
decreased.
A significant contributor to ongoing high mortality in children are
16 6
deaths from unnatural causes, causing just over a third (18.5%) of
Table 1: Standardised death rates (per million of population) for
deaths in children aged 1–4 years in 2014.25 Natural deaths in England and Wales in 1901 and 1971
20 IL
the same age-group were attributed to intestinal infectious diseases
(17.2%), influenza and pneumonia (9.1%) and malnutrition (8.6%), %
1901 1971 Reduction
with TB and HIV ranked fourth and fifth.25
Some neonatal deaths,
Y T Infectious Diseases
which contribute the bulk of under-five deaths, are preventable
Airborne Diseases
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through addressing modifiable factors that are intertwined with
Respiratory infection 2 747 603 78
social determinants of health. CoMMiC reports that modifiable
Pulmonary TB 1 268 13 99
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factors are 30% home-based, including seeking medical attention Whooping cough 312 1 100
earlier, failure to recognise severity of illness, and inadequate Measles 278 0 100
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nutrition.26 The majority of health system-modifiable factors (80%) Scarlet fever and Diphtheria 407 0 100
relate to health personnel.26 Smallpox 10 0 100
Upper respiratory tract infections 100 2 98
The total contribution of CDs to stillbirthsc
in South Africa is unknown.
O
due to restricted diagnostics and unavailability of screening. The Typhus, Typhoid 155 0 100
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Lancet Ending Preventable Stillbirths Series Study Group estimates a Sub-total 1 931 35 98
N
global median of 7.4% stillbirths attributed to CDs based on reliable Other Infections
O
However, the role and contribution of CDs to the ongoing high level Non-communicable diseases
of mortality is not visible in the available data. Birth defects 126 127 0
Perinatal problems 1 249 192 85
Heart disease 1 186 1 688 - 42
Congenital disorders and epidemiological Rheumatic heart disease 487 88 92
transition Cancer 844 1 169 - 39
Other diseases 4 598 1 406 69
During the process of epidemiological transition, CD deaths remained
Sub-total 8 490 4 670 45
invisible, essentially ‘buried’ among deaths due to communicable
Overall reduction for non-communicable diseases 45%
diseases, and only emerging as these diseases were adequately
Total 16 958 5 384 68
controlled.16 As industrialised countries moved through the second
68% Overall Reduction in Death Rate of All Diseases
stage of epidemiological transition, there was a slight decrease in
CD birth prevalence and deaths due to fetal environmental factors, Source: McKeown, 1976.30
essentially teratogens.14 This was because of improved care and
prevention strategies for these disorders. However, since 85–90% A further example of the increasing proportion of child deaths
of CDs have a genetic or partially genetic aetiology, their birth from CDs is shown in Figure 2, which shows the percentage of
prevalence and resulting mortality remained high.14 Deaths from deaths due to congenital anomalies using the World Bank Country
Classificationsd according to Gross National Income (GNI) per
c In South Africa, a stillbirth is defined as a fetus of at least 26 weeks’ capita.4 As GNI increases, the percentage of child deaths from CDs
gestation and born with no signs of life after complete birth. This definition
varies between countries, making data compilation and comparison
complex. d South Africa is classified as an upper middle-income country.
1 40 S A H R 20 1 6
Congenital disorders
(congenital anomalies only) increases, contributing a greater portion Congenital disorders in South Africa
in the higher GNI classification. An increase can be seen in all
groups between 2010 and 2013. Today, CDs account for 28% of Prior to the HIV and AIDS epidemic in the early 1990s, CDs began
child deaths in high-income countries and they are the leading cause to emerge as a healthcare issue in South Africa due to falling child
of death in infants and children younger than five years. mortality and increasing longevity. A national task force of experts
was established in collaboration with the WHO to investigate the
Figure 2: Percentage of under-five deaths resulting from congenital need for, and implementation of, services for the care and prevention
anomalies using World Bank Country Classifications of CDs. Following wide consultation, the National Policy Guidelines
for the Management and Prevention of Genetic Disorders, Birth
30
28 Defects and Disabilities were published in 2001.31
26
25 The 2001 National Policy Guidelines31 outlined goals, objectives,
strategies and delivery of clinical and laboratory services
20 appropriate for the care and prevention of CDs in South Africa.
Priority disorders were designated, which included Down syndrome,
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15 14 neural tube defects, fetal alcohol syndrome (FAS), albinism, cleft-lip
and palate, and club feet. The financial cost to society and to the
10 9 State resulting from burden of disease was estimated at several billion
6 Rand annually at the time. Personnel requirements to implement
16 6
5 5
5 3 these services were specified in the 2001 Guidelines, based on UK
criteria, and were later revised using more relevant criteria for South
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0 Low Income Lower middle Income Upper middle Income High Income Africa in the Strategic Framework for the Modernisation of Tertiary
2010 2013
Hospital Services.32
of infant deaths resulting from CDs, demonstrating that as infant and describing common CDs and strategies for their care and
mortality drops, the contribution (proportion) of CDs relative to infant prevention.
4 ED
mortality increases. This is particularly noticeable as the IMR drops After this surge of policy generation, the HIV and AIDS and TB
to between 40 and 50 per 1 000 live births.
epidemics obscured the issue of CDs once more.5 As a result, the
It is clear from the literature and mounting evidence that the growing commitment and momentum towards CDs as a healthcare
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contribution of CDs to child mortality increases as countries issue was redirected to these competing healthcare priorities along
develop, and that MLICs, including South Africa, are following this with the associated resources.
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decreases.
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Figure 3: Relationship between infant mortality and percentage of infants dying from CDs based on global country figures
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80
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70
60
% of infant deaths due to CDs
50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100 110 120 130
S A H R 20 1 6 141
Data modelling of CDs Figure 4: The cycle caused by the underestimation of CDs
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to one in every 15 live births in South Africa being affected by a
CD.5 The proportion of teratogenic CDs is more than the 10–15%
expected in MLICs and is one of the highest documented prevalence
rates in the world due to the high prevalence of FAS, which is Emerging data
16 6
entirely preventable.14
Despite the lack of evidence-based data, available mortality data
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Reliable surveillance data provide a vital information tool for policy- are beginning to reveal the hidden disease burden of CDs. Under-
makers to plan, implement, monitor and evaluate policy accordingly reporting of births and deaths leading to incomplete vital registration
Y T
to prevent adverse health conditions and improve public health. data, especially for children, makes it an unsuitable source for
With 6.8% of live births affected by a CD in South Africa, a total monitoring and evaluating child mortality. District Health Information
A N
of 83 118 live births would have been affected in 2012, based System (DHIS) data, which record deaths in public sector hospitals,
on vital registration data.34 However, only 2 174 cases were also tend to be inadequate, as outlined by McKerrow in 2010.3 The
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reported via the Birth Defects Collection Tool (BDCT) administered PPIP is the most detailed source of information on factors contributing
by the Department of Health in 2012.35 With only 2.6% of the to perinatal death and hence child mortality.3 The 2012/13 PPIP
4 ED
expected CDs being reported, this indicates under-reporting by data,27 representing 75.6% of all DHIS-recorded births in South
97.4% for 2012. When taking into account that only 26% of CDs Africa, indicated that congenital abnormalitiesh have overtaken
are diagnosable during the early neonatal period,36 under-reporting infection as the third leading cause of death during the first week of
O
of 90% is still unacceptably high. This is hampering the recognition life in neonates after deaths from immaturity and hypoxia. Congenital
of CDs as a key contributor to the burden of disease. abnormalities accounted for 11.24% and 8.20% of early neonatal
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neglected. The lack of CD diagnosis due to poor services leads to This trend continued in the Western Cape Province (WC) in 2014,
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under-reporting and poor data. Under-reporting contributes to an with congenital abnormalities ranked as the third cause of early
underestimate of CD deaths and disability. CDs are not considered neonatal death in infants weighing >500g and >1 000g.i At
to be a healthcare priority and the cycle resumes. Modelling is used 10%, deaths in the under-fives from congenital abnormalities
as a tool to highlight the gap between the expected health need and in the province are double that recorded in other provinces and
current services available. nationally.4,39 The WC neonatal mortality rate is also half the
national rate of 11 per1 000 live births,40 making the province a
good example of what will occur in other provinces in the coming
decade as healthcare services improve and CDs are revealed.
1 42 S A H R 20 1 6
Congenital disorders
to post-mortems and lack of paediatricians to assess (diagnose) the reduce the number of babies born with CDs through screening,
cases.41 Between 2005 and 2014, mortality data were submitted prenatal diagnosis, avoidance of potentially teratogenic substances
to CHILD PIP by 198 hospitals across 49 districts. Of the 44 854 during pregnancy and the option of termination of pregnancy;
deaths recorded,k 2.2% cited congenital abnormalities as either and tertiary prevention, being the early detection, diagnosis, cure
the main cause or underlying cause of death. Although higher than and mitigation of CDs after the child is born, including surgical
the 2005 figure, this too was reported as an underestimate due interventions and palliative care. Tertiary prevention is equivalent
to the lack of identification of CDs by health workers conducting to care that constitutes diagnosis, treatment, counselling and
the audit, and limitations in the cause-of-death categorisation in the psychosocial support of those affected by CDs.
current CHILD PIP programme, which is now being rectified by the
In lower-resourced countries, prevention tends to be overemphasised
development of a new data form.l
to the detriment of care due to the misplaced myth that care
As the U5MR has decreased, the proportion of deaths in the is expensive.14,16 This may cause those affected by CDs and
perinatal period has risen.42 In South Africa, just over 40% of deaths consequently living with a disability to be marginalised, which
among under-fives occur during the neonatal period.43 Globally, the undermines their human dignity and human rights. Christianson’s
contribution of neonatal deaths to under-five mortality is projected mantra, “Care is an absolute. Prevention is the ideal” was coined in
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to rise from 45% to 52% by 2030.6 The contribution of CDs to 2000.47 This emphasises both care and prevention (at all levels) as
these deaths should be recognised and addressed if child mortality, integral components of medical genetic services, and one cannot be
particularly neonatal mortality, is to be reduced further. neglected at the expense of the other.
16 6
Since available data sets reported only include sub-groups of CDs, In many MLICs, comprehensive services for the care and prevention
the true contribution of CDs to the burden of disease is likely to be of CDs are not implemented. In addition to the immense loss of
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higher than estimated. life and suffering of those affected, there is a significant economic
cost. Implementation of key interventions can reduce this cost and
Y T save lives, as outlined in Table 2. Congenital malformationsm are the
Congenital disorders and disability most common type of CD and also the most treatable. Almost half
A N
CDs are not merely a cause of child mortality but also of morbidity. of the congenital malformations such as cleft lip and/or palate and
For every child who dies as a result of a CD, many survive serious CDs congenital heart defects can be cured through paediatric surgery, but
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and sustain lifelong mental, physical, auditory or visual disability.14 without this intervention, the result is death or permanent disability.
The economic cost as a result of this morbidity is considerable. In To date, the folate fortification of staple food (maize meal and
4 ED
2012, 116 000 beneficiaries – caregivers of children older than bread) to reduce neural tube defects (NTDs) – an example of
one year with severe disabilities or disabling chronic illnesses primary prevention – is the only preventative intervention being
requiring permanent home-based care, including those affected by comprehensively implemented in South Africa. Since fortification
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CDs, acquired conditions and injuries – received means-tested care began in 2003, a 30.5% reduction in NTDs has been seen.48 In
dependency grants of R1 200 per month.44 This totals R1.6 billion addition to the obvious reductions in mortality and morbidity, there
G
annually, excluding inflation, adult disability grants and other costs. is also a considerable cost benefit. According to Sayed et al.,48 with
the average estimated cost of treatment being R100 000 per NTD
R
care, and a further 3.2 million who survive are disabled for life.14
minimal cost of R1.4m per year for the 2% fortification.
Early intervention and relevant care can save the life of the child from
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a life-threatening serious CD, and cure or ameliorate the degree of If all other interventions were implemented as outlined in Table 2,
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long-term disability. Many of these interventions, including one-off the burden of genetically determined CDs could be reduced by
surgeries for congenital malformations, are relatively inexpensive almost 70% and would generate sizable economic benefits due
compared with the cost of ongoing chronic care for untreated CDs. to the gain of almost three years of healthy life per head of the
Many community-based preventative measures are both inexpensive population.14,16,46 However, the current static child mortality rates
and ‘low-tech’.14 Where appropriate services for the care and in South Africa are an indication that current interventions being
prevention of CDs are available, 30% of CD deaths in the first year implemented fall far below this level of potential.
cannot be prevented. However, 40% of the cases can be cured,
mainly by surgery, and 30% survive with disability.45,46 In South
Africa, specialised surgery capacity is limited and unavailable in
some provinces, preventing widespread access to such intervention.
Strengthening surgical capacity in all areas is required, as both
general and specialised surgery could help to alleviate this shortfall.
S A H R 20 1 6 1 43
Table 2: Summary of estimated potential effects of interventions for preventing genetically determined CDs
Estimated
Maximum average increase
Birth prevalence postnatal lives in longevity
per 1 000 live saved (per 1 000 Maximum per head of
Type of CD births Intervention live births) reduction (%) population (years)
Congenital 36.5 Paediatric surgery 17.70 48.5 1.24
malformationsn (Tertiary Prevention/care)
Folic Acid Supplement 11.50 31.5 0.81
(Primary Prevention)
Prenatal diagnosis 3.50 9.6 0.25
(Secondary Prevention)
Total congenital malformations 32.70 89.6 2.30
Chromosomal 3.8 Family planning 0.75 19.7 0.05
disorderso (Primary Prevention)
Prenatal diagnosis 0.5 13.2 0.04
(Secondary Prevention)
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Total Chromosomal disorders 1.25 32.9 0.09
Genetic risk 2.4 Routine antenatal & neonatal care 2.40 100 0.17
factorsp (Tertiary Prevention/care)
Inherited 11.5 Genetic counselling 1.73 15 0.12
disorders (Primary Prevention)
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(severe, early Neonatal screening 0.7 6.1 0.05
onset)q (Tertiary Prevention/care)
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Prenatal diagnosis 1.15 10 0.08
(Secondary Prevention)
Total inherited disorders
Y T 3.60 31.1 0.25
Total 54.2 39.90 73.7 2.80
A N
Source: Christianson and Modell, 2004;16 Christianson et al., 2006.14
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Interventions to prevent, detect and care for CDs are collectively Since the early 1970s, the mainstay of medical genetic services
known as medical genetic services. The aim of genetic services in South Africa has been the work of human genetics departments
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is two-fold: to reduce suffering by offering care to those affected, at major academic centres and medical schools in urban areas,
and to improve health by preventing CDs.14 These services are starting in Johannesburg and Cape Town.51 Access to these services
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key in reducing the contribution of CDs to the burden of disease. was limited mainly to urban areas, with some outreach into rural
By providing the ‘best possible patient care’ in the prevailing areas being conducted by the academic centres.
R
as possible’.17,49,50
by the National Health Laboratory Service increased in response
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In many lower-resourced countries, the development of medical to the policy.51 However, implementation continued through the
genetic services has been driven by epidemiological transition. established framework of academic centres, rather than through the
Governments begin to see CDs as an important public health issue integration of services into primary health care and the extension of
when the IMR falls below 40–50 per 1 000 live births and only limited clinical genetic services beyond urban areas, as was recommended
reductions in child mortality can be achieved by addressing other in the 2001 Guidelines.
health issues.12,16,17,50 With an IMR of 28 per1 000 live births in
2014,8 South Africa is well past this threshold when medical genetic As services for HIV and AIDS developed over the past decade
services should be comprehensively implemented. CDs should be to combat the epidemic, tertiary medical genetic services were
prioritised alongside other NCDs and ongoing interventions against neglected.5 By severely limiting the implementation of the 2001
communicable diseases in order to further reduce child mortality policy guidelines, the lack of investment in medical genetic services
and to provide better care for those who are disabled as a result of has resulted in insufficient trained personnel, inadequate capacity
CDs.5 When the IMR reaches 20 per 1 000 live births (the MDG at all levels, and severely compromised laboratory services.5,51
4 target for South Africa), CDs will emerge as a leading cause of In 2013, South Africa was reported as the only country of eight
death in infants.12 emerging economies evaluated where positive development in
improving medical genetic service structures had ceased, and
indeed retrogressed.37
n Obvious structural abnormalities/malformations due to multifactorial
inheritance.
o A structural or numerical abnormality of the chromosomes.
p G6PD deficiency and Rhesus haemolytic disease of the newborn.14
q Single gene disorders, including autosomal-dominant, autosomal-recessive,
sex-linked inheritance and mitochondrial disorders.
144 S A H R 20 1 6
Congenital disorders
Table 3: Overview of medical genetic services across health care in South Africa
(X=service in place in SA; S= service required in SA)
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X X X X X X
• Iron (200mg daily)
• Alcohol/Smoking (education)
Pre-conception screening Su Su Su X X X
Maternal infections:v
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Detection and treatment X X X X X X
(primarily syphilis)
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Treating health conditions:
• Diabetes mellitus X X X X X
• Epilepsy Y T X X X X X
• DVT or cardiac conditions (Wafarin) X X X X
A N
Genetic counselling
Sw Sw X X X
(if required)
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Screening:
Secondary Prevention:
Reducing the number of children
born with CDs
Ultrasound S S X X X
Advanced maternal age screening S S S S X X
4 ED
Sw Sw Sw X X
support
Options:
G
• Therapeutic S X X X X
• Termination of pregnancy
R
Early diagnosis:
Tertiary Prevention/Care:
Early detection, cure,
amelioration and care once
a child is born with a CD
S S X X X
N
(Hypothyroidism)
Care interventions:
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• Medical/therapeutic X X X X X
• Surgery Xx Xx Xx Xx
• Habilitationy X X X X
• Palliative care X X X X
• Genetic counselling and psychosocial
Sw Sw Xw X X
support
r Family planning is associated with specialist services in these secondary and v The rubella (German measles) vaccine is available only in the private
tertiary hospitals although it is not listed as an official service. sector in South Africa.
s Mandatory iodisation of table salt (40–60ppm) was introduced in South w Genetic counselling for common disorders such as Down syndrome
Africa in 1995 to prevent iodine-deficiency disorders. and spina bifida.
t Mealie meal and wheat flour have been fortified with folic acid in South x This may be limited to general surgery in some provinces where
Africa since 2003. specialised surgery (e.g. cardiac, cranofacial, etc.) is currently
u Pre-conception screening at the level of community health centres and district unavailable. Some CDs may require only general surgery (e.g.
hospitals should include screening for advanced maternal age, taking a Meckel’s diverticulum), whilst others require more specialised surgical
family history and relevant referral. intervention (e.g. cleft lip and/or palate).
y For example, occupational, speech and physiotherapies.
S A H R 20 1 6 1 45
Table 4: A comparison of medical genetics services capacity in 2001 and 2015
Medical genetic services are now at a lower base than in 2001, trained labour ward nurses, together with midwives, obstetricians
as outlined in Table 4. The 2003 recommended human capacity and paediatricians, are the frontline healthcare professionals
requirements32 to be trained and in-post by 2010 remain unfulfilled. encountering CDs in the continuum of care.
Today there are 12 medical geneticists, compared with four in 2001
and the 20 recommended by 2010.
Legislative and regulatory framework
Of the 14 genetic counsellors practising today, only eight practise in
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The World Health Assembly (WHA) call in 201013 to prioritise CDs
State services, compared with 20 in 2001 and the 80 recommended.
as a healthcare issue through Resolution 63.17 was fundamental
Since existing posts were frozen and no new posts were created
for medical genetic services worldwide. WHA 63.1713 recognised
to accommodate newly qualifying genetic counsellors, many have
the importance of CDs as a cause of stillbirths and neonatal deaths,
been forced to leave the service or the country, or to work in
16 6
and their contribution to under-five mortality, and it is recognised
private practice. No provision was made for genetic counsellors
that for MDG 4 to be achieved, “accelerated progress in reducing
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in the Occupational Specific Dispensation (OSD), a government
neonatal mortality including the prevention and management
initiative aimed at attracting and retaining skilled employees through
of birth defects” was required. Although South Africa is yet to
improved remuneration. Budget cuts have also reduced diagnostic
Y T respond to WHA63.17,13 a number of other international treaties
laboratory personnel numbers to unsustainable levels and equipment
and protocols of relevance to CDs have led to the development of
A N
has not been upgraded or maintained.5,51 Many practitioners have
equivalent national legislation. Table 5 lists international treaties
left, retired or emigrated due to a high service workload, limited
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services. To reverse this, adequate staffing and modern equipment South Africa is well placed to respond to WHA 63.1713 since a
are required along with the necessary training to ensure the comprehensive, national legislative framework already exists for the
translation of this technology is appropriate to the country’s needs provision of medical genetic services for the care and prevention
and circumstances.
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across the health system in terms of South Africa achieving health fundamental rights to life, equality, dignity, freedom and security
goals,26 including the MDGs. Rectifying the shortfalls in specialist of the person, and education. The socio-economic right for all to
R
healthcare professionals in the medical genetic services sector is access healthcare services, including reproductive health care, is
critical. provided subject to the concept of progressive realisation.ad Every
BA
education postgraduate training course for nurses and rural medical social services’ (section 28, 1c), but these rights are not subject to
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officers. This equips in-post healthcare professionals with basic progressive realisation.
knowledge and skills to identify and diagnose common disorders,
counsel patients and to refer those affected by CDs appropriately, The provision of medical genetic services is specified in the National
providing an additional supporting capacity for medical geneticists Health Act (NHA) 61 of 2003 through a clear directive in Chapter
and genetic counsellors. Between 2004 and 2013, over 1 000 3, under “Main functions of the National Department” in section 21
healthcare providers, mainly labour ward nurses, were trained (2) (b) (vii) as follows:
through the MGEP course held countrywide.ac Today, fewer than
The Director-General must, in accordance with national health
100 remain in services for the care and prevention of CDs. The
policy, issue and promote adherence to, and norms and
lack of continued government support for this training, including
standards on health matters including genetic services.54
financial, trainee contact and uptake of these skills by facility
management, has forced trainees to discontinue their genetic nursing Also of relevance to CDs in the NHA are epidemiological
role and move to other fields. This has had a direct negative impact surveillance, management, prevention and control of NCDs, and
on the national surveillance of CDs via the BDCT, as many MGEP- the health needs of vulnerable groups including children and the
disabled.54 Other key national legislative instruments of relevance
z No medical geneticists are employed by the State in Gauteng. Personal
communication: A. Krause, 11 February 2016. to CDs are outlined in Table 6.
aa Of these eight genetic counsellors, three are employed full-time directly
by the State, three full-time by tertiary institutions, and four are employed
part-time, plus six in private practice. Personal communication: T. Wessels,
25 February 2016.
ab NHLS academic medical scientists only. Personal communication: H.
Soodyall, 27 July 2015.
ad Defined as recognising that economic and social rights can only be
ac Personal communication: D. Tshikedi, 2 October 2013. achieved over time, subject to the availability of resources.
146 S A H R 20 1 6
Congenital disorders
Table 5: International treaties, conventions, declarations and protocols of relevance to medical genetic services
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United Nations Millennium Declaration (signed 2000)1 Goal 4: Reducing under-five mortality by two-thirds by 2015
United Nations Convention on the Rights of Persons with Disabilities (signed and 5 Equality/non-discrimination
ratified 2007) 6 Women with disabilities
7 Children with disabilities
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8 Awareness-raising
9 Accessibility
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10 Right to life
19 Living independently
Y T 20 Personal mobility
23 Respect for home and family
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25 Health
26 Habilitation and Rehabilitation
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African Charter on the Rights and Welfare of the Child (‘Children’s Charter’) (signed 5 Right to life
1997 and ratified 2000) 13 Protection of physically/mentally disabled to ensure dignity
14 Physical/ mental health and healthcare
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The New Partnership for Africa’s Development (2001) Healthcare provision and delivery
African Youth Charter (signed and ratified 2009) 16 Health
23 Girls and young women
O
N
O
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S A H R 20 1 6 1 47
Table 6: Key national legislation of relevance to medical genetic services
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• 23(1)(a)(ix) and 27(1)(a)(ix) Epidemiological surveillance and
monitoring of national and provincial trends
• 21, 23, 25, 27 Implementation of national/provincial policy and
compliance
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• 39(2)(a)&(d), 70(2)(d) Health needs of vulnerable groups including
children and people with disabilities
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• 48 Development and provision of human resources in national
health system
• 52 Regulations relating to human resources
Children’s Act (38 of 2005) Protection of children and their rights • 11 Children with disability or chronic illness
• 156 (1)(G) Care and protection
R
Social Assistance Act (13 of 2004) Rendering of social assistance • 7 Care dependency grants
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• 9 Disability grants
N
O
National policy
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The National Policy Guidelines for the Management and Prevention Strategic Plan for Maternal, Newborn, Child and Women’s Health
of Genetic Disorders, Birth Defects and Disabilities31 and the and Nutrition in South Africa 2012–2016.56 While CDs are
National Guidelines for the Care and Prevention of the Most mentioned as a cause of neonatal death and as contributing to
Common Genetic Disorders, Birth Defects and Disabilities33 are the 15–20% of children affected by long-term/chronic health conditions
only two policy documents that focus solely on CDs. In 2014, a “not receiving the care they require”, no responding interventions
process of revision of the 2001 Policy Guidelines was initiated and are outlined.56 In other documents, individual CDs or categories
is due for completion in 2016. such as mental health disorders are recognised in the National
Department of Health’s Strategic Plan 2014/15–2018/19,57 but
A new edition of the Guidelines for Maternity Care in South
with no acknowledgement of the genetic predisposition of such
Africa was published in 2015,55 replacing the 2007 edition. This conditions.
contains relevant content on the identification of mothers at high
risk of having babies with a CD, as well as essential information for CDs are the first NCDs experienced by people – infants and
children.12 However, they are not contextualised as such in national
primary prevention of CDs and referral to genetic services.
strategies and interventions to address the growing NCD disease
Implementation of the 2001 Policy Guidelines,31 and therefore of burden. In the 2nd Triennial Report of the Committee on Mortality
the underpinning legislation, has been fragmented, especially in the and Morbidity in Children (CoMMiC),26 CDs are included under
past decade. The lack of recognition for the contribution of CDs to long-term health conditions in children together with acquired
the disease burden has resulted in the exclusion of comprehensive childhood conditions resulting from infections. This precludes the use
interventions from national strategies. The lack of integration of key of the term ‘NCD’, effectively burying CDs beneath communicable
interventions is noticeable in the National Department of Health’s disease once again.
148 S A H R 20 1 6
Congenital disorders
Conclusions and recommendations uphold the dignity and constitutionally and legally enshrined rights
of those affected by CDs.5,60
CDs are currently not recognised as a healthcare issue in South
Africa. Thus, their contribution to the disease burden is currently Priority actions include:
underestimated, and the impact of interventions for their prevention
and care is not considered. Instead, those born with and dying from ➢➢ Increased political will and financial commitment – This
CDs are largely overlooked and those surviving with disability are should be accompanied by appropriate CD-related expertise
largely ignored, as care is not being provided to this most vulnerable on ministerial and government committees dealing with the
group. Despite the lack of data due to poor national surveillance, neonatal/infant/child mortality and the development of
CDs are beginning to emerge as a significant cause of mortality in women, maternal and child health services.
children. Data from child mortality audit programmes indicate the ➢➢ Improvement of national surveillance, patient registries and
growing contribution of CDs to neonatal death and to deaths in monitoring of CDs – Linked to existing systems for sustainability,
children under five years of age. Following the epidemiological trend these should be accompanied by ongoing training to increase
of industrialised countries, the contribution of CDs to the disease coverage and accuracy of CD data identification and
burden will continue to increase in South Africa as the country documentation.
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develops, until they eventually constitute the leading cause of child
➢➢ Capacity-building – The education and training of healthcare
death and disability. By not addressing this issue comprehensively
professionals and the creation of related posts is required at
now, many lives will be lost unnecessarily and others will survive
all levels, especially for staff in primary health care facilities.
with lifelong disability as the result of serious CDs. There is also
16 6
a significant economic cost associated with CDs. Up to 70% of ➢➢ Increased community education and awareness – Such pro-
the deaths and the disability caused by CDs can be prevented or grammes are required to ensure awareness, understanding
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mitigated through relevant interventions.45,46 and knowledge of available services and how to use them.
South Africa has already passed the point at which other nations
Y T ➢➢ Role of lay advocacy/patient support groups – These need to
have identified the need to develop comprehensive medical genetic be recognised, supported and strengthened to partner with
A N
services in order to reduce child mortality further. This is largely government and the medical genetics community.
a consequence of the abating HIV and AIDS and TB epidemics
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which have buried CDs as a health issue. While the control of these
epidemics must continue, it cannot be at the expense of other child
4 ED
South Africa, such interventions must also plan for morbidity and
ongoing treatment of those affected. Such interventions have major
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S A H R 20 1 6 1 49
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1 52 S A H R 20 1 6
Integrating mental health into South Africa’s
health system: current status and way forward
13
Authors:
Marguerite Schneider i Emily Baron i Erica Breuer i
Sumaiyah Docrat i Simone Honikman i Ashraf Kagee ii
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Michael Onah i Sarah Skeen ii Katherine Sorsdahl i
Mark Tomlinson ii Claire van der Westhuizen i Crick Lund i
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A 20 IL
s implied by the World Health Organization’s statement, “There is no health Integration of mental health
without mental health”, it is essential to think of mental health as an integral
Y T
part of health. As such, it should be integrated into health policy and practice requires a vision, high-level
A N
in order to improve global health and address the significant treatment gap for commitment, allocation of
mental, neurological and substance use (MNS) disorders.
resources, as well as oversight
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Efforts to address this in South Africa have included policy responses as well as and support of the provinces
research and service innovations integrating mental health into general health care.
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This chapter provides an overview of the current policies and services in place for in the implementation of
mental health care in South Africa; it also describes current research on effective mental health services.
strategies for providing such services, and identifies key barriers and facilitators in
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The examples of research projects and service initiatives described reflect strategies
of integration into Primary Health Care, such as using task-sharing together with a
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strong support structure for supervision and referral. Once effectiveness is established,
the challenge of how to scale up these interventions remains. Further research will be
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required to evaluate both the outcomes of scaled-up mental health care and the best
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i Alan J Flisher Centre for Public Mental Health, Psychiatry and Mental Health, Universit y of Cape Town
ii Alan J Flisher Centre for Public Mental Health, Psychology, Universit y of Stellenbosch
1 53
Introduction
The prevalence of mental disorders is relatively high in South Africa, alcohol use play an important role in determining their onset and
as reported in the 2003 South African Stress and Health (SASH) severity.10,31 Also, the comorbidity of mental health, neurological,
study.1,2 The SASH study reported a 12-month prevalence of 16.5% and substance use (MNS) disorders and NCDs has adverse
and a lifetime prevalence of 30.3% for depression and anxiety implications for the prognosis of both conditions, and affects mood-
disorder in the adult South African population. Although anxiety related quality of life, family relationships, adherence to medical
disorders were most common, high rates of substance abuse were treatment and the potential for suicidal ideation.32
also reported.
Finally, non-fatal injuries as a victim, perpetrator/protagonist or
Yet, in South Africa, it is estimated that 75% of people with a mental witness have serious mental health implications.33 This is especially
disorder do not receive mental health services.3 This is commonly relevant in South Africa, where the South African Medical Research
referred to as ‘the mental health treatment gap’. Addressing this Council’s Burden of Disease Unit found that interpersonal violence
treatment gap is key to ensuring equitable access to health care for was the second leading risk factor for healthy years of life lost
people with mental disorder. This was clearly set out in Daar et al.’s in South Africa, associated with an increased burden of mental
Declaration on Mental Health in Africa: Moving to Implementation,4 disorders such as major depression and anxiety disorders, and
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which noted that people with mental disorders have psychosocial also increasing harmful alcohol use.34 The SASH study noted that
disabilities arising from their mental disorder, as well as from the having suffered an accident (20%) or physical violence (21%),
stigma, discrimination and social exclusion that they, their families having witnessed atrocities (4%) and having witnessed a death or
16 6
and their caregivers experience on a recurring basis. These someone else being injured (20%) accounted for the majority of the
psychosocial disabilities lead to difficulty with accessing health traumatic events experienced in the sample.35 In addition, over half
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services, finding and keeping employment, obtaining adequate of the relative post-traumatic distress burden was accounted for by
schooling, and engaging in social activities and development witnessing an injury event or death.35
programmes.5 Y T
Mental disorders result in lower life expectancy and increased risk
These issues are exacerbated in the context of elevated levels of
poverty. Over one fifth of South Africa’s population lives below the
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of co-morbid physical illnesses, and often result in limited access ‘food poverty line’, and with a Gini co-efficient of 0.65, South Africa
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to appropriate general healthcare services.6–8 Furthermore, people has one of the highest rates of inequality globally.36 Population
with physical health conditions have increased risk of common mental health is shaped by the social and economic environment of
mental disorders.9,10 In South Africa, mental disorder often co- a country,37 and common mental disorders have been linked with a
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occurs with and exacerbates what is known as the quadruple number of indicators of poverty in low- and middle-income countries,
burden of disease,11,12 namely: maternal and child illnesses; including low education level, food insecurity, inadequate housing,
infectious diseases such as HIV and TB; non-communicable diseases social class, socio-economic status and financial stress.38
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ranging from 18% to 47% for antenatal depression13–16 and obstetric risks, and exposure to violence.39 Simultaneously, those
from 32% to 35% for postnatal depression.17 The consequences with mental disorders are more likely to slide into poverty due to
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of maternal depression on maternal and child outcomes are well stigma and exclusion from social and economic opportunities,39 the
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documented and include premature delivery and other birth high cost of accessing treatment, or the loss of employment due to
complications, and delayed milestones for the children,17–19 as well diminished productivity.40 Up until recently, mental health was often
as increased risk of suicide, substance and alcohol abuse and non- omitted from national health and development policies.41
adherence to medical treatment regimens in mothers.13,20,21
However, the National Development Plan, intended to guide
Research suggests a high prevalence of mental disorders among development in South Africa until 2030, identified the need to
people living with HIV,22,23 as well as those diagnosed with TB.23–25 bolster the network of professionals to treat and support people
This is particularly important given the high prevalence of both TB experiencing psychosocial problems.42 The recent national Mental
and HIV in South Africa.26 There is growing evidence of increased Health Policy Framework and Strategic Plan adopted in 2013 also
risk of HIV infection for people with mental disorders as well as showed that the government was ready to integrate mental health
an increased prevalence of mental illness in people living with in the South African health system, and reduce the mental health
HIV. There is also substantial evidence showing that mental and treatment gap and health burden.43 Concerns remain, however,
substance use disorders are associated with poor adherence to HIV as to whether this plan is feasible and sustainable, and whether
and TB treatment.20,27–29 other activities and policies should be put in place for full integration
In recent years there has been increasing acknowledgement of of mental health into the health system. The aims of this chapter
the growing prevalence of NCDs, such as cardiovascular disease, are therefore to provide an overview of the current policies and
cancer, diabetes and chronic respiratory disorders, in low- and examples of health services research and implementation for mental
middle-income countries (LMICs).11,30 While there may be genetic health care in South Africa; to identify gaps; and to propose a way
antecedents of these conditions, there is growing evidence that forward for policy, research and practice to facilitate the integration
behavioural factors such as diet, physical inactivity, smoking and of mental health in South Africa’s health system.
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health care
which provided a framework for provinces to develop their own
mental health policies and plans. In 1997/1998, the Department ➢➢ To ensure that the planning and provision of mental health
of Health commissioned a study on mental health service norms services is evidence-based.41
and standards for South Africa.46 This initially focused on severe
16 6
Prior to this policy, the mental health services context was
psychiatric conditions, and was followed by further studies on norms
characterised by the treatment gap for mental disorders previously
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for community mental health services,47 and child and adolescent
described. A situational analysis of public mental health services
mental health services.48 The Mental Health Care Act of 200249 was
and policies in South Africa and its nine provinces undertaken in
promulgated in 2004, and was a major piece of legislation reform
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in line with international human rights instruments and World Health
Organization (WHO) guidelines. The 1997 Mental Health Policy
200551 showed weak policy implementation at provincial level,
marked inequality between provinces in terms of available resources
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for mental health care, lack of routine data collection for monitoring,
Guidelines were reviewed a decade later50 and showed limited
and reliance on mental hospitals rather than more decentralised
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mental disorders, with little effort to detect and treat other mental
implementation of guidelines.
disorders such as depression and anxiety. However, there were
In 2012, the Minister of Health convened a series of provincial some changes noted, such as endorsement of the integration of
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Mental Health Summits (February–March 2012), attended by over mental health into primary health care with training of some PHC
4 000 mental health stakeholders around the country. The purpose nurses, and integration within emergency management and ongoing
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of these summits was to generate national consensus around policy psychopharmalogical care for those patients with stabilised chronic
priorities for mental health in South Africa. This culminated in a mental disorders.43
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Plan,55 which set clear targets and indicators for increasing policy out-of-pocket payments are not part of the public service financing
commitment to mental health and scaling up mental health services mix.44,61–63 For example, South African households with illness
globally between 2013 and 2020. Every two years, the WHO Atlas (including mental disorders) often spend over 10% of their household
survey collects data for these indicators to assess the extent to which income on public health-related needs, much of this being for costs
countries are making progress towards these targets.55 The four such as transport, care arrangements and management of complex
major objectives of the action plan are to: healthcare needs.64
➢➢ strengthen effective leadership and governance for mental With the recent release of the NHI White Paper, the South African
health; NHI scheme has recognised the quadruple burden of disease in the
➢➢ provide comprehensive, integrated and responsive mental country, with NCDs including mental illness playing a contributory
health and social care services in community-based settings; role.65 The proposals set out in the NHI White Paper already
face major financing and implementation constraints because of
➢➢ implement strategies for promotion and prevention in mental
low growth rates, prevailing drought and power shortages. The
health; and
consequences of this are that health insurance for neglected health
➢➢ strengthen information systems, evidence and research for problems like mental health are likely to be relegated to the ‘back-
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mental health. burner’, making the National Mental Health Policy Framework difficult
to implement. Aside from the financing structure of the proposed
In 2015, mental health was also included in the United Nations
NHI, the content of the comprehensive package for insurance-
(UN) Sustainable Development Goals. In the Health Goal of the
holders should also be redefined to incorporate mental health, as
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declaration, the UN points out the importance of mental health for
well as substance abuse. Indeed, although the White Paper includes
overall health and global development. It states that by 2030, the
mental health services and health counselling services as part of
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aim of all countries is to “reduce by one third premature mortality
the comprehensive package, it does not acknowledge the wide-
from non-communicable diseases through prevention and treatment
ranging nature of mental disorders, from depression and anxiety
to promote mental health and well-being” (target 3.4); “strengthen
Y T through to psychosis and mood disorders. Therefore, while the NHI
the prevention and treatment of substance abuse” (target 3.5), and
implementation is likely to improve mental health systems through
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implement “universal health coverage” (target 3.8). This is a major
enhanced infrastructure and augmented investment in primary and
departure from the WHO Millennium Developmental Goals56,57
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development.56,57
mental health needs of South Africa will be adequately addressed.
Financing barriers The research consortium EMERALD (Emerging mental health systems
in low- and middle-income countries) is currently attempting to
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health system barriers to, and solutions for, the scaled-up delivery
disorder than to treat it.58 Bearing this in mind, together with the
of mental health services in LMICs, and by doing so to improve
recognised lack of financial resources in South Africa and other
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sustainable financing.
primary objectives in the South African context:
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a http://www.EMERALD-project.eu
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Programme for Improving Mental Health Care (PRIME) implementation provides a model for scaling up the implementation of this
PRIME is a research consortium working in five LMICs (Ethiopia, India, type of service. This piece of research addresses the need to develop task-
Nepal, South Africa and Uganda) funded by the United Kingdom’s sharing interventions for maternal depression that are feasible to scale up
Department for International Development (DFID).70 In each country, at all antenatal care services.
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a district demonstration site has been established to consult with local
stakeholders and develop and implement a district mental healthcare plan.
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The South African site is a NHI pilot site recommended by the national Integration of mental health services into chronic
Department of Health: Dr Kenneth Kaunda District in the North West disease care
Province. PRIME team members have been working with the Department
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of Health and local stakeholders to develop and implement the district
mental health care plan. The South African plan is integrated with the
In South Africa, the integration of chronic disease and mental
health services delivery has been slow due to limited knowledge of
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Department of Health’s chronic disease management approach, and feasible, acceptable and effective collaborative care models.
includes core intervention packages at the healthcare organisation, facility
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and community levels, providing care for individuals with psychosis, The project entitled ‘Strengthening South Africa’s health system
depression and alcohol use disorder.52 PRIME-SA has worked to strengthen through integrating treatment for mental disorder into chronic
the mental health components of the Primary Care 101 (PC101) clinical
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detection surveys (to discern changes in the capacity of primary care model of care. In the horizontal model, within the chronic disease
staff to detect people with depression, and alcohol use disorders), cohort team, one or more healthcare providers are designated to provide
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In addition, the PRIME team is working with the Department of Health to designated personnel who are responsible for their usual chronic
scale up the PRIME packages for depression in a large cluster-randomised disease duties as well as mental health care. In the vertical model,
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controlled trial for people living with HIV and hypertension.b This initiative services are provided by separate cadres of health providers, where
addresses the need to integrate mental health care services within PHC mental health services are provided by dedicated personnel whose
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Integration of mental health into primary care and effective task-sharing interventions67,80,81 and the AFFIRM trial
should provide further evidence on this nature.
Two current services where mental health care is fully integrated in
the health system are described in Box 2. Limitations
Box 2: Examples of integration of mental health into primary care Although there are a number of effective evidence-based treatment
interventions available in the South African and broader LMIC
The Perinatal Mental Health Project context, such as those described, these remain largely at the testing
The Perinatal Mental Health Projectc (PMHP) provides a stepped-care, phase and need to be scaled up more broadly and their feasibility
collaborative model for delivering a mental health service at three MOUs
assessed. Many of the models are research-led, with access to
in Cape Town.75 Given that 99% of pregnant women attend antenatal
care facilities for an average of 3.7 visits,76 this provides an important
resources that might otherwise not be available in primary care
opportunity to screen for common perinatal mental health problems, and settings. Indeed, effective services, especially task-sharing models of
provide integrated care. All women are offered psychosocial risk and services, require strong training, supervision and support structures
depression screening at their first antenatal visit, and those who meet the to ensure high-quality services and retention of human resources.
criteria for being at risk are offered on-site, free-of-charge counselling
Stigmatisation of patients with mental or substance use disorders by
with one of the trained PMHP counsellors. Two counsellors are nurses
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who were trained in counselling and the third counsellor has a BPsych
healthcare workers may directly affect health-seeking behaviours of
degree; all three are supervised by a clinical psychologist. The counsellors patients, and must also be addressed on an ongoing basis during
conduct a detailed assessment and tailor their intervention according training and supervision.73
to the needs of the patient. This may include couple or family therapy,
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motivational interviewing, problem-solving therapy, psycho-education, Furthermore, research shows that mental disorders can be detected
and interpersonal and cognitive behavioural therapy. The counsellor is through effective screening by trained non-professionals; however,
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also responsible for co-ordinating referrals, as required, to a wide range of we need more definitive evidence on optimal detection methods,
social support services. A small minority of women with severe symptoms
including when and for whom screening might be appropriate.74
are eligible for and accept referral to psychiatric services.
Y T
Several years of service delivery, with embedded monitoring and This should be provided together with a well-functioning referral
evaluation procedures, have resulted in the development of several design mechanism to ensure that those who require more specialised
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features that address access to care, stigma and mental health awareness. services are able to access these. Indeed, system strengthening is
For example, the PMHP has conducted participatory capacity-building and important to ensure continuity of care across primary, secondary
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training activities with all maternity care staff at the three MOUs to improve
and tertiary care, and access to medication and psychosocial care.
mental health literacy, empathic skills and self-care practices. This training
has created an enabling environment for the sustained integration of the Given the financial, systemic and human resources challenges that
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mental health services. The number of women screened has increased, the South African health system faces, the scaling-up of research-
as has the rate of uptake with a reduction in the loss to follow-up. While related programmes is complex.
the programme is currently self-funded, the model of care developed by
PMHP provides an example of the feasibility of integrating the content into
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existing maternal health care services. Challenges remain as to the funding Conclusion
model and the support structures required to ensure that the counsellors are
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effective and avoid burnout. Progress has been made in South Africa with regard to integrating
mental health into health systems. Recent South African policy
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secondary-level health facilities for the care of adults and children who
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have been sexually assaulted. These Centres were established under Health Advisory Committee in 2015. However, despite compelling
the mandate of the Sexual Offences and Community Affairs Unit of
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utilise implementation science and health systems research methods
and frameworks to ensure effective programmes. The PRIME project
is starting to do this in the NHI pilot site in the North West Province.
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Integration of mental health requires a vision, high-level commitment,
allocation of resources, as well as oversight and support to the
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provinces for the implementation of mental health services. The
vision is apparent in the South African Mental Health Policy and
Strategy Plan – implementation of this policy is the task ahead.
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URL: http://www.ncbi.nlm.nih.gov/pubmed/20621748 bp.114.153726
39 Patel V. Poverty, inequality, and mental health in developing 53 Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin
countries. In: Leon D, Walt G, editors. Poverty, Inequality and G, et al. Challenges and opportunities for implementing
Health. Oxford: Oxford University Press; 2001. p.247–62. integrated mental health care: A district level situation analysis
from five low- and middle-income countries. PLoS One.
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54 Lancet Global Mental Health Group, Chisholm D, Flisher AJ, 69 Spedding MF, Stein DJ, Sorsdahl K. Task-shifting psychosocial
Lund C, Patel V, Saxena S, Thornicroft G, Tomlinson M. Scale interventions in public mental health: A review of the evidence
up services for mental disorders: a call for action. Lancet. in the South African context. In: Padarath A, King J, English
2007 Oct 6;370(9594):1241–52. [Internet]. [cited 24 March R, editors. South African Health Review 2014/15. Durban:
2016]. Health Systems Trust; 2015. p.73–87. [Internet]. [cited 24
URL: http://www.ncbi.nlm.nih.gov/pubmed/17804059 March 2016].
URL: http://www.hst.org.za/publications/south-african-health-
55 World Health Organization. Mental Health Action Plan review-2014/15
2013–2020. Geneva: World Health Organization;
2013.p.1–44. [Internet]. [cited 224 March 2016]. 70 Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R,
URL: http://www.who.int/mental_health/publications/ Jordans M, et al. PRIME: a programme to reduce the treatment
action_plan/en/ gap for mental disorders in five low- and middle-income
countries. PLoS Med. 2012 Jan;9(12):e1001359. [Internet].
56 Thornicroft G, Patel V. Including mental health among [cited 24 March 2016].
the new sustainable development goals. BMJ. 2014 Aug URL: http://www.ncbi.nlm.nih.gov/pubmed/23300387
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URL: http://www.ncbi.nlm.nih.gov/pubmed/25145688 71 Sorsdahl K, Stein DJ, Corrigall J, Cuijpers P, Smits N, Naledi
T, et al. The efficacy of a blended motivational interviewing
57 Votruba N, Eaton J, Prince M, Thornicroft G. The importance and problem solving therapy intervention to reduce substance
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58 Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ. Mental Treat Prev Policy. 2015;10(1):46. [Internet]. [cited 24 March
illness and lost income among adult South Africans. Soc 2106].
URL: http://substanceabusepolicy.biomedcentral.com/
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59 Dixon A, McDaid D, Knapp M, Curran C. Financing mental
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health services in low- and middle-income countries. Health 72 Lund C, Schneider M, Davies T, Nyatsanza M, Honikman S,
Policy Plan. 2006;21(3):171–82. Bhana A, et al. Task sharing of a psychological intervention
for maternal depression in Khayelitsha, South Africa: study
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Geneva: World Health Organization; 2014. Jan;15(1):457. [Internet]. [cited 24 March 2016].
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61 Patel V. Mental health in low- and middle-income countries. URL: http://www.ncbi.nlm.nih.gov/pubmed/25416557
Br Med Bull. 2007 Jan;81–82:81–96. [Internet]. [cited 24 73 Van Boekel LC, Brouwers EPM, Van Weeghel J, Garretsen
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Human Development Network; 2010. common mental disorders in low resource settings: reasons
63 World Health Organization. Mental Health Atlas. Geneva: for caution and a way forward. Int Health. 2013 Mar
1;5(1):11–4. [Internet]. [cited 24 March 2016].
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household costs of health care in rural South Africa with free 75 Honikman S, van Heyningen T, Field S, Baron E, Tomlinson
public primary care and hospital exemptions for the poor. M. Stepped care for maternal mental health: a case study of
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URL: http://www.ncbi.nlm.nih.gov/pubmed/19254274 76 Day C, Gray A. Health and related indicators. In: Padarath
A, English R, editors. South African Health Review 2012/13.
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Sex work and South Africa’s health system:
addressing the needs of the underserved
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Authors:
Andrew Scheibe i,ii
Marlise Richter iii,iv,v
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Jo Vearey v
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ex work remains illegal and highly stigmatised in South Africa, resulting in South Africa will not
sex workers – the majority of whom are internal or cross-border migrants –
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experiencing ongoing human rights violations and a high HIV burden. High reach the United Nations
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levels of unemployment, limited socio-economic opportunities and associated Joint Programme on
migration dynamics mean that sex work remains a key livelihood option for many
HIV and AIDS 90-90-90
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a focus on HIV-related programmes. The analysis is based on the World Health attention and political will
Organization’s health system ‘building blocks’ framework and is informed by a are invested in sensitive,
policy scan, literature review, consultation with sex work experts, and reflection.
appropriate and evidence-
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sex work law reform, the removal of ideological provisions in donor grant agreements,
and the need for strong political will to roll-out sex work-specific health programmes. worker health.
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The authors argue that South Africa will not reach the United Nations Joint Programme
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on HIV and AIDS (UNAIDS) 90-90-90 targets unless adequate attention and political
will are invested in sensitive, appropriate and evidence-based responses to sex
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worker health.
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Limited but important progress has been made in expanding appropriate programmes
for sex workers in South Africa. Much more is needed to reach and empower sex
workers to keep themselves safe, safeguard public health, and achieve health-related
sustainable development goals. Delays in addressing data gaps, implementing
global recommendations on sex work law reform and evidence-based interventions
continue to impact negatively on sex worker morbidity and mortality, and have wide-
ranging implications for public health and related expenditure.
1 65
Introduction
The healthcare system is a central determinant of health, with quality system that may not meet their health needs. Against this background,
and access – comprising availability, acceptability and affordability the chapter reviews current sex worker health interventions in South
– to health services being recognised as key to achieving equity in Africa, and analyses policy and legal frameworks relating to sex
health and wellbeing.1 This is especially relevant for populations on workers, the sex work setting and public health. The analysis
the peripheries: those who are often excluded from social welfare focuses on the World Health Organization (WHO) health system
provision, face disproportionately high levels of vulnerability to ‘building blocks’ framework4 from a sex worker health perspective.
illness, and endure an increased impact of poor health.2 The context The chapter concludes with recommendations for health system
of sex work in South Africa places sex workers – referred to here as strengthening to address the health inequities experienced by sex
adults who consent to the sale of sex3 – on the periphery: individuals workers in South Africa. Some of the key terms used in this chapter
involved in the sale of sex in South Africa are criminalised; are are presented in Box 1.
particularly vulnerable to illness, sexually transmitted infections
(STIs), violence and abuse; and are underserved by the current
health system. As a result, sex workers face increased exposure to
Methods
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health risks and are often unable to mitigate dangers. These risks A rapid analysis of sex work, health and rights, with a focus on
are compounded by migration status, sexual orientation, gender HIV, in the South African context was conducted. The WHO Health
non-conformity, working in unsafe spaces where clients are solicited, Systems Framework was used to analyse the South African health
and through harmful substance use. system from a sex work health perspective, structured on the health
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system building blocks7 (see Figure 1). Data were collected through
This chapter provides a contextual understanding of sex work in
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a policy scan and literature review, supported by engagement
South Africa, and an overview of the health and rights inequities
with sex worker service providers and reflections on the authors’
experienced by sex workers. These inequities are linked to their
professional experience. Each author has over eight years’
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exclusion from society, and their dependence on a public health
experience of working on issues relating to sex worker health in
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South Africa, with various areas of focus, including HIV prevention,
Box 1: Key definitions and terminology
sex worker human rights advocacy and law reform, and migration
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and health.
Terminology, identity politics and sexual behaviours
Gender refers to the social attributes and opportunities associated with The literature review on sex work and health in South Africa
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being male and female, which are socially constructed, learnt and presented in this chapter builds on recently published work and
therefore changeable.3 work in press undertaken by the authors, with searches conducted
Biological sex is a classification based on reproductive organs and via ScienceDirect, Pubmed and Google Scholar. Apart from data
functions that are present from birth.3
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norms and expectations traditionally associated with biological sex.3 2005 and 2015 and focusing on sex work, health and rights in
Transgender refers to people whose gender identity and expression does the South African and sub-Saharan setting were incorporated.
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not conform to the norms and expectations traditionally associated with The review of grey literature, policy and technical documents
their sex at birth.3 was informed through the authors’ ongoing work in this area,
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Who is a sex worker? involvement in policy spheres, and through engagement with key
An important assumption of sex work-specific health care programming actors and experts who were invited to share recent unpublished
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is that healthcare users would self-identify as the target group – thus grey literature. A range of sex work experts were contacted via
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that women, men and transgender people who sell sex would perceive email or telephone and programme documentation was reviewed.
themselves as being ‘sex workers’ – and would want to utilise these Expert key informants included sex workers, programme managers,
services. “Conceptually – but also programmatically – some of the biggest
researchers and representatives from technical agencies, who were
challenges for policy-makers and researchers in Africa in addressing
this vulnerability [to STIs] are the diverse forms of sex work and their
requested to provide additional information related to the WHO
overlap with sexual networks in the general population. The difficulty health system building blocks. Recommendations were developed
of distinguishing ‘sex work’ from transactional sex in all its various using a social determinants of health lens.1
manifestations demonstrates this vividly”.5
While precise definitions of sex work remain elusive, the outdated socio-
legal understanding of ‘sex-for-reward’ could conceivably include a
cascade of sexual interactions including transactional sex, ‘sugar-daddies’,
survival sex and even sex within marriage.6 Although definitions remain
varied and imprecise, the importance of peer educators reaching out
into sex worker communities and linking health care users to specialised
services remains important.
Male sex workers: Refers to sex workers who were born biologically male.
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Responsiveness
Health workforce
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Improved efficiency
Service delivery
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Source: World Health Organization, 2016.7
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Key findings Y T
Context
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Background to sex work in South Africa
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In 2013 it was estimated that between 132 000 and 182 000 restrictive Immigration Act – which makes it difficult for lower-skilled
people sold sex in South Africa.8 Sex work is an important livelihood and job-seeking migrants to regularise their stay in the country –
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strategy and approximately two-thirds of female sex workers in the presents additional legal challenges for non-national sex workers
sub-Saharan region report being responsible for dependants.5 The who may struggle to obtain and maintain the documents required
majority of female sex workers operate on their own and seldom rely to be in South Africa legally.17,18 This compounds the discrimination
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on intermediaries (such as ‘pimps’ or ‘controllers’). In South Africa, experienced from healthcare providers and the police.19
sex work typically offers higher earnings than other work available
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Research has shown that the removal of criminal penalties for sex
for the same education level.9–11 Many part-time sex workers do
work – specifically the decriminalisation of sex work where no
not identify with the term, concept or identity associated with sex
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S A H R 20 1 6 1 67
Often, municipal by-laws rather than the Sexual Offences Act are and behavioural factors.15,31 The majority of sex workers are
used to arrest sex workers because of the difficulties inherent in migrants from elsewhere in South Africa (internal migrants) or from
proving the elements of the offence, particularly in relation to the neighbouring countries (cross-border migrants) and their status as
client. migrants presents additional HIV risk factors. Whilst a full discussion
of the association between migration and HIV is beyond the scope
The South African Law Reform Commission was charged to research
of this chapter, please see Richter and Vearey (in press).17 In areas
and provide recommendations on law reform for sex work (South
where sex workers are poorly organised, negotiating condom use
African Law Reform Commission Project 107 ‘Adult Prostitution’).
with clients may be particularly fraught and sex workers may not be
This process has been ongoing for more than 15 years, and the
able to insist on protected sex.32,33 Various studies have documented
Commission has not yet released recommendations on amendments
harmful use of alcohol and drugs in sex work settings, which impacts
to this outdated law.22
on sex workers’ ability to refuse dangerous clients or to negotiate
Sex work, health and HIV safer sex.34,35 Violence against sex workers remains high and has
been well documented as a risk factor for HIV.36,37 Regrettably,
Whilst this chapter will focus on HIV to highlight the ways in which few studies on sex work in South Africa focus on exploring the risk
a range of social determinants influence the health and wellbeing mitigation strategies used by sex workers.5
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of sex workers, individuals who sell sex experience a wide range of
health inequities including those related to reproductive health and In the hierarchy of dangers associated with sex work, street-
rights, chronic illness, mental health and substance use.23 based sex workers are often designated as the most vulnerable;
they tend to be independent operators not tied to obligations and
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Unprotected paid sex is a significant factor in the HIV epidemics of commissions associated with brothel-based sex work, with flexibility
sub-Saharan Africa;24 HIV prevalence among sex workers and sex of work and autonomy being prized,38 yet their visibility in public
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worker clients is about 10–20 times higher than among the general spaces increases their exposure to police arrest, harassment
population in the region.25 In 2013, the first multisite integrated and abuse by the general public.39,40 Attempts at keeping their
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HIV biological behavioural surveillance (IBBS) study was conducted
among female sex workers in South Africa. The IBBS (n=2 180)
profession a secret while having sex in cars or public places may
impose time and security pressures which impede safer sex.41,42
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estimated that HIV prevalence among female sex workers was Whilst the stigmatising attitudes of healthcare workers have been
71.8% in Johannesburg (Gauteng Province); 39.7% in Cape Town
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among 173 female sex workers in Harrismith (Free State Province) possession, either confiscating or destroying them, or using them as
and Pietermaritzburg (KwaZulu-Natal Province) to be 88.4%.27 proof that the person is guilty of prostitution.44 This is in direct conflict
Another study in 2014/15 found HIV prevalence among female with public health policy, and this contradiction is highlighted in the
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sex workers in Port Elizabeth (Eastern Cape Province) (n=410) to be South African National Sex Worker HIV Plan.45
63.7%.28 These figures indicate that HIV prevalence among female
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15 years and older in the general population.29 Equally worrying Despite clear evidence being available since the onset of the HIV and
is the significant proportion of female sex workers who know that AIDS pandemic showing that sex workers are particularly vulnerable
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they are living with HIV but are not currently on antiretroviral to HIV, and that the sex work context impacts on public health, South
therapy (ART): 12% in Cape Town; 25% in Durban and 38% in Africa’s health and policy responses to sex work have a chequered
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Johannesburg.28 A range of barriers – including mobility and their history. South Africa’s first AIDS Plan in 1994 recommended that
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status as migrants – impede sex worker access to health care, HIV the criminal law around sex work should be removed; several years
testing, retention in treatment, care and support, and access to HIV later, the only mention of sex work in the National HIV/AIDS/STD
prevention technologies. Some of these are described in this section. Strategic Plan for South Africa 2000–2005 was to task several
government actors to investigate the decriminalisation of sex work.
Critically, a lack of national data on (1) the number of sex workers
The National Strategic Plan (NSP) 2007–2011 included a more
who are HIV-positive and have tested for HIV; (2) the number of sex
rigorous engagement with sex work; it rejected discrimination
workers living with HIV who are eligible for ART; (3) the number of
against sex workers, acknowledged the increased vulnerability of
sex workers on ART, and (4) the number of sex workers on ART who
sex workers to HIV, recommended the rolling out of customised
are virologically suppressed, hinders the quantification of progress
prevention packages for sex workers, and proposed that sex work in
towards reaching the Joint United Nations Programme on HIV and
South Africa be decriminalised.46 Regrettably, little changed during
AIDS (UNAIDS) 90-90-90 targets that are needed to bend the
that period, with a mid-term review of the 2007 NSP noting scant
trajectory of the HIV epidemic.30
progress in the implementation of sex worker programmes.47
Factors inf luencing HIV risk among sex workers
Significantly, sex workers were recognised as a key population
A number of characteristics of the sex work context increase the in the National Strategic Plan on HIV, STIs and TB 2012–2016
risk of HIV acquisition and ill-health among sex workers and their (the ‘2012 NSP’).48 The drafting of the 2012 NSP in 2011 saw
partners, most notably that of frequent sexual intercourse with the insertion of several strong human rights provisions including
multiple partners where protected sex cannot always be negotiated. the decriminalisation of sex work. However, these important and
Cisgender and transgender women and men who sell sex face progressive additions were removed by Cabinet before the 2012
different configurations of HIV risk, related to social, biological NSP was launched on World AIDS Day 2011, despite civil society
168 S A H R 20 1 6
Sex work
consensus on the inclusion of these provisions.49 The subsequent support from PEPFAR are required to sign a so-called ‘Anti-prostitution
South African National AIDS Council (SANAC) compromise with Pledge’. According to the United States’ ‘Leadership Against HIV/
the SANAC Sex Work Sector was the drafting of a separate NSP for AIDS, Tuberculosis, and Malaria Act of 2003’, all non-United States
sex workers. Regrettably, this comprehensive National Strategic Plan (US) non-governmental organisations (NGOs) that receive United
for HIV Prevention, Care and Treatment for Sex Workers (the ‘SW States Government Grants (i.e. PEPFAR, United States Agency for
NSP’)50 was never officially launched. International Development (USAID), Centers for Disease Control and
Prevention (CDC)) are required to sign an agreement with PEPFAR
Despite the removal of some key human rights sections, the final
that commits them to the following (section 22 U.S.C. § 7631(f)):
version of the 2012 NSP did include a number of key programmatic
areas for sex workers. In spite of this, the 2012 NSP Progress Report No funds made available to carry out this chapter, or any
noted limited successes in reaching the sex worker population, amendment made by this chapter, may be used to provide
despite citing studies that showed HIV prevalence among sex assistance to any group or organization that does not have
workers to be 26–59.6%, thus highlighting the urgent need for a policy explicitly opposing prostitution and sex trafficking,
programmes to reach sex workers. The report described the Sex except that this subsection shall not apply to the Global Fund
Worker NSP (that was never officially launched), and a sex workers to Fight AIDS, Tuberculosis and Malaria, the World Health
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size estimation survey, as “important achievements”.51 Organization, the International AIDS Vaccine Initiative or to any
United Nations agency.
In 2015, the SANAC Secretariat brought together a Sex Worker
Technical Working Group to draft a South African National Sex Even though these funding requirements have been found in various
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Worker HIV Plan 2016–2019 (‘the Sex Worker Plan 2016–2019’). court challenges to violate freedom of speech in the United States
This plan was launched in March 2016 and emphasises a and cannot be applied to NGOs in the US (‘domestic affiliates’)
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“comprehensive and nationally coordinated response”. It delineates or to its ‘foreign affiliates’ in other countries,55 they still apply to
clear aims and targets, and recommends the decriminalisation of ‘foreign NGOs’.a,56 Commendably, PEPFAR has enabled the
sex work.45 Y T scale-up of much-needed services and has thereby averted millions
of AIDS-related deaths and prevented HIV infections. Against the
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Review of South Africa’s health systems building blocks backdrop of such far-reaching success and impact, it is regrettable
from a sex work perspective that organisations receiving PEPFAR funds that are aware of sex
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rights.49
the United Nations Development Programme (UNDP) recommend
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the decriminalisation of sex work.52 These recommendations are Due to the high levels of migration and mobility within South
informed by recommendations of the Global Commission on HIV Africa and the region, health policy and programmatic responses
and the Law, which synthesised available evidence around the should engage with migration and enable all people who migrate,
advantages and disadvantages of a range of legal frameworks including sex workers, to have continued access to public healthcare
and their influence on health and rights with a mounting evidence services.58 Within the Southern African Development Community
base.20 The delay in legal reform and lack of high-level commitment (SADC), efforts are under way to harmonise responses relating
to address sex work issues in South Africa has contributed to ongoing to mobility and healthcare access, including the ratification of a
HIV infections among sex workers, their clients and society at large. declaration on tuberculosis (TB) in the mines and the drafting of
The lack of high-level stewardship to interrogate outdated morally a financing framework for a regional response to communicable
based frameworks that are often used to influence policy and laws diseases and population mobility.58,59
also contributes to the high levels of stigma and discrimination faced
by sex workers in the community, and ultimately in health facilities.53
S A H R 20 1 6 1 69
Financing Health workforce
Globally, less than 1.0% of HIV prevention funding focuses on sex Healthcare providers in the community and in health facilities
work,60 while fewer than 50.0% of sex workers had access to HIV play an important role in enabling health. An ethical health sector
prevention services in 2009.61,62 This investment-burden of disease response to sex work would aim to create a safe, effective and non-
mismatch is reflected in South Africa’s investment in the HIV response. judgemental space that would attract sex workers – including non-
In 2013/14, R130.7 million (R3.6 million by the Global Fund, national sex workers – to its services, with a workforce capacitated
R23.7 million by PEPFAR and R103.4 million by the South African to provide high-quality, acceptable health services.67,68
Government) was spent on HIV prevention, HIV testing and linkage
Peer-delivered prevention, testing and linkage to care services are
to care programmes for sex workers. This is equivalent to about
recommended best practices for sex work programming.52 Peers
1.5% of spending on ART, half the amount spent on communication
provide a range of services within South African communities.
for behaviour change, and almost a tenth of the amount spent on
Between 2012 and 2015, there were 2 240 peer educators
HIV testing services for the general population.54
employed as part of the National Department of Health’s High
Investments in 2013/14 were higher than in 2011, and reflected Transmission Areas programme, 560 sex work peers through the
investments from the South African Government, PEPFAR and the Global Fund-supported Red Umbrella programme, and 122 through
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Global Fund to support the scale-up of sex worker prevention and PEPFAR-supported programmes.45
testing services. Current funding mechanisms have supported civil
In 2012, Quality Assurance Standards for Peer Education and
society organisations to provide sex work-appropriate services and
Outreach Programmes for High Risk Vulnerable Populations in
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also enable effective public-private partnerships, largely through
South Africa were developed by ICF International, with input from
the South African Government’s HIV/AIDS Conditional Grant,b
organisations implementing large-scale sex work programmes.69 The
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PEPFAR through CDC and USAID, and the Global Fund’s ‘Red
National Department of Health’s High Transmission Area Guidelines
Umbrella Programme’ that is co-ordinated through SANAC and the
include minimum standards for peer outreach programmes and
Networking HIV/AIDS Community of South Africa (NACOSA).63,64
Y T recommendations for community mobilisation for key populations,
Regrettably, HIV expenditure on ART is not disaggregated by key including sex workers.70 In 2015, South African Partners used
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population group. Current government financing does not allow for these as part of quality assurance and quality improvement
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the provision of oral pre-exposure prophylaxis, ‘Universal Treatment’ processes for key population peer programmes, including sex
and ‘Test and Treat’, which are key components to safeguarding worker programmes.71 While a recent systematic review found that
sex worker health. These are currently under consideration by community empowerment-based approaches to addressing HIV
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the South African Government.65 Decreasing international donor among sex workers were significantly associated with reductions in
funding poses a particular threat to sex work programming as it HIV, and with increases in consistent condom use with all their clients,
currently accounts for a quarter of direct financing for sex work it found pernicious challenges to scaling up these programmes,
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Sex work
for peer outreach workers.77 However, data quantifying rights efforts in general, problems with supply and availability would have
violations in healthcare settings are not currently available. a disproportionate effect on sex workers and their clients due to their
necessity and increased demand in the sex work setting.
To our knowledge, the University of Pretoria’s medical students’
service learning and community-based education programme is the The National Department of Health is developing Oral Pre-Exposure
only undergraduate training programme for health professionals Prophylaxis (PrEP) and Test and Treat guidelines.65 The targets of
that exposes students to community-based HIV-related programming. the Sex Worker Plan 2016–2019 include the provision of PrEP to
Through this project, medical students engage with community-based 3 000 sex workers and that 90% of sex workers who test positive
HIV prevention services for sex workers provided by civil society are on ART. HIV self-testing is currently being researched among
organisations.78 The Desmond Tutu HIV Foundation developed sex key populations.83 The National Department of Health’s National
worker sensitisation training tools79 and organisations working with Contraception and Fertility Planning Policy and Service Delivery
sex workers implement in-service health worker sensitisation training Guidelines and National Contraception Clinical Guidelines (2012)
around sex work in line with WHO recommendations.52 Most explicitly include consideration of sex workers and of migration.84
recently, the South African Government partnered in a programme
that integrated issues relating to sex work and other key populations. Information
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Regrettably, inclusion of this training into medical and nursing The provision and use of high-quality information is another building
training colleges and into regional training centres, and subsequent block of an effective health system. Information includes research,
scale-up, have not happened.80 Laudably, the Southern African HIV surveillance and programmatic data.
Clinicians’ Society has recently supported the decriminalisation
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of sex work,81 while bodies such as the South African Medical A range of quantitative and qualitative sex worker research is
Association and the Nursing Council have yet to develop a position ongoing, spanning HIV biomedical prevention research (including
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statement on the provision of services for sex workers. oral and topical PrEP and Test and Treat), health systems strengthening
(inclusion of sex worker services in existing health systems), and
A key concern relates to ensuring treatment continuity for HIV – and
Y T epidemiology and other social determinants of health (including
other chronic conditions – for migrant and mobile sex workers. The violence and rights abuses).85–87 The process and ethics of research
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World Health Assembly passed a Resolution in 2008 that provides on sex work is improving and sex workers are more involved in all
specifically for the need to improve health systems responses to stages of research. Research–sex worker organisation partnerships
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migrant and mobile populations, which are critical for sex workers are being established, improving the quality and ethical nature of
in South Africa.58 Whilst healthcare workers currently receive no research and enabling advocacy. Despite advances in research and
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training on migration, which results in misunderstanding about surveillance data, evidence-informed responses are lacking and
mobility and movement in the country and region, training modules research gaps remain on male and transgender female sex workers
produced by the International Organization for Migration in and the non-HIV health burden affecting sex workers.
partnership with the African Centre for Migration and Society at the
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Routine data collection within the health information system does Sex worker programming
not include any measure of migration or mobility.58 As a result,
The increased focus on HIV prevention programming for sex
health system responses are not migration-aware nor responsive to
workers has enabled 152 993 interactions with sex workers to be
migration. Failure to collect information that can be disaggregated
documented between 2012 and 2015 (see Table 1). The majority
by migration status or sex work prevents monitoring of health system
of programmes employ peer-based mobilisation approaches
performance in real time, relies on expensive surveillance activities
that include basic behaviour change interventions, prevention
(i.e. IBBS), and will result in problems in managing migration,
commodities, and linkage to testing and other community-based
movement and ART adherence.
services. This approach is employed through the High Transmissions
Data gaps – including a lack of data on migration and mobility Area Programme which has the greatest reach, although the need
– impact resource allocation and the monitoring of impact. for peers working in areas targeting sex workers to be sex workers
Challenges in linking data between community and facility-based themselves was emphasised only in 2014.70
elements should be addressed, as these are important components
In 2015, the Red Umbrella Programme, implemented by the Sex
for tracking linkage to care and adherence, and for continuity of
Workers Education Advocacy Taskforce and 18 other sub-recipient
treatment for other conditions.
organisations through NACOSA, made contact with approximately
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40 000 sex workers per quarter across 70 sites across the country
Service delivery
and provided them with basic health services.92 However, a
UNAIDS recommends that the health system’s response to sex reduction in Global Fund investments for sex work programmes
work should be based on commitments to achieve universal
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in South Africa has commenced, with the number of Global Fund-
access, a supportive environment, and the reduction of sex worker supported sex worker programmes diminishing to nine districts
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vulnerability.60 Sex work programming should be guided by the between 2016 and 2019.d
principles of meaningful involvement of sex workers, promotion of
Sex worker programmes supported by PEPFAR through USAID and
rights-affirming public health approaches, and implementation of
Y T the CDC include the University of the Witwatersrand’s Reproductive
appropriate interventions.60 The 2014 WHO Key Population HIV
Health and HIV Institute’s sites in the City of Johannesburg,
A N
Guidelines include a package of essential health sector interventions,
Ekurhuleni and Pretoria, and in collaboration with North Star
which are outlined in Box 2.52
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Essential health sector interventions to provide mobile peer-based HIV prevention, testing and linkage-
❖❖ Condom and lubricant programming
to-care programmes in five major metropolitan areas;90 Re-Action!
Consulting, which provides HIV-related services to sex workers
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❖❖ HIV testing and counselling provides peer-led prevention programmes targeting sex workers
❖❖ HIV treatment and care who operate in shebeens and bars in Mpumalanga Province.94
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❖❖ Community empowerment
172 S A H R 20 1 6
Sex work
Table 1: HIV, STIs and TB response for sex workers in South Africa (2012–2015)
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Sex worker-led movements such as Sisonke, and spaces formed for Conclusions
sex workers to come together (‘Safe Spaces’ in the Red Umbrella
Sex work like much other human behaviour is a complicated
Programme, ‘Community Advisory Groups’ established by the TB/
experience, and reductionist approaches, in which researchers
16 6
HIV Care Association, and ‘Creative Space’ set up by Sisonke)
and public health intervention implementers assume that sexual
provide mechanisms for community engagement and mobilisation.
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intercourse is always heterosexual, penile-vaginal, that all clients
Novel modalities of research, alongside the development of new
seek services of sex workers without the knowledge of their
information, education and communication materials, have been
Y T spouses, and that sex work is motivated by poverty, may not be
developed to improve research and to provide sex workers with
as meaningful as when the actual practices are understood.99
appropriate and attractive materials (see Box 3). Service delivery
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has been informed by local evidence, and will be bolstered by the Approximately 153 000 individuals in South Africa make a living in
implementation of the Sex Worker Plan 2016–2019. the sex industry.100 In a context of high unemployment and limited
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Act. Until recently, the rights and health issues of sex workers have
importance.
been largely ignored and similarly have been reflected in the dearth
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between July 2012 and September 2015. The magazine has been reported
to be a useful resource for sex workers.97 to improve the health outcomes for sex workers has been slow.
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S A H R 20 1 6 173
Financing
➢➢ The South African Government should increase investments broader health and social factors that are essential for health
in evidence-based, rights-affirming health programmes to and rights.
address existing inequities in access to health care for sex
➢➢ The National Department of Health and other health service
workers.
providers should enhance surveillance systems in order for
➢➢ Novel methods of private sector financing for sex worker- data to be collected and used at the local level, and such
focused programmes should be explored. systems should facilitate size estimations, HIV prevalence
➢➢ Financing should support the health and rights-related activities (and where possible incidence) and risk assessments, as well
of civil society organisations and sex worker-led movements. as measures of entry and retention along the HIV treatment
cascade.
Health workforce ➢➢ Information and new research findings should be released
➢➢ The Departments of Education and Health should ensure and made freely available as soon as possible. This is in line
that pre-service health professional training includes greater with research ethics that stipulate respect for sex workers
who participate in research and the organisations involved.
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emphasis on understanding the social determinants of health
and the dimensions of stigma and discrimination. Sensitive A responsive health system is reliant on high-quality, timeous
and appropriate care for all marginalised groups – including information.
sex workers and migrants – must be emphasised and values- ➢➢ Health information systems should capture information about
16 6
clarification training should be conducted. sex work and migration more efficiently, while ensuring privacy
and confidentiality. The use of biometric systems, which can be
20 IL
➢➢ In-service training, particularly in large urban areas, along
transport routes and other locations where the demand for used for community-based interventions and could link data
sex work is high, should pay increased attention to building with government systems while maintaining confidentiality in
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health worker capacity to provide sex worker- and migration-
appropriate and competent services.
the interim, should be explored in collaboration with the sex
worker community.
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➢➢ SANAC and the National Department of Health should ➢➢ The intelligent use of information and the decriminalisation
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implement mechanisms to monitor and quantify human rights of sex work and removal of legal risks posed by breaches
violations within the health system and the findings should be in confidentiality are needed to achieve the Sustainable
4 ED
services to register complaints, could be adapted for use ➢➢ Services should be provided by sensitive and competent
for other sexual and reproductive health service quality staff, with flexible and appropriate hours in locations that are
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➢➢ Universal access to a minimum package of health services support retention in care across geographical boundaries, to
(peer-delivered HIV prevention commodity distribution, peer maximise health outcomes and to reduce the risk of increased
EM
education and behaviour change, HIV testing services and costs due to treatment failure and new HIV infections.
linkage to other services, including biomedical interventions)
should be prioritised.
Information
➢➢ Researchers should address current gaps in knowledge around
HIV (i.e. gaps among transgender and male sex workers; in
areas beyond major metropolitan areas; effectiveness of
interventions to retain sex workers in HIV treatment) and the
174 S A H R 20 1 6
Sex work
Acknowledgements
Two anonymous reviewers, Sally-Jean Shackleton (Sex Worker
Education and Advocacy Taskforce), Kholi Buthelezi, Gavin Jacobs,
and Munya Masunga (Sisonke Sex Worker Movement), Eva Marumo
(National Department of Health), Maria Stacey and Marieta de
Vos (NACOSA), Kerry Mangold (South African National AIDS
Council), Helen Savva (United States Centers for Disease Control
and Prevention, South Africa), Leora Casey and Jami Johnson (Mott
MacDonald Development South Africa), Andrew Lambert (TB/
HIV Care Association), Teresa Guthrie (independent consultant),
Gesine Meyer-Rath (Health Economics and Epidemiology Research
Office (HE2RO), Department of Internal Medicine, Faculty of Health
Sciences, University of the Witwatersrand and Center for Global
Health and Development, Boston University), Thuba Ngubane and
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Anthony Diesel (South African Partners), Greta Schuler and Elsa
Oliveira (African Centre for Migration and Society, University of
the Witwatersrand), Mariette Slabbert and Wayne Helfrich (Wits
Reproductive Health and HIV Institute), Sharon White and Petro
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Roussaeu (Re-Action! Consulting), Mike Grasso (University of
20 IL
California, San Francisco), Jenny Coetzee (Perinatal HIV Research
Unit), Nondumiso Makhunga-Ramfolo (FHI360), Jannie Hugo and
Angelika Schutte (University of Pretoria).
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S A H R 20 1 6 17 5
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178 S A H R 20 1 6
Trauma, a preventable burden of disease
in South Africa: review of the evidence,
15
with a focus on KwaZulu-Natal
Authors:
Timothy C. Hardcastle i George Oosthuizen ii
Damian Clarke ii Elizabeth Lutge iii
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rauma is a major burden of disease in lower- and middle-income countries, Trauma constitutes
and to address the causes and treatment requires specialist services and
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multidisciplinary care. Despite this, governments have given trauma low priority approximately 25% of the
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as they have focused largely on primary health care. emergency workload at
most public hospitals in
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systems of quality trauma care and accreditation programmes for hospitals and there is limited capacity for
systems. Current and optimal staffing of trauma-care facilities, compliance with rehabilitation and lack of
minimum equipment standards, and the potential for patient harm are addressed.
intensive care facilities.
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The authors show that trauma constitutes approximately 25% of the emergency
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workload at most public hospitals in KZN, where there is limited capacity for
rehabilitation and lack of intensive care facilities. There is no defined trauma system
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and the existing resources at regional and tertiary public facilities are strained.
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The role of sound databases in providing numerical and outcome data is highlighted
and a call is made for the establishment of a National Trauma Data Bank. The
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authors highlight the need for prevention programmes and draw attention to the
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cost implications of trauma care, noting the cost-benefit ratio of good trauma care
compared with the litigation risk to government when such care cannot be provided.
i Trauma Unit, Inkosi Albert Luthuli Central Hospital; and Department of Surgery, Universit y of KwaZulu- Natal
ii Pietermaritzburg Trauma Service; and Department of Surgery, Universit y of KwaZulu- Natal
iii Epidemiology Division, KwaZulu- Natal Department of Health; and Department of Public Health, Universit y of KwaZulu- Natal
179
Introduction
Trauma is well known to be a major disease burden in lower- and mainly to local research published in the past five years from
middle-income countries (LMICs), with South Africa falling into the KwaZulu-Natal (KZN) and other parts of South Africa, and from
middle-income group. Over 90% of trauma deaths occur in LMICs, theses published online by the University of KwaZulu-Natal (UKZN).
yet facilities that can provide optimal care and rehabilitation are Data were also sourced from public service planning and policy
lacking in many of these countries. Recent publications from the documents. Extrapolation of KZN data to arrive at national estimates
World Health Organization place the global injury mortality rate was based on the fact that the province contains over one-fifth of the
at five million per annum, with one-fifth of these deaths occurring national population, rendering extrapolation from a 20% sample
in India, and almost one-fifth in Africa.1,2 In the near future, the statistically relevant.
injury mortality rate will exceed that of HIV and AIDS, tuberculosis,
The study addressed current and optimal staffing of trauma-care
malaria and obstetric causes combined.1 Over 50 000 trauma-
facilities, compliance with minimum equipment standards, and the
related deaths were recorded in 2009 across South Africa, with the
potential for patient harm in the current trauma system. The chapter
majority related to transport and violence.3
provides insight into the accreditation programmes for hospitals,
and options for establishing cost-efficient high-quality trauma care
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For every mortality that occurs it is estimated that there are between
10 and 50 injured survivors, half of whom will have a permanent systems. The role of sound databases in providing numerical and
disability.4 Lack of access to rehabilitation services in most LMICs outcome data is highlighted and a call is made for the establishment
leads to severe loss of disability adjusted life-years (DALYs).5 of a National Trauma Data Bank. The chapter also provides insight
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into the need for prevention programmes and the cost implications
Injuries in LMICs are largely violence or transport-related, and occur
of trauma care, noting the cost-benefit ratio of good trauma care
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mostly among young healthy men of low socio-economic status
compared with the litigation risk to government when such care
influenced by alcohol and drug misuse, which increases the burden
cannot be provided.
on developing communities. Data from Cape Town, where a large
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single-centre electronic record was recently implemented, reflect the
same demographic pattern of violence- and transport-related injury
All these aspects are considered in the context of the relevant
Sustainable Development Goals (SDGs), specifically: SDG 3 (Good
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in young male adults, with alcohol playing a central role in the injury health and wellbeing); SDG 11 (Sustainable cities and communities);
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The burden of trauma has been given low priority by government, We also identify some good practices and hindrances to policy
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and institutional apathy, lack of translational research and implementation, while noting possible implications for policy reform
government’s primary health care focus have resulted in neglect in terms of cost and human resource requirements.
of this disease process and a trauma care crisis. Trauma requires
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inaugural professorial speech highlighted the following with regard For the purposes of this chapter, ‘trauma’ is defined as injuries,
to trauma: both intentional and non-intentional, while ‘major trauma’ is defined
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180 S A H R 20 1 6
Trauma
Review of the evidence seen in the major KZN hospitals annually. This implies that around
90 000 cases will be seen annually across the country.
The burden of injuries Wall and associates28 examined trauma incidence among the
Trauma forms a significant component of the emergency centre pregnant population in Pietermaritzburg and surrounding areas,
workload at public hospitals and involves indeterminate budget and found that 4% of all female trauma cases admitted to the
consumption due to unpredictability of the general burden and Pietermaritzburg Trauma Service were injured during pregnancy,
injury severity. Additionally, the need for scarce high-dependency with over 50% due to assault; this resulted in foetal loss in over
and intensive care resources16 leads to roll-over blockages for 33% of cases, rising to 86% in those requiring emergency surgery.
urgent elective surgery.17,18 In order to assess and contextualise They further noted that 3 000 female patients sought trauma care
this healthcare burden and its impact on the health system, a series in the 30-month study period, implying 1 200 cases per year at
of studies,17–19 was undertaken in 2010 to determine the trauma their centre. This was extrapolated to around 8 400 female trauma
burden in KZN covering three major categories of injury, namely patients per year across the major KZN hospitals, and therefore
motor-vehicle-related, violence-related and domestic/work-related. almost 42 000 countrywide.
These studies examined both the pre-hospital and in-hospital disease Moodley and associates29 examined trauma burden and mortality
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burden, using two non-holiday season months extrapolated to a one- in the Pietermaritzburg region and noted that over 5 000 trauma
year incidence, and determined that almost 102 000 pre-hospital cases per year were treated at the three hospitals under review,
trauma (emergency medical services (EMS)) call-outs were recorded, with an almost 4:1 male/female ratio. Extrapolation of these figures
equating to almost 12/1 000 of the population per year, while
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to the province suggests that almost 35 000 trauma admissions
over 124 000 persons were treated in public hospitals for these occur per year in KZN. During that period, 1 105 trauma deaths
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three injury categories in 2010. Over 70% of these EMS callouts underwent forensic post-mortems, of which over half took place at
or hospital attendances were for either motor-vehicle related or the accident scene.29
violence-related injuries.
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The challenge noted was that almost 80% of patients were
Pillay, Ross and Van der Linde30 reviewed King Edward VIII
Hospital’s emergency centre trauma attendances and noted that in
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considered serious or critical (meeting the criteria for major trauma), a one-month period, 1 465 trauma cases were treated, equating
yet due to the primary-care focused referral pathway, only 40%
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to over 17 500 per annum for their facility alone. Importantly, over
were admitted directly to the correct level of care. These rates far 66% of cases had a violent underlying cause and almost 10%
exceed the comparative international incidence.17,18 Furthermore, required ICU admission.
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recent work showed that almost 15% of the total trauma burden
are critically injured patients requiring direct admission to a major This disease burden involves not only the emergency centre or the
trauma facility20 and this data correlates with the 18% determined surgical wards; it also influences the workload of orthopaedics,
with 63% of the 850 operative cases at one facility in 2000 being
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at regional and tertiary facilities, and necessitates costly inter- over 100 patients treated for road-related injury per month at the
hospital transfers. Pietermaritzburg service, one-third of which required admission
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of all trauma admissions to the teaching hospitals were due to either pedestrians,32,33 and with figures in the paediatric population
transport- or violence-related mechanisms and almost 38% of these ranging from 21% to 58% at a referral centre and as high as 75%
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incidents were preventable.21,22 Similar patterns were also reported in those with major chest trauma.34–36 Recent published data from
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in Mpumalanga.23 The excessive EMS workload means that many the Red Cross War Memorial Children’s Hospital, a referral centre
patients do not arrive during the immediate post-injury period.24 in Cape Town, demonstrates very similar rates of injury mechanism,
Findings in the Western Cape (mainly urban areas) are in keeping with boys between five and nine years of age accounting for 75%
with the numbers and mechanisms of injury found in more rural of pedestrian trauma cases. Many of them had traumatic brain
provinces, and the need for improved, locally relevant injury injury.37,38
surveillance programmes applicable to LMICs has been identified.25
Most of these studies excluded burn patients; however, the burn-
Other studies examining the epidemiology of injuries have largely injury burden in KZN was reviewed in four recent papers from
focused on single-centres or specific pathologies. For example, the three main burn centres in the province (two regional and one
Howlett and colleagues found that passengers on the back of pick-up quaternary). The reviews demonstrated that children and epilepsy
trucks (‘bakkies’) were at severe risk of injury through ejection (90% sufferers were at particular risk, with flame burns and hot-water
of such injuries involved prolonged hospital stays of around two scalds predominating. Annual incidence across the province was
weeks, and almost one-third of survivors required ICU admission).26 estimated to be somewhere between 7 000 and 30 000 cases,
Mnguni et al. examined abdominal injury over a seven-year period depending on whether minor burns treated at clinics and outpatient
at King Edward VIII Hospital in Durban and noted that 488 cases facilities were included.39–42 Major burns (>30% body surface area
were admitted to a single surgical firm (of six firms in total), with in adults and >20% in children) constituted around 320 cases per
penetrating trauma outnumbering blunt trauma by a staggering year referred to the major burn units, with regional and district
9:1, and an overall mortality rate of 11%.27 Extrapolation of these hospitals caring for the majority of moderate and minor burns. Data
figures suggests that around 18 000 abdominal trauma cases will be from other major burn centres in Cape Town show that across the
S A H R 20 1 6 181
Western Cape (a better-resourced province) there was satisfactory largely absent in the public sector, making accurate costing difficult.
initial burn care, but again a delay in definitive care through the They examined trauma patients in Johannesburg in 2004 and found
primary care pathway, leading to multiple transfers.43 that for 48 patients reviewed, the cost was in excess of R220 000,
excluding personnel and bed costs. More recent work from a large
Much of the published work from other trauma care facilities around
trauma referral centre serving most of rural KZN showed that the
South Africa reports on the specific management of single injuries
cost of interpersonal violence only (38% of the trauma burden),
or small numbers of complex injury patterns, while some report
amounted to over R8 million per three-month period, therefore more
on management consequences after ICU admission. While these
than R32 million per year.69
facilities are excellent in clinical management, there is insufficient
overall information provided to determine the actual provincial Costing estimates using data from trauma-burden studies17,18,70
trauma burden in the host provinces to enable comparative show that at 2010 Rand-value, the overall cost of trauma care in
extrapolation of the disease burden of trauma. What these studies KZN would amount to almost R5.4 billion, excluding the cost of
do highlight is the enormous surgical burden that trauma adds to the proposed facility upgrades to ensure compliance with the National
already large burden of non-communicable surgical disease.44–59 Core Standards.70,71
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Human resources
are faced with a major space challenge, and overcrowding is not
uncommon in South Africa. Trauma care often requires more time There are low staffing levels in emergency departments, which
and resources than ordinary medical care, so that given the huge are often served by the most junior doctors; insufficient basic
16 6
burden identified in these studies, it is even more essential to develop resuscitation facilities; and limited imaging facilities at clinics and
robust trauma systems in South Africa.60,61 district hospitals, especially after normal hours, which is when most
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trauma incidents occur. This leads to delays in initial care and
The KZN studies led to the development of the first province-wide
definitive care, resulting in more complications and the subsequent
data-capture tool linked to the District Health Information System
Y T need for ICU care. There is also a lack of nurses specifically trained
(DHIS),62 which captures basic epidemiological data from every
to manage trauma and emergency cases.16–18 Moreover, there is
public district, regional and tertiary, as well as the single quaternary
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poor access to surgical facilities and, despite expectation of the
central hospital. Over two years’ data have been collected, collated
existence of surgical capability, very few minor operations are
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were 197 219 emergency department visits for trauma in the period have been estimated using standardised formulae applied to public-
under review, which constituted 27% of all emergency department service facilities. Estimations include the following, per referral
visits in the province, with 18 716 cases (9.5%) requiring ward hospital expected to manage major trauma:64,65
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or ICU admission. This demonstrates that the actual burden was ➢➢ Three to six medical officers per emergency centre (depending
significantly greater than earlier estimates.63,64 While similar on size) dedicated to trauma and acute care, with two
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figures were reported from primary care facilities in the Western emergency medicine specialists to lead the emergency centre
Cape where injuries accounted for 20% of the emergency centre
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the DHIS in the other provinces with which to compare these results.
N
Healthcare costing is a difficult process, given that government- with enrolled nurses (ENs) to assist in a ratio of three per 10
employed healthcare practitioners are salaried staff, and that patients.
trauma patients may require multiple aspects of care (emergency
➢➢ Radiographers to cover computed tomography (CT) and other
department, ward care, intensive care, rehabilitation services, allied
imaging services 24/7.
health services and various medical specialists, etc.). Despite these
challenges, a number of recent studies have attempted to provide ➢➢ Laboratory service staff to cover all laboratories 24/7.
trauma costing in South Africa. ➢➢ Surgeons with a commitment to consultant-led trauma care,
ideally headed by a certified trauma surgeon, if available, at
Lutge and Muirhead31 undertook costing using a bottom-up/top-
regional hospital level, preferably in a hospital certified as a
down approach to determine the costs of managing orthopaedic
‘Trauma Centre’.
injuries in the year 2000, and found that using either method,
the costs were in excess of R5 million. Allorto and colleagues66 ➢➢ Allied health service staff to provide ward services.
undertook a costing study on burns patients at Edendale Burn ➢➢ Operation room staff (scrub nurse, circulating nurse and
Service over an 18-month period and estimated an overall cost in anaesthetic assistant) to provide a dedicated trauma operation
excess of R29 million for the 450 patients treated during that period. suite 24/7, not competing with Caesarean sections and non-
Parkinson et al. examined the cost of road-traffic injury in trauma acute surgery, or elective surgery; plus anaesthetic
Pietermaritzburg67 and found that the cost per patient was around specialist cover for the operation suite.
US$6 988.50 (almost R105 000 at current rates). However, ➢➢ Clerk and porter services to ensure adequate internal
Bowman et al.68 highlighted that costing and a cost-culture were administrative support.
1 82 S A H R 20 1 6
Trauma
➢➢ Cleaners and infection-control staff to ensure a safe working indicate the success of prevention strategies if reduced injury numbers
environment. were achieved over time. There are currently locally designed and
highly functional local and regional databases that could easily be
➢➢ Management support, enabling patient-focused resource
expanded to provide such a national trauma database, including a
allocation.
‘shareware’ phone-based app offered by the Trauma Association of
➢➢ Wards staffed with nurses in a 1:10 PN/patient ratio and a Canada.33,75–79
1:5 EN/patient ratio, with the High Dependency Unit (HDU)
staffed in a 1:2 nurse/patient ratio and ICU staffed in a 1:1
PN/patient ratio, with additional staff to allow for continuity of Accreditation programmes
care during teas and lunches.
To achieve both competence and a demonstrable commitment to
➢➢ ICU staff should be trained to use dialysis equipment. quality trauma care, independent assessment of trauma facilities is
➢➢ Regarding pre-hospital trauma care, there should be at least common practice across the world, as reflected in World Health
one intermediate paramedic per ambulance and at least one Organization and American College of Surgeons documents.80,81
advanced paramedic per five ambulances; this should exclude The Trauma Society of South Africa15 has developed a locally
relevant assessment model and accreditation programme, currently
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staff at the call centres and management officers who should
be trained in efficient management of resources. with uptake mainly in the private health sector, and with over 15
hospitals currently accredited. However, there may be merit in
Infrastructure requirements examining the system for its suitability in the public sector.
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Despite self-reported assurances regarding the existence of Quality assurance in trauma care
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adequate equipment at various healthcare facilities, one study18 in
KZN showed this was not the case, with 54% of district facilities A useful overview of management theory relative to quality assurance
having inadequate resuscitation-area facilities, none having in- in trauma care highlighted that using a strategic planning approach
Y T
house CT-scanners, only 62.5% having emergency mobile X-ray enables quality metrics to be applied to the acute care system.82
Additionally, a number of other studies have demonstrated that
A N
units, and 58% not having access to an emergency operating room
(a requirement of the District care-package). Only 25% of district quality assurance systems can be implemented effectively and readily
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hospitals had an emergency observation ward, despite the need assessed.83–88 Many of the problems identified in such assessments
to accommodate many patients awaiting transfer to a higher level are related to missed injury89,90 or delayed diagnosis, which can
be addressed through the various quality assessment tools and
4 ED
Equipment and facilities will need to be upgraded according to the can guide the assessment of quality of care and the success of new
established national norms, such as the Trauma Society of South interventions undertaken.
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Africa (TSSA) criteria for trauma centres, the Council for Scientific
and Industrial Research (CSIR) built-environment guidelines, The role of primary health care in trauma
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S A H R 20 1 6 1 83
In the case of severe injury (major trauma/ISS>16), patients taken countries, in particular developing countries, with regard to early
to regional-level hospitals have to compete for emergency care with warning, risk reduction and management of national and global
medical and obstetric emergencies, often in inadequately designed health risks, achievable though disaster planning that would include
and equipped emergency centres. There is also competition for EMS and trauma care.
access to operation rooms and imaging facilities, which may be
SDG 11 addresses the potential root cause of violence-related
unavailable after hours. There is also insufficient ICU capacity at
trauma through recommending that cities be made safe and
most regional facilities, and lack of dialysis for acute kidney injury,
sustainable by ensuring access to safe and affordable housing.
which often complicates major trauma and other emergencies.
This also involves upgrading slum settlements, investing in public
transport, creating green public spaces, and improving urban
Risks of litigation
planning and management in a way that is both participatory and
When the care of trauma and other emergency cases is not inclusive, thus reducing reliance on own-transport and potentially
adequate, there is a significant possibility of litigation against the reducing pedestrian collisions on highways.
various Departments of Health.99,100
SDG 11 can be read hand-in-hand with SDG 16, which aims
The obligation to provide emergency medical care was illustrated in to reduce all forms of violence significantly, and to encourage
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a recent Constitutional Court ruling in the case of Oppelt vs. Head: governments and communities to work together to find lasting
Health Western Cape.101 The court held that any life-threatening solutions to conflict and insecurity. By strengthening the rule of law
medical emergency requiring further specialist intervention as through effective policing and traffic enforcement, the two major
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part of the resuscitation/stabilisation process is now regarded components of the trauma burden can be prevented and mitigated.
as part of emergency medical treatment, and any specialist/ Promoting respect for human rights is central to this process.
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consultant contacted by an emergency department doctor for further
assistance/consultation and who refuses to provide such support, Good practices and hindrances to policy
will be held liable for refusing emergency medical treatment.
Y T implementation
The court also held that strict adherence to a protocol that does
Good practices in the current KZN trauma care environment are
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not accommodate emergencies is not an excuse for the delays
mainly based on optimal clinical care in the face of logistical and
caused by such refusal. The court also found that the purpose
human resource challenges. The Pietermaritzburg Metropolitan
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hospital that is able to provide the necessary treatment. The court Some examples of the results of good practice at these units include:
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found that emergency medical treatment is not confined to that ➢➢ assessment of the knowledge and skills of junior staff regarding
which is undertaken in an emergency department, but includes that chest-drain placement, an important technical skill;107
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kidney injury;108,109
multi-trauma patients to a Level 1 Trauma Unit.101 This judgment has
implications for the National Department of Health to plan efficient, ➢➢ avoidance of tracheal damage due to high cuff pressures or
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and minimise morbidity, and avoid costly legal battles. This would
➢➢ optimal control of body temperature in trauma patients (now
indirectly release more money to fund actual health care across all
part of the National Core Standards);111
the disease burdens.102
➢➢ optimal management of vascular injury in the polytrauma
Sustainable Development Goals population;112 and
184 S A H R 20 1 6
Trauma
the entire health system, while meeting acceptable standards of care Implications of findings
and achieving positive health outcomes. This aim is similar to that of
trauma care and as such is unfortunately a cost driver for curative The findings illustrate the burden of injuries and violence on the health
care in a poorly resourced and poorly structured health system. This system, both in KZN and nationally,127,128 and the current lack of
is seen in light of the major cost drivers such as blood products, human and infrastructural resources to mitigate this burden. Proper
surgical consumables and laboratory services. Given the scale of re-engineering of the primary care pathway and strengthening of
the injury burden, this is not unexpected, but it is worsened by the the regional and tertiary/quaternary levels of care, together with
private sector, which treats limited trauma profiles and refers many establishment of committed and well-resourced trauma care services
of the indigent cases to the already overburdened public sector. will reduce risk of litigation. Prevention and rehabilitation services
However, the injury burden cited in the White Paper seems to at primary-care level should include community health improvement
underestimate significantly the real effect on the healthcare system, strategies, which will enhance the return of injured survivors to
and the financing mechanisms have not yet been clearly spelt gainful employment.
out.121,122 A multi-sector approach is required, including strategies to reduce or
It is encouraging that emergency medical services have been prevent motor-vehicle and interpersonal or industrial injuries through
PM
highlighted in the White Paper and that comprehensive pre- and inter-ministerial units including law-enforcement (Justice/Police),
in-hospital aspects are mentioned, with a specific note that district road safety (Transport) and social change (Social Development/
hospitals may be partially removed from emergency care in favour Home Affairs). The recently implemented Road Incident Management
of regional and higher levels of care due to the need for specialist System (RIMS) is a good example of interaction between the
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involvement.104 Optimal preparation of the system for trauma Departments of Health, Transport, Police Services and broader
care, in anticipation of the single-payer national plan, must include professional societies.129
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consultation with practising trauma surgeons.
achieve the SDGs and ensure a functional trauma system that is both
outcomes.72,123–126 The current referral pathway in South Africa
cost-efficient and quality-assured, for the proposed NHI to succeed.
delays the time to arrival at the appropriate facility. There is also
The KZN DHIS model should be adopted as a national priority.
4 ED
Policy reform in trauma care must therefore be considered in the light right patient to the right facility in the right timeframe, and reduce
of the disease burden outlined, and take into account the challenges morbidity and mortality through provision of quality care. A national
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of the current human resources and facilities. A system of trauma Trauma Data Bank should be established to detail the disease
care must be implemented that ensures early access to definitive burden and the current outcomes, while at the same time, taking into
BA
care, allowing EMS bypass of less-equipped facilities and ensuring account the varying injury and trauma profiles across the county.
that the patient gets to the appropriate facility within the correct Additionally, there should be access to rehabilitation services across
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timeframe, thus reducing morbidity and preventing unnecessary the spectrum of care to ensure that injured patients are restored as
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mortality.102 The current primary care pathway is not optimal for economically viable members of society, through a well-orchestrated
trauma care. The major challenge is that time is required to gauge continuous care pathway.
the long-term mortality reduction of trauma systems, with most
reports suggesting a 10-year time-lag before statistically significant
change can be recorded.124–126
S A H R 20 1 6 1 85
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(COHSASA). Emergency Centre Standards, Post Pilot, Thomson SR. An audit of the quality of care of traumatic brain
November 2007. Cape Town: Council for Health Service injury at a busy regional hospital in South Africa. S Afr J Surg.
Accreditation of Southern Africa; 2007. 2009 Nov;47(4):120–2,124–6.
74 Fleming E, IUSS N&S Task Team. Infrastructure Unit Support 89 Hardcastle TC. Missed Injury: Decreasing Morbidity and
Systems (IUSS) Health Facility Guides. Emergency Centres, Mortality. A literature review. S Afr J Surg. 2011;49:199–
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90 Clarke DL, Gouveia J, Thomson SR, Muckart DJ. Applying
75 TraumaBank and MediBank. [Internet]. [cited 29 December modern error theory to the problem of missed injuries in
2015]. trauma. World J Surg. 2008 Jun;32(6):1176–82.
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91 Stassen W, Welzel T. The prevalence of hypotension and
76 Razek T, Deckebaum D, Bracco D. iTrauma: a novel electronic hypoxaemia in blunt traumatic brain injury in the prehospital
data collection system designed to collect essential trauma setting of Johannesburg, South Africa: A retrospective chart
information in resource-poor settings. [Internet]. [cited 29 review. S Afr Med J. 2014;104(6):424–7.
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77 Laing GL, Bruce JL, Aldous C, Clarke DL. The design,
construction and implementation of a computerised trauma 93 Tiska M A, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN. A
registry in a developing South African metropolitan trauma model of prehospital trauma training for lay persons devised
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service. Injury. 2014;45:3–8.
78 Zargaran E, Schuurman N, Nicol AJ, et al. The electronic 94 Sun JH, Wallis LA. Learning and retention of emergency first
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Trauma Health Record: design and usability of a novel aid skills in a violent, developing South African township.
tablet-based tool for trauma care and injury surveillance in Emerg Med J. 2013;30(2):161–2.
low resource settings. J Am Coll Surg. 2014;218(1):41–50. 95 Sun JH, Shing R, Twomey M, Wallis LA. A strategy to
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79 Zargaran E, Adolph L, Schuurman N, et al. A global agenda
for electronic injury surveillance: Consensus statement from the
implement and support pre-hospital emergency medical
systems in developing, resource-constrained areas of South
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Africa, and the PanAmerican Trauma Society. J Trauma Acute
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Resources for the optimal care of the injured patient. Chicago: Med J. 2013;103(9):621–5.
American College of Surgeons; 2014. 97 Chokotho LC, Matzopoulos R, Myers JE. Drivers’ risk profile
81 Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. indicates the need for a graduated driving licence in South
Africa. S Afr Med J. 2012;102(9):749–51.
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of a comprehensive structure to facilitate quality improvement 99 Hardcastle TC. Ethical and Medico-legal aspects of Trauma.
in rural trauma and acute care in KwaZulu-Natal, South S Afr J Bioethics Law. 2010; 3:25–7.
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and trauma education. Injury. 2014;45:285–8. Department of Health Provincial Administration: Western
Cape. CCT 185/14, Judgement dated 14 October 2015.
84 Laing GL, Skinner DL, Bruce JL, Aldous C, Oosthuizen GV,
Clarke DL. Understanding the burden and outcome of trauma 102 Hardcastle TC. The 11 P’s of an Afrocentric Trauma System.
care drives a new trauma systems model. World J Surg. S Afr Med J. 2011;101:160–2.
2014;38(7):1699–706. 103 United Nations. Sustainable Development Goals. [Internet].
85 Laing GL, Bruce JL, Clarke DL. Tick-box admission forms [cited 23 December 2015].
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but have limited impact on clinical behaviour. S Afr Med J. 104 South African National Department of Health. National Health
2014 Apr 30;104(6):435–8. Insurance for South Africa. White Paper version 40. Pretoria:
86 Kong VY, Oosthuizen GV, Sartorius B, Keene C, Clarke National Department of Health; 10 December 2015.
DL. An audit of the complications of intercostal chest drain 105 Roberts DJ, Bobrovitz N, Zygun DA, et al. Indications for Use
insertion in a high volume trauma service in South Africa. Ann of Damage Control Surgery in Civilian Trauma Patients: A
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87 Clarke DL, Furlong H, Laing GL, Aldous C, Thomson SR. Using Ann Surg. 2015 Oct 1. [Epub ahead of print]
a structured morbidity and mortality meeting to understand 106 Roberts DJ1, Bobrovitz N, Zygun DA, et al. Indications for use
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107 Kong VY, Oosthuizen GV, Sartorius B, Keene CM, Clarke 123 Cameron PA, Gabbe BJ, K. Smith K, Mitra B Triaging the right
DL. Correlation between ATLS training and junior doctors’ patient to the right place in the shortest time. Br J Anaesth.
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J Surg Educ. 2015;72(4):600–5.
124 Nathens AB, Jurkovich GJ, Cummings P, et al. The effect of
108 Skinner DL, Laing GL, Ryan L, Rodseth RN, Hardcastle TC, organized systems of trauma care on motor vehicle crash
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125 Mann NC, Cahn RM, Mullins RJ, et al. Survival among injured
109 Skinner DL, Hardcastle TC, Rodseth RN, Muckart DJ. geriatric patients during construction of a statewide trauma
The incidence and outcomes of acute kidney injury system. J Trauma. 2001; 50:1111–6.
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long-term trend in mortality from injury in a mature inclusive
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112 Muckart DJJ, Hardcastle TC, Pillay B, Skinner DL. Vascular 129 Road Incident Management Systems. Pietermaritzburg: South
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113 Steinwall D, Befrits F, Naidoo SR, Hardcastle TC, Eriksson
A, Muckart DJ. Deaths at a level 1 Trauma Centre: A
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clinical finding and post-mortem correlation study. Injury.
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114 Heinonen E, Hardcastle TC, Barle H, Muckart DJJ. Lactate
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118 Madsen AS, Laing GL, Bruce JL, Oosthuizen GV, Clarke
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Strengthening the measurement of quality
of care
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Authors:
Ronelle Burger i
Shivani Ranchod ii
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Laura Rossouw i
Anja Smith i
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here is growing recognition that access to healthcare facilities is unlikely to More public debate is
improve health outcomes if the quality of the care provided at these facilities
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is inadequate. The emerging consensus on the importance of quality of health needed on meaningful,
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care is reflected in proposed policy reforms in South Africa, as well as in increased affordable and robust
measurement of quality at primary health care facilities.
approaches to quality
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Through focus on clinical quality and client satisfaction, we provide a critique of measurement.
current approaches used to measure quality. We argue that the measurement of
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191
Introduction What does ‘quality of health care’ mean?
There is growing recognition that access to health facilities is unlikely A significant challenge in researching the measurement of quality
to improve health outcomes if the quality of care at these facilities is of health care is the lack of conceptual clarity. Indeed, as Buttell
inadequate.1 Increasingly, it has become clear in South Africa that and colleagues note if “a group of healthcare professionals is asked
reliable access to affordable public health care providers is no longer what quality means, there may be as many definitions as people in
a serious constraint,2 yet health outcomes remain disappointing, the room”.18
with a high burden of disease3 and too many preventable deaths.4,5
In this chapter we employ the widely used definition of the Institute
South Africa’s under-performance is often attributed to the country’s
of Medicine (IOM), which defined quality as
high HIV burden6 and the inequitable health system,6,7 but new
studies are pointing towards poor quality of care and missed the degree to which health services for individuals and
opportunities at healthcare facility level as contributing factors.8,9 populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge.19
In South Africa, the move towards increased emphasis on quality
has been reflected in recent reforms, including the National Health For the purposes of this chapter we selected two specific dimensions
of quality, namely clinical quality and client satisfaction to examine
PM
Insurance (NHI) plan. The White Paper on universal health coverage
acknowledges concerns about the quality of care provided in the in more depth. Clinical quality is expected to increase the likelihood
public sector and makes clear the intention to invest in quality of desired health outcomes.20,21 Client satisfaction can be a useful
improvement.10 Similarly, the National Development Plan identifies construct and measure due to its linkages to client responsiveness
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“quality health care for all” as a key priority for the country.11 and client-centric care, but there is little reason to anticipate a strong
correlation with clinical quality or health outcomes. However, client
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Directly related to the overarching policy context for quality
satisfaction is important in its own right because satisfaction serves
improvement is the imperative to strengthen quality measurement
as a mediating variable for health-seeking behaviour and adherence
in South Africa.a This is clear from a number of important policy
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initiatives and processes including the establishment of the Office
of Health Standards Compliance (OHSC).14 The OHSC was
to treatment,22 which is expected to link to health outcomes at a
population or sub-population level.
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tasked with the development of a set of National Core Standards
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(NCS) against which to measure and monitor the quality of care Current approaches to measuring client
provided, with the aim of supporting the improvement of quality of satisfaction and clinical quality in the public
care in health facilities.15 By 2011, the NCS were finalised and
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health sector
implementation of the standards by the OHSC had commenced.15
There have been few attempts at measuring clinical quality in the
More recently, the Ideal Clinic Initiative was launched; it aims to
public sector, presumably because of the complexities of ensuring
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care facilities, and the quality indicators of the Ideal Clinic Initiative,
status by April 2018.17
focus mainly on structural measures of quality of care, namely the
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The renewed focus on quality also links to increasing emphasis nature and availability of physical, administrative and managerial
on how monitoring and evaluation systems can reliably identify infrastructure at health care facilities.23 These measures do not
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under-performing facilities or clinics that need more support.15 explicitly measure clinical quality of delivered services. While, for
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These policy shifts are overdue and have created a window of example, the Ideal Clinical Initiative includes client safety (clinical
opportunity to debate how the elusive concept of ‘quality’ should be governance and clinical care) as one of its 10 domains,16 this is
understood within health care and to experiment with how we can measured by focusing on the existence and availability of these
best approximate and measure it. The definition and measurement protocols to staff, rather than measuring the actual implementation
of quality is at the heart of policy debates on how we can make the of these protocols.24
health system function better to ensure that clients are respected and
Data on some health outcomes are routinely collected at facility level
that avoidable mistakes and the associated negative outcomes such
through the District Health Information System (DHIS).25 However,
as injuries and deaths are reduced or eliminated altogether.
these health outcomes are often too complex to interpret meaningfully
This chapter aims to contribute to the on-going discussion on how without information on the underlying health needs and burden of
to improve the quality of care in South Africa. We critically analyse disease of the facility’s clients.13 Additionally, outcomes tend to
current quality measurement tools in the South African public reflect both client factors such as early health-seeking behaviour
sector, suggest alternative quality measurement tools, and make or adherence to treatment, and provider factors such as correct
recommendations for improved quality measurement. diagnosis, explaining the risks of the disease and guiding the client
to make the correct treatment choice. Without additional survey
work, analysts and researchers cannot isolate the clinical quality-
of-care component. Research that investigates the clinical quality
a Although the focus here is on quality measurement, the goal of measuring of care in for example maternal health26 therefore supplements the
quality is to enable quality improvement, as is the case in most of the
analysis of individual-level health records25 with additional survey
international literature.12,13
b The dashboard includes 212 elements, categorised into 10 components and work, but such work is relatively rare.
32 subcomponents.
1 92 S A H R 20 1 6
Quality of care
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➢➢ Opacity and complexity of the concept of satisfaction: Client
It is useful to make a distinction here between satisfaction reports
satisfaction ratings are influenced by the personal preferences
and satisfaction ratings.31 Satisfaction reports consider specific
of the client, the client’s expectations, and the health care
and often more tangible elements of providers and health care
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received.31 Disregard for the complexities of the concept
(e.g. waiting times), while satisfaction ratings capture a personal
has been described as the “single greatest flaw”32 in client
evaluation of care that is not verifiable or observable by a third
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satisfaction research.
party.31 A satisfaction rating is more subjective, with a larger
➢➢ Fallibility of self-reported information: The respondent’s component that could be reflective of the respondent rather than
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responsiveness to perceived social norms and time pressure
can compromise the reliability of self-reported information,33,34
the health care service.31 Consequently, this measure would also be
more amenable to social conditioning and social desirability. This
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yet few studies critically consider these concerns. could explain the high overall satisfaction ratings we found in the
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➢➢ Positivity bias: The statistical distribution of client-satisfaction General Household Surveys amidst unfavourable satisfaction reports
survey scores tends to be negatively skewed and overly highlighting several serious complaints about providers and the care
received.
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perspective, but represent an optimistic picture of the general who are accustomed to long waiting times may rate their evaluation
public outlook because such surveys exclude individuals who of service differently to those who have an expectation of shorter
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➢➢ Poor diagnostic tool: Low client satisfaction may signal that Differences in expectations will therefore be reflected in clients’
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a specific facility is experiencing problems, but it cannot interpretation and response to the subjective questions in surveys,
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diagnose the underlying causes of reported disappointing and an identical health visit may be rated differently depending on
client experiences.42,43 the expectations of individual respondents. Expectations may also
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S A H R 20 1 6 1 93
more affluent clients had higher service expectations than poorer systematically more or less likely to overestimate or underestimate
clients, who may have been more accepting of the status quo. the quality of the health system’s responsiveness.49
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We explored the 2008 World Health Organization’s Study on
0.77
Global Ageing and Adult Health (SAGE) data47,48 for South Africa
0.75
to provide evidence on how vignettes can be used to correct for
Most poor 2 3 4 Most affluent reporting bias. The SAGE data contains a set of questions asking
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Per capita expenditure categories respondents who interacted with the health system about the manner
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Source: Authors’ calculations using Statistics South Africa, 2010,44 2011.45 and environment in which they were treated during the interaction
with the system (health system responsiveness or experience).59 This
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Alternative approaches to the measurement of reported experience of the health system from his or her expectations
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of the system.46 This separation is accomplished in two ways: firstly,
client satisfaction and clinical quality by focusing on relatively objective dimensions of client experience,
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As a response to the critique of current approaches to the such as waiting time and cleanliness and, secondly, through the use
measurement of clinical quality and client satisfaction, we discuss of anchoring vignettes.49
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Anchoring vignettes and reliable South African data set containing client-experience
vignettes and we therefore used it here although the data are slightly
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system’s responsiveness (or health system experience) relative to the Figure 2 shows the difference between self-reported client experi-
particular hypothetical person for a specific health system domain. ence prior to and after controlling for reporting bias. The figure
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Client-experience surveys can be enhanced by collecting subjective shows the percentage of clients in wealth quintile 160 (the poorest
quintile) reporting moderate, poor or very poor (i.e. not good)
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1 94 S A H R 20 1 6
Quality of care
Figure 2: Percentage of respondents in wealth quintile 1 reporting moderate to very poor outpatient health care services experiences
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
-2.0%
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-4.0%
-6.0%
Waiting time Treated Clear Involved in Privacy Freedom inchoice of Cleanliness
respectfully explanation decision process healthcare provider
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Unadjusted Adjusted
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Source: Authors’ calculations using World Health Organization data.g,58
A standardised (simulated) client or patient (SP) measurement prejudice. This is done through the detection of variation in clinical
approach involves the use of an actor or a community member who quality across clients.
presents to a nurse or doctor with a set of typical symptoms that
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practices and policy protocols enables researchers to test clinical consent of providers a while before the standardised client arrives
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quality at facility level across a sample of SPs. While this approach at their facility. Obtaining the cooperation and buy-in of providers
is expensive, various studies have shown that it provides reliable before the study commences is one way of compensating for lack
results that do not necessarily correlate with alternative facility of informed consent at the point of interaction with the SP.68 This
measures such as user satisfaction or clinical knowledge.67–69 A type of concealed research is referred to as ‘covert’ research and
recent study using a sample of TB SPs in India validated quality is ethically allowable if it is integral to the nature of the research
of the data collected by showing high reliability of recall among question and if the research question is deemed important enough
the SPs upon exiting health care facilities. The study found only from a societal perspective.69
a small difference between data collected through exit interviews
The time burden on scarce nursing staff is always a concern, but a
with the SPs (relying on memory), and data collected through voice
SP does not necessarily present a greater time burden than surveys
recordings of the interactions between SPs and providers.65
that require interviews with nursing staff. Furthermore, it is generally
The SP method allows for the measurement of a unique and only ethically advisable to conduct this type of research at primary
important dimension of health care. While the method is used mainly health care (PHC) level. Gathering data through SPs at secondary
to ascertain clinical and/or process quality, it can also be used to or tertiary levels of care will potentially consume critical and life
measure staff attitudes, client responsiveness and discrimination or saving resources.
g These percentages were calculated while also controlling for differences in It has been proposed that SPs should be used in the training of South
gender, education, age, marital status and race of clients. Other factors that African health students70,71 as is done internationally. Currently this
were controlled for include whether respondents lived in an urban area,
whether they accessed private or public facilities, their self-reported quality method is not widely used in South Africa to evaluate the quality of
of life and health, how long it took them to travel to the facility, the gender of PHC. We were able to find only one South African study that utilised
the doctor who assisted them, and their health outcome after accessing the
facility.63
S A H R 20 1 6 195
this methodology to assess quality of care. In that study, the method adjusting their behaviour because they know that they are being
was used to evaluate the impact of three different training initiatives observed. A further drawback with direct observation is that there
to improve the management and treatment of sexually transmitted may be a selection effect in terms of the type of clients examined.
infections in South Africa at PHC (clinic) level.72 The study was done There is a possibility that only clients with a limited set of health
across 40 clinics (four intervention arms, three health sub-districts) conditions will present for care.66 This means that the observer
and included a total of 242 analysed SP interactions. It found an may not be able to build a full picture of the health care worker’s
increase of 11% in the average number of sexually transmitted competency across a number of health areas or cases. However,
infection tasks (as defined by the study) completed by health care knowledge or clinical vignettes combined with direct observation,
workers at the facilities in the intervention arms, which had received provides a way to ensure a more balanced case-load mix when
training.72 assessing the competence of providers.66
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presenting with certain symptoms. To simulate an actual client sought, actual services received as well as the specific nature of the
interaction, the interviewer poses as the hypothetical client and the interaction with the health care worker (nurse or doctor). Questions
clinician is invited to proceed as she normally would, asking questions can, for example, be asked about whether an HIV test was offered,
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on illness history or conducting required examinations.1,65,66 The whether the client’s weight and blood pressure were measured
interviewer provides standard predetermined responses for all and communicated, and whether any questions were asked about
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questions and examinations. A recorder (or second interviewer) medical history. A drawback of this type of data collection is that it is
notes the observation and provides supplementary information likely to suffer from recall bias.74 It is thus important that respondents
as required if the interviewer or test client is unable to provide
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additional information in response to questions by the health care at a later stage. Depending on the way the question is phrased, it
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worker. The provided responses are evaluated relative to clinical may also evoke social desirability bias in the respondent’s answer.
best practice (protocol).1 Studies using clinical vignettes have been Consequently, careful thought has to be given to the phrasing of the
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This process measure avoids the potential bias of client-satisfaction Questions like these have already been incorporated into some
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or experience surveys by focusing on a more objective process surveys exploring care-seeking behaviour in South Africa (such
measure. Depending on the assessment of the health care worker’s as antenatal care attendance and care for a cough or possible
knowledge and adherence to protocols as measured through TB symptoms). A study on the timing of the initiation of antenatal
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the clinical vignette, the measure potentially also provides clear care attendance in inner-city Johannesburg found low levels of
guidance on remedial action. It is, however, important to note compliance with some service components that are considered
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that data collected through clinical vignettes represent a best case antenatal care best practice in the public sector.75 Only 67.2% of
or upper bound scenario as the medical vignettes only measure those who attended antenatal care (n=198) reported having been
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knowledge or ‘competence’ and not actual effort.1 informed of pregnancy danger signs, while only 59.6% reported
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having all routine health checks included in the survey done at the
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who reported coughing for two or more weeks and who reported
a SP process. The difference between knowledge (as measured
seeking help for their cough at public PHC facilities, TB testing
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Quality of care
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➢➢ Affordability and feasibility: In a resource-constrained
setting, the cost and time invested in gathering data will be
an important consideration. The costs and value of quality
indicators will have to be balanced. While SP studies are
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relatively expensive, the approach is unique because it allows
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researchers a very detailed and reliable account of the patient-
provider interaction. Including vignettes into client-satisfaction
surveys increases the length and therefore cost of such surveys.
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However, implementation can be made more feasible by
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including these measures for only a sub-set of the sample.
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Financing and Medical Products
Financing and Medical Products
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HIV and AIDS financing in South Africa:
sustainability and fiscal space
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Authors:
Mark S. Blecher i Gesine Meyer-Rath ii,iii
Calvin Chiu ii Yogan Pillay iv
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Fareed Abdullah v Aparna Kollipara i
Jonatan Davén i Michael Borowitz vi
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Nertila Tavanxi vii
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outh Africa has the largest number of persons living with HIV and on Overall, the analysis suggests
antiretroviral treatment (ART) in the world. In December 2015, 3.26 million
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South Africans were on ART, with this figure scaling up by approximately that introducing the
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400 000 persons per annum. To sustain increasing ART roll-out an additional HIV 90-90-90 targets will
R1–1.5 billion above inflation has been allocated annually over recent years, while
be hard to achieve, but
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R8.9 billion of the Comprehensive HIV and AIDS Conditional Grant is budgeted for
the ART programme in 2015/16. that they are likely to be
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The roll-out may need to expand more rapidly, as South Africa has amended the affordable and cost-effective,
treatment threshold to a CD4 cell count of 500 cells/mm3 and aims to reach the Joint provided that this is done in a
United Nations Programme on HIV/AIDS 90-90-90 targets, effectively a form of
phased way and that annual
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HIV and AIDS treatment accounts for a significant and growing share of limited health
budgets over the medium term through the current period of fiscal constraint. These AIDS budgets are sustained.
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pressures will be aggravated by other competing demands such as the 2015 wage
agreement. Simultaneously in terms of bilateral agreements, funding is declining
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from donors such as the United States President’s Emergency Plan for AIDS Relief.
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This chapter analyses these questions using the results of the recent HIV and tuberculosis investment case, which includes the most
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recent national costing, cost-effectiveness and allocative efficiency modelling of the epidemic, while on the funding side it includes
fiscal and budgetary information from recent national budgets, including Budget 2016.
Overall, the analysis suggests that introducing the HIV 90-90-90 targets will be hard to achieve, but that they are likely to be
affordable and cost-effective, provided that this is done in a phased way and that annual increments to Government AIDS budgets are
sustained. The HIV Investment Case has shown that the most cost-effective set of interventions can still massively affect outcomes such
as mortality and HIV incidence. If Government spends more now on the most cost-effective interventions, the impact over 20 years will
be greater, resulting in improvements in outcomes along with reductions in total spending in the long run.
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Introduction
Globally, South Africa has the largest number of persons living with unless cost-saving measures such as task-shifting are implemented.5
HIV and AIDS and on antiretroviral treatment (ART). Even though This chapter looks closely at this potential challenge by analysing
South Africa is an upper middle-income country, it has continued the fiscal space and sustainability of expanding the national HIV
to receive significant funding support from the Global Fund to Fight and AIDS programme.
AIDS, Tuberculosis and Malaria (GFATM) and the United States
The objectives of this chapter are to describe the following:
President’s Emergency Plan for AIDS Relief (PEPFAR), given its
high disease burden. With 6.4–6.8 million South Africans being ➢➢ Cost implications over time of scenarios studied in the recent
HIV-infected and 3.26 million persons on ARTa in December 2015, national HIV investment case, including the 90-90-90 scenario
scale-up of the treatment programme by 400 000–600 000 persons and enhanced prevention interventions
per annum has necessitated that an additional R1–1.5 billion above ➢➢ Affordability in terms of fiscal space, government health
inflation be allocated annually over recent years. R8.9 billion of the spending and total spending
Comprehensive HIV and AIDS Conditional Grant is budgeted for • Trends in public health spending and budgets, and to
the ART programme in 2015/16, which comprises 61% of the total what extent health spending growth projections allow for
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health sector HIV and AIDS budget. However, the programme may increasing HIV and AIDS spending, also in the light of
need to expand even more rapidly, given South Africa’s increased future NHI financing reforms
treatment threshold, namely a CD4 cell count of 500 cells/mm3,
• Trends in total government expenditure and revenue and
and its aim to reach the UNAIDS 90-90-90 targets.b,1
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the health sector’s share of these:
The issue of fiscal sustainability refers to the ability of countries – These trends in the context of fiscal space and overall
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to afford and continue to implement programmes using domestic macro-economic indicators such as the national gross
funding in the short, medium and long term, without jeopardising domestic product (GDP) growth and government debt;
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their national fiscal position. In the field of public health,
sustainability (which has both fiscal and programmatic dimensions)
– Macro-economic indicators benchmarked against other
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upper middle-income countries.
has been defined as the capacity to maintain programme services
at a level that will provide ongoing prevention and treatment for ➢➢ Sustainability of HIV and AIDS funding in light of:
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a health problem after termination of major financial, managerial • declining donor funding and ultimately full reliance on
and technical assistance from an external donor.2 An entire service domestic sources; and
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High Level Meeting on HIV and AIDS in 20116,7 which has been
While South Africa has increasing national spending needs, embedded in South Africa’s National Strategic Plan for HIV, TB and
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funding is simultaneously declining from major donors such as sexually transmitted infections (STIs) (2012–2016).8 The GFATM
defines an HIV investment case as a document that:
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H IV and A IDS financing
the case of HIV, the South African Investment Case added a category The process of identifying interventions to be included into the
of technical efficiencyc (TE) factors, which work to improve the investment case started with stakeholder consultation workshops
efficiency of single interventions (whereas enablers and synergies attended by over 250 participants representing government,
often aim at improving the efficiency or uptake across a number academia, civil society, non-governmental organisations and
of interventions). Furthermore, the South African HIV Investment the healthcare profession. Based on the outputs from stakeholder
Case placed the optimisation of allocative efficiencyd at the heart consultation workshops, the evidence collected went through several
of the exercise by pioneering a novel optimisation methodology that rounds of scrutiny, using a standardised grading system – first by
allows for consideration of the combined impact of a large number members of the Investment Case Task Team who reviewed the evidence
of interventions, TE factors, and enablers on the programme’s for each intervention under one of 10 programme areas, then by
effectiveness and cost. members of the economics and modelling sub-working group. In
short, interventions had to have strong evidence demonstrating their
Separate but interrelated investment cases were developed for TB
effectiveness, and be compatible with existing model architecture
and HIV. This chapter focuses on the results and recommendations
in order to be included. Table 2 lists the interventions, technical
of the HIV Investment Case only; the results of the TB Investment
efficiency factors and critical enablers that passed successive rounds
Case as well as further details regarding the methods and evidence
of scrutiny and were included in the HIV Investment Case for testing
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review and synthesis process of the investment case overall can be
within the optimisation model.
found elsewhere.8,10
The model computed the incremental cost-effectiveness ratio (ICER)
for each intervention and scenario, using cost per life year saved. A
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Methodology
total of 50 combinations of interventions and coverage levels were
The aim of the South African HIV Investment Case was to establish
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modelled and ranked using the ICER. Subsequently, the most cost-
the most cost-effective mix of interventions against HIV for South effective option was added onto the baseline scenario. This process
Africa over the next 20 years (from 2014/15 to 2034/35), with was repeated iteratively until the budgetary constraint was reached
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the aim of improving the allocative efficiency of HIV funding. Cost-
effectiveness was measured as cost per life year saved by the entire
(in the constrained optimisation scenario). The full list of options was
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defined as the unconstrained optimisation scenario.
programme of interventions, incremental to a baseline of current
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coverage with all interventions constant over 20 years. In order to An established epidemiological model projected the HIV epidemic in
assess the comparative merits of a range of interventions, several South Africa under each of the four scenarios. The Thembisa model,
different scenarios for HIV were constructed (Table 1), based on a dynamic model of the South African HIV epidemic maintained by
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the currently available budget envelope for the current mid-term the Centre for Infectious Disease Epidemiology and Research at the
expenditure framework (MTEF) timeframe (i.e. covering the three University of Cape Town,12 produced the number of HIV infections
financial years from 2016/17 to 2018/19) and a custom-built averted and the number of life years saved over 20 years under
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optimisation routine.11 Costs were modelled in real 2014/15 each scenario. Thembisa was chosen over other models used in
Rands over a 20-year period. A further 90-90-90 scenario was applying the investment framework internationally, such as Spectrum
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also constructed, but in the final iteration this was so similar to or Optima, as it provides a better fit to the past and current HIV
the constrained optimisation scenario that it is not reported on epidemic in South Africa.
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separately here.
Affordability and sustainability
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Table 1: List of scenarios analysed under the HIV investment case The cost implications arising from the Investment Case were
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Scenario Description assessed with reference to domestic fiscal and budgetary trends
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Baseline The baseline for the incremental analysis. This over the medium term. Current funding levels as estimated by the
scenario keeps the coverage of all interventions and South African National Treasury are summarised. In addition, the
technical efficiency factors constant at current (2014)
coverage levels throughout the 20-year projection
fiscal situation and projections for the country are outlined, based
period. on National Treasury documentation13 and estimates. Provincial
Unconstrained Using a custom-built optimisation routine that spending estimates for 2015/16 are drawn from Vulindlela on
optimisation considers the cost-effectiveness of each intervention
and iteratively adds the most cost-effective
5 April 2016.
intervention to a rolling baseline, this scenario scales
up interventions without regard to a funding envelope. The possibility of higher revenue and funding for the health sector is
Constrained This scenario repeats the optimisation routine explored in the context of the recently published NHI White Paper.
optimisation but stops once the total cost of the package of South Africa’s overall spending and revenue are compared with
interventions exceeds the combined available budget
for the HIV programme (i.e. from the South African other upper middle income countries as a benchmark, using data
Government, PEPFAR, and the GFATM) in any of the from the International Monetary Fund (IMF).14 Fiscal sustainability
years from 2015/16 to 2017/18.
and space was assessed using various indicators including deficit to
GDP ratio; debt-to-GDP ratio and interest payments as a proportion
of total spending and as a share of GDP. The potential of Government
to take over donor funding progressively was assessed with respect
to potential for government spending increases for HIV and AIDS.
c Technical efficiency in the context of this analysis refers to the maximisation
of output (for example, HIV tests done) given a set level of inputs (for Options to achieve greater technical and allocative efficiency in the
example, healthcare staff).
HIV and AIDS response are also presented.
d Allocative efficiency in the context of this analysis refers to the maximisation
of a socially desirable output (for example, life years saved) given a set level
of funding.
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Table 2: Interventions, technical efficiency (TE) factors and enablers included in the main analysis for the HIV investment case
Programme area Intervention/ technical efficiency (TE) factor/ Impact represented in model
enabler
1. Interventions
Care and treatment Cotrimoxazole ART uptake
ART at current guidelines ART uptake in children and eligible adults (CD4 <500)
Universal test and treat ART uptake in children and all HIV-positive adults
HIV Counselling and Testing (HCT) uptake
Medical male circumcision General population MMC MMC uptake in highly sexually active men
(MMC) Early infant male circumcision (EIMC) EIMC uptake
Comprehensive condom Condom availability Condom use
programming Male and female condom education Condom use
Key population interventions Pre-exposure prophylaxis (PrEP) for sex workers PrEP uptake for sex workers
Prevention of mother-to-child PMTCT (triple ART initiation in pregnant women) ART uptake in pregnant women
transmission of HIV (PMTCT) Infant testing at birth Uptake of infant testing at birth
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Infant testing at 6 weeks Uptake of infant testing at 6 weeks
HIV counselling and testing General population HCT HCT uptake
(HCT) Testing of pregnant women HCT uptake in pregnant women
Testing of adolescents HCT uptake in adolescents
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Social and behaviour change SBCC campaign 1e HCT uptake in adolescents
communication (SBCC) Multiple sexual partners
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SBCC campaign 2 Condom use
SBCC campaign 3 Condom use
HCT uptake
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Other biomedical prevention PrEP for discordant couples PrEP uptake
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PrEP for adolescents PrEP uptake for adolescents
2. Technical efficiency (TE) factors
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ART cost
Point-of-care CD4 testing ART uptake
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3. Critical enablers
Gender-based-violence intervention, e.g. SASA!f Multiple sexual partners
Life skills and vocational training for adolescent girls Condom use in adolescents
Risk reduction for alcohol and substance users Condom use
Risk reduction for substance users Condom use
School-based HIV/STI risk reduction Multiple sexual partners
Condom use
Teacher support Multiple sexual partners
Parental monitoring Multiple sexual partners
Condom use in adolescents
School feeding Condom use in adolescents
Positive parenting Multiple sexual partners
Supporting adolescent orphan girls to stay in school Age of sexual debut
State-provided child-focused cash transfers Age disparate sex
e A number of organisations responsible for SBCC campaigns were involved in a government tender submission process at the time of analysis, so we anonymised
the campaigns in order not to influence the tender process.
f SASA! is a community mobilisation intervention to prevent violence and reduce HIV-risk behaviours piloted in Uganda.
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Overall, scaling up condom availability and medical male
General population R13 358
circumcision (MMC) were the most cost-effective options – the model
HCT
in fact suggests that they were cost-saving overall, since both of them SBCC campaign 3 R19 692
prevent significant numbers of new infections, which translate into (condoms, HCT,
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MMC)
savings in treatment costs (Table 3). In terms of cost-effectiveness,
HCT for sex workers R28 727
these two options were followed closely by ART at current guideline
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Infant testing at birth R31 638
price (with an eligibility threshold of 500 CD4 cells/mm3, and
PrEP for sex workers R107 165
prevention of mother-to-child HIV transmission (PMTCT) coverage of
HCT for adolescents R219 417
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women not on lifelong ART. The currently available budget left space
for additional interventions under the ‘constrained optimisation’
PrEP for young
women
R286 581
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scenario – including infant testing at six weeks; improving linkage Early infant male R988 614 783
circumcision
to care and escalating initiation under a policy of universal ‘test and
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treat’ (UTT); and scaling up a mass-media campaign aimed at social * ICER (cost/LYS) = Incremental cost-effectiveness ratio as cost per life year
and behaviour change (with a broadcast message of increasing saved
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HIV counselling and testing (HCT) among adolescents and reducing Source: Authors’ calculations. See also references 10 and 11.
multiple sexual partners (MSP)). The constrained optimisation
scenario almost allowed the country to reach the 90-90-90 targets As a result of UTT being included in all scenarios other than the
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by 2021, although progress towards the second target was only baseline scenario, the total number of patients on ART (the main
88% (percentage of diagnosed HIV-positive people initiated on cost driver of the country’s HIV programme) did not differ much
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ART) instead of 90%. Moreover, although UTT is an expensive among the scenarios. From a starting point of 3.3 million people
programme, it must be seen in the light of the long-term cost-saving on treatment at the end of 2015 in the public sector (or 3.6 in both
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stemming from the number of HIV cases averted. the private and public sectors), the baseline scenario, in which ART
is offered only to people with CD4 cell counts <500 CD4 cells/
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Figure 1: Total number of patients on ART, including private sector8,16
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Patients on ART (Millions)
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1
0
2016 2018 2020 2022 2024 2026 2028 2030 2032 2034
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Table 4: Selected coverage data by scenario for South Africa’s by far the largest contributor to the cost of the entire HIV and AIDS
HIV and AIDS programme, 2016/17–2018/19 (public
and private health sector)
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findings from previous expenditure analyses of the South African
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Constrained Unconstrained HIV and AIDS programme.17
Year Baseline optimisation optimisation
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2017/18 4 580 194 4 809 905 4 838 683 on ART, while the unconstrained optimisation scenario is much more
2018/19 4 936 373 5 307 556 5 349 098 expensive than all other scenarios, with costs substantially higher
New patients starting ART than the currently available budget from the three main funders:
South African Government, PEPFAR and GFATM. In the unconstrained
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2018/19 462 014 613 831 627 901 but instead almost triple over 20 years, owing to the scale-up of
Number of condoms in circulation less cost-effective interventions in the second half of the ranked
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2016/17 337 308 240 481 541 212 470 949 722 list in Table 3. In contrast, the constrained optimisation scenario
2017/18 341 080 893 485 688 017 475 133 498 becomes less expensive than the baseline scenario by 2027 and the
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2018/19 346 113 637 491 680 366 481 562 685 constrained optimisation scenario by 2030, with increased savings
Number of medical male circumcisions
over baseline every year thereafter. In short, the model continues to
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Source: Authors’ calculations. See also references 10 and 11. Figure 3 shows the projected HIV incidence, prevalence and number
of AIDS deaths under each scenario. From an incidence of 0.70% in
The different intervention packages included in the scenarios result 2015/16 in the baseline scenario, incidence continued to decrease
in different costs of the overall HIV and AIDS programme (Figure 2). at a constant pace until 2019, then stabilised at 0.47–0.42% over
Of particular note is that the cost of the South African HIV and AIDS the remaining 15 years. In both optimisation scenarios, incidence
programme is projected to continue to increase year-on-year under continued to drop dramatically throughout the projection period,
each of the scenarios, including the baseline scenario in which no to 0.15% in the constrained and 0.12% in the unconstrained
additional interventions are scaled up and all existing interventions optimisation scenario, respectively, by 2035. All scenarios will
remain at baseline coverage. Across all scenarios, the cost of the reduce incidence by at least half over 20 years when compared with
ART component of the Care and Treatment programme area was the baseline scenario, to between 0.12% and 0.17% by 2034/35.
Of note is that none of the scenarios managed to reduce incidence
h The actual number of condoms assumed to be used to protect sex acts in the
model are a fraction of this number, about 29%.
20 8 S A H R 20 1 6
H IV and A IDS financing
Figure 2: Total cost of the National HIV/AIDS programme in South Africa, by scenario*
45
40
35
30
Billions ZAR
25
22.08
21.38 21.08
20
15
10
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5
0
2016 2020 2024 2028 2032
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* Even though the cost of inpatient care per patient on or off ART was included in the calculation of incremental cost-effectiveness, it is excluded here as this
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cost is borne by the general hospital budget, not the HIV/AIDS budget.
1.6%
1.4% Total AIDS deaths followed a similar pattern, with a decline in all
1.2%
scenarios from the 2015/16 level of 160 065 deaths per year with
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1.0%
0.8% the largest decrease, to 47 421 deaths per year in 2034/35. In
0.6%
0.4%
both the unconstrained optimisation, and constrained optimisation
0.2% scenario deaths fell to 49 831 per year.
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0.0%
1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033
As a result of the changes in both incidence and mortality,
Constrained optimisation Unconstrained optimisation Baseline
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Total HIV prevalence to decline in all other scenarios to between 10.8% in the constrained
16% and 10.1% in the unconstrained optimisation. Increasing ART
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14%
coverage is likely to have played a significant role in this, as the
12%
10% ART scale-up options contributed the greatest number of life years
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8%
saved in the respective scenarios.
6%
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4%
2%
Cost-effectiveness
0%
1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033 In terms of total life years saved over the baseline, the unconstrained
Constrained optimisation Unconstrained optimisation Baseline optimisation scenario was more effective than the constrained
optimisation scenario, but comes at a higher price (Table 5). While
both scenarios increase life years saved by 20–22% compared with
Total AIDS deaths
the baseline over 20 years, the unconstrained optimisation scenario
350 000
300 000
increases costs by 31%, in contrast to the marginal cost differences
250 000 of 1.14% in the constrained optimisation scenario. As a result, the
200 000
constrained optimisation scenario is much more cost-effective, at
150 000
100 000
an incremental cost-effectiveness ratio of R442 per life-year saved
50 000 (compared to R10 963 for the unconstrained optimisation scenario).
0
1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033
S A H R 20 1 6 209
Table 5: Summary of cost, outcomes and cost-effectiveness over sourced from the Budget Review.11 Worth noting is also that debt-
20 years, by scenario service cost is the fastest-growing expenditure item in the budget,
increasing at an annual average of 11.4%.
Constrained Unconstrained
Cost/Outcome Baseline optimisation optimisation
Total life years lost due 79 983 916 64 266 044 62 674 622 Economic growth
to AIDS
National revenue growth is highly dependent on economic growth,
Life years saved - 15 717 872 17 309 294
Change in baseline - -20% -22%
which has declined annually over the past five years to 2015/16
Total cost 610 617 799 (Figure 4), and has only exceeded 3% in one year, in the low growth
(R, billions) decade following the global recession of 2008. Lower economic
Incremental cost (R, - 6.95 189.76 growth is leading to lower increases in Government budgets.
billions)
Growth is projected to increase slightly over the next three years
Change in baseline - 1.14% 31.12%
but may not reach 3% in this Medium-term Expenditure Framework.
Incremental cost per - R442 R10 963
life year saved
Figure 4: South Africa’s annual GDP growth
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The investment case was limited to data available by January 2015
(with limited updates thereafter), and will be subjected to updates 4.0
3.0
16 6
Affordability and fiscal space 2.5
Although the investment case findings clearly show the most cost- GDP growth (Percentage)
2.0
20 IL
effective option, these still require significant additional funding 1.5
in the medium term, while the SA Government faces real revenue 1.0
Y T
constraints that may limit its ability to implement the most cost-
effective option. The South African Budget 2016 encompassed
0.5
A N
0.0
further weakening of the fiscal position, requiring an increase in tax -0.5
M U
Financial year
basic education and social development. This is shown in Table 6,
Source: Compiled by the authors based on Budget Reviews 2011–
2016.13,19,20,25
Table 6: Consolidated national budget 2016, R million*
O
Basic education 213 676 228 803 245 414 264 969 17.6% 7.4%
BA
Health 159 377 168 393 183 629 198 556 13.1% 7.6%
Defence, public order and safety 171 522 181 519 192 444 203 644 13.7% 5.9%
O
Defence and state security 49 900 52 344 54 063 56 373 3.9% 4.1%
Police services 82 648 87 508 94 095 100 225 6.7% 6.6%
EM
Law courts and prisons 38 974 41 667 44 285 47 047 3.2% 6.5%
Post-school education and training 64 158 68 715 74 715 80 493 5.3% 7.9%
Economic affairs 187 796 211 962 217 965 231 091 15.7% 7.2%
Industrial development and trade 29 550 31 844 31 938 35 314 2.4% 6.1%
Employment, labour affairs and social security funds 65 915 73 127 75 270 77 358 5.4% 5.5%
Economic infrastructure and network regulation 73 613 87 105 90 493 97 460 6.5% 9.8%
Science, technology, innovation and the environment 18 718 19 886 20 263 20 959 1.5% 3.8%
Human settlements and municipal infrastructure 178 233 182 631 199 821 216 215 14.2% 6.7%
Agriculture, rural development and land reform 25 249 26 417 27 744 29 147 2.0% 4.9%
General public services2 97 450 73 652 77 770 82 611 5.6% -5.4%
Executive and legislative organs 12 485 13 378 13 988 14 768 1.0% 5.8%
General public administration and fiscal affairs 67 802 41 597 44 701 46 491 3.2% -11.8%
Home affairs 7 247 7 391 7 052 8 935 0.6% 7.2%
External affairs and foreign aid 9 916 11 286 12 029 12 417 0.8% 7.8%
Social protection 154 353 167 479 180 634 194 945 12.9% 8.1%
Allocated by function 1 251 815 1 309 571 1 400 135 1 501 671 100.0% 6.3%
Debt-service costs 129 111 147 720 161 927 178 556 11.4%
Contingency reserve - 6 000 10 000 15 000
Consolidated expenditure 1 380 926 1 463 291 1 572 062 1 695 227 7.1%
* Numbers stated in this table are in nominal terms (i.e. not adjusted for inflation).
Source: National Treasury, 2011.19
210 S A H R 20 1 6
H IV and A IDS financing
Health spending is in turn highly dependent on economic growth. The fact that the actual increases in health budgets seen in Figure 4
Based on current GDP and existing ratios of expenditure, the authors are lower than this arises from the revenue growth being largely
estimate that an average of 1% growth in GDP would generate a used to reduce the deficit and pay for higher interest rates.
R1.5 billion real increase in public health spending annually, 2%
would generate R3 billion, 3% R4.5 billion, etc. (based on GDP*% Fiscal policy : national revenue and public spending
growth in GDP*non-interest expenditure/GDP*health spending/ When the global economic recession reached South Africa in 2008,
non-interest expenditure; in this case for 2016/17, a 1% increase growth slowed and, as can be seen in Figure 5, national revenue
in GDP would generate a R11.6 billion increase in-non-interest decreased markedly by 2010/11, but national expenditure levels
expenditure, of which R1.5 billion might be for health services.) were largely maintained as part of a counter-cyclical fiscal stance
1 400
1 200
PM
1 000 Revenue
Real 2015/16 R billion
16 6
Expenditure
800
20 IL
Non-interest expenditure
600
400 Y T
A N
200
M U
0
/96 /98 /00 /02 /04 /06 /08 /10 /12 /14 /16 /18
95 97 99 01 03 05 07 09 11 13 15 17
4 ED
Financial Years
Figure 6: Real annual increase in total government spending (non-interest*; Rand billion)
R
180 30%
BA
160 25%
O
140 20%
EM
120
15%
Real 2015/16 R million
100
10%
80
5%
60
0%
40
-5%
20
0 -10%
-20 -15%
-40 -20%
/03 /05 /06 /07 /08 /09 /10 /11 /12 /13 /14 /15 /16 /1 7 /18 /19
02 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18
Financial year
* Non-interest rather than total expenditure is used because it better reflects spending on government services rather than debt payments which vary; a wider
selection of information is available in the Budget Reviews.
S A H R 20 1 6 2 11
that was intended to protect social spending.20 Figure 5 shows a Fiscal space can be increased by increasing revenue or decreasing
sharp decline in the revenue line from 2009/10, after which the expenditure. Both of these have been done in Budget 2016.
expenditure line far exceeded the revenue line. The lower revenue National revenue will reach 26.9% of GDP on the main budget
line, higher deficit (gap between revenue and expenditure lines) and in the medium term, and consolidated national revenue (including
higher total expenditure line, partially due to higher interest costs, all social security funds and public entities) will reach 30.5% of GDP.
reflect limited fiscal space (despite national spending exceeding one In both Budget 2015 and Budget 2016, various tax rates have
trillion Rand). Nevertheless, some of the increase seen in non-interest been increased (personal, fuel levy, excise taxes on alcohol and
spending, which funds services, reflects increased allocations pro- cigarettes) and some new forms of taxation have been announced
vided to the HIV and AIDS Investment Case in Budget 2016. (e.g. tax on sugar-sweetened beverages).19
Figure 6 shows year-on-year real spending growth in non-interest Table 7 compares South Africa’s total public expenditure and revenue
expenditure in the main budget. Growth in total government with a basket of income comparable to upper middle-income (UMIC)
spending was strong in the six years before the 2008 economic countries.21 South Africa’s spending is comparable to the median,
recession, but has been followed by considerably lower spending but several comparator countries have slightly higher revenue and
growth since 2010/11. There is no real total year-on-year spending expenditure (e.g. Brazil, Argentina, Botswana and Turkey). Note
PM
growth anticipated in 2016/17, with some recovery into 2017/18, that increasing fiscal space does not necessarily imply that spending
with an average total spending growth (non-interest) of R8.5 billion would be allocated to health or to HIV specifically.
per annum across government over the next three financial years.
Note that if the health sector were to receive 10–15% (15% is the
16 6
Abuja Declaration target) of R8.5 billion non-interest spending
growth, this would amount to an increase of R850 million to R1.3
20 IL
billion.
Table 7:
Y T
General government revenue, expenditure and deficit as a percentage of GDP
A N
Expenditure Revenue Deficit
M U
Costa Rica 16.1 19.0 18.3 15.9 13.6 13.7 -0.3 -5.4 -4.6
Peru 18.8 20.3 19.6 21.3 20.2 21.7 2.6 -0.1 2.1
Dominican Republic 19.3 16.5 20.7 15.9 13.6 14.0 -3.4 -2.8 -6.8
O
Kazakhstan 27.1 22.5 22.4 28.3 23.9 26.9 1.2 1.5 4.5
Mauritius 23.8 25.1 23.3 21.0 21.9 21.4 -2.8 -3.2 -1.8
G
China 20.4 22.8 24.8 19.7 21.3 22.6 -0.7 -1.5 -2.2
Thailand 21.2 23.2 24.9 21.4 22.4 23.1 0.1 -0.8 -1.8
R
Panama 25.7 27.1 26.6 26.1 25.2 25.1 0.4 -1.9 -1.5
Mexico 25.6 26.7 27.2 24.7 22.4 23.5 -1.0 -4.3 -3.7
BA
Gabon 18.7 22.8 27.4 29.6 25.4 29.0 10.9 2.7 1.5
Colombia 26.6 29.4 28.3 26.4 26.1 28.4 -0.3 -3.3 0.1
O
Malaysia 28.2 27.8 29.5 24.6 23.1 25.9 -3.6 -4.7 -3.6
EM
Jamaica 38.6 33.2 29.9 27.5 26.8 25.8 -11.1 6.3 -4.1
Lebanon 34.7 29.7 31.3 24.7 22.2 22.6 -10.0 -7.6 -8.7
South Africa 30.1 32.4 32.6 29.6 27.5 28.3 -0.5 -4.9 -4.3
Namibia 26.8 32.7 34.0 31.0 28.1 32.7 4.2 -4.6 -1.3
Bulgaria 35.2 36.7 34.4 38.0 32.7 34.0 2.9 -4.0 -0.5
Romania 37.0 38.6 35.4 32.2 32.2 32.9 -4.8 -6.4 -2.5
Botswana 46.9 39.9 35.7 39.4 32.5 35.9 -7.5 -7.5 0.2
Turkey 34.5 36.7 36.3 31.8 33.3 34.5 -2.7 -3.4 -1.8
Azerbaijan 31.1 31.7 36.7 51.1 45.7 40.5 20.0 14.0 3.8
Belarus 48.8 42.1 38.9 50.7 41.6 40.5 1.9 -0.5 1.7
Venezuela 34.9 31.6 40.0 31.4 21.2 23.4 -3.5 -10.4 -16.6
Ecuador 34.5 34.6 40.4 35.1 33.3 39.5 0.6 -1.3 -0.9
Brazil 38.3 39.9 40.4 36.7 37.1 37.7 -1.6 -2.8 -2.8
Iraq 57.3 49.6 43.3 56.4 45.4 47.4 -0.9 -4.2 4.1
Argentina 37.9 38.5 44.3 34.3 37.2 40.3 -3.6 -1.4 -4.0
Hungary 49.2 49.9 48.9 45.5 45.6 46.9 -3.7 -4.4 -2.0
Serbia 44.8 46.4 49.3 42.8 42.5 42.1 -2.0 -3.9 -7.2
Median SA comparator 30.6 31.6 31.9 29.6 26.5 28.3 -1.0 -5.2 -3.6
Medium upper middle income 34.2 32.0 33.9 30.3 27.8 29.5 -3.9 -4.2 -4.4
2 12 S A H R 20 1 6
H IV and A IDS financing
Figure 7: Public health expenditure trend (real Rand million 2015/16 prices)
200 000
180 000
160 000
140 000
Real 2015/16 R million
80 000
60 000
40 000
PM
20 000
0
/96 /98 /00 /02 /04 /06 /08 /10 /12 /14 /16 /18
95 97 99 01 03 05 07 09 11 13 15 17
16 6
Financial year
20 IL
Source: Compiled by the authors.
Figure 8: Health spending annual growth – two projections (real Rand million 2015/16 prices)
Y T
A N
18 000
M U
16 000
14 000
4 ED
12 000
Real 2015/16 R million
10 000
O
8 000
6 000
G
4 000
R
2 000
BA
0
O
-2 000
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
EM
Financial year
Real increase consolidated health expenditureuse Real increase provincial and national
Source: Compiled by the authors based on Budget Reviews 2011–2016, Estimates of National Expenditure 2010–2016, and Estimates of Provincial Revenue
and Expenditure 2010–2016.13,19,20,25
S A H R 20 1 6 213
Figure 9: Government and donor funding for HIV/AIDS-dedicated programmes (R billion real 2014/15 prices)*
25 000
20 000
opportunistic infections
15 000
Donor
Total
10 000
5 000
PM
0
/08 /09 /10 /11 /12 /13 /14 /15 /16 /17 /18 /19
07 08 09 10 11 12 13 14 15 16 17 18
20 20 20 20 20 20 20 20 20 20 20 20
Financial year
16 6
Source: Compiled by the authors based on Estimates of National Expenditure 2010–2016, Estimates of Provincial Revenue and Expenditure 2010–2016, and
the Partnership Framework Implementation Plan agreement with PEPFAR.
20 IL
* The declining trend of donor spending reflects the bilateral Partnership Framework Implementation Plan agreement with PEPFAR which envisaged a funding
decline from US$450 million to US$250 million over five years. However, in practice, donor funding is likely to be higher in Rand terms because of currency
depreciation and additional funding from PEPFAR and GFATM for targeted HIV interventions.
Y T
* Funding to treat opportunistic infections in general health services is excluded here to make the numbers more comparable to the cost estimates shown in the
investment case.
A N
Health budget trends
M U
Health’s share of the budget is currently 13.1% (Table 5) and not far being distributed out to health departments. These estimates draw
4 ED
from the 15% called for in the Abuja Declaration. Figure 7 shows on in-year preliminary provincial projections for 2015/16 which
trends in public health spending, expressed in real Rand 2015/16 may overestimate the year’s spending outcome. Nevertheless, both
prices, and using three different spending measures. The simplest estimates suggest a considerable slowdown in health expenditure
measure is the sum of health spending by provincial and the national in 2016/17, which will need to be managed, and partial recovery
O
Departments of Health; the consolidated measure is used in the Budget in 2017/18 and 2018/19. Published provincial numbers from all
G
Review and incorporates public entities such as the South African nine provinces for Budget 2016 will be available from May 2016.
Medical Research Council (MRC) and National Health Laboratory
HIV and AIDS spending and funding
R
and Correctional Services, among others. All these measures show since 2007/08, as shown in Figure 9, while donor funding is
that real growth was quite strong until 2011/12 (exceeding 5% projected to decline in terms of the bilateral agreement with
O
per annum), but slowed substantially from 2012/13 and especially PEPFAR.22 In practice, however, the donor funding trajectory may
EM
in the recent years, when it started to level off in real terms. At the be more positive in the short term, given the strong US Dollar and
time of writing, provincial budgets had not yet been gazetted for additional allocations from PEPFAR and the GFATM for specific
budget 2016. The consolidated estimate shows somewhat stronger programmes.
growth going forward than do the other two estimates, because its
Annual real growth in government expenditure on HIV and AIDS
methodology assumes that provincial surpluses will be allocated out
(Figure 10) is expected to average R913 million per annum over
over time.
the medium term. This represents a significant commitment by
Figure 8 presents year-on-year real increases in health budgets using government, noting the revenue constraint and that total real
two projections of forward growth. The lower projection covers only government non-interest expenditure growth across all departments
provinces and the National Department of Health, and is based on is anticipated to average R8.5 billion per annum over the MTEF
estimates provided by provinces earlier in the budget process, which (Figure 6) and between R627 million and R2.0 billon per annum for
will change when final provincial 2016 budgets are published. health services overall (Figure 8).
Whereas health expenditure increased by an average R10 billion
per annum in real terms for the four years to 2012/13, spending
is projected to slow over the medium term. This lower estimate of
growth projects 0.4% or an average of R627 million per annum
increase over the medium term. The higher estimate, based on
consolidated expenditure, estimates real growth of 1.3% per annum
or averaging R2.0 billion per annum over the medium term. This
higher estimate includes assumptions about provincial surpluses
214 S A H R 20 1 6
H IV and A IDS financing
Figure 10: Annual real growth in government HIV and AIDS has been rising and will reach 46.2% by 2018/19. While this in itself
spending on dedicated programmes R billion is still lower than is the case in several developed countries, South
2 500 Africa pays higher interest rates, and as interest as a proportion of
total government spending increases to 11.7% in 2016/17, it could
2 000 soon overtake health expenditure. Government’s interest payments
as a proportion of GDP will now reach 3.5%, higher than the upper
Real 2015/16 R million
PM
Rising debt-to-GDP ratio, interest payments and high deficits are
Government HIV spending excluding opportunistic infections
considered to be indicators of risk in the ability of governments to
make debt payments and are of concern to Government.24 These
Source: Compiled by the authors based on Estimates of National Expenditure
2010–2016 and Estimates of Provincial Revenue and Expenditure have led to two sovereign ratings downgrades (i.e. independent
16 6
2010–2016. scorings of the risk of governments defaulting on debt payments),
which have in turn led to higher borrowing costs. To reduce fiscal
20 IL
It is clear that HIV and AIDS takes up a considerable share of risk, the Government increased taxes (personal income, fuel levy,
limited budgetary space for health, particularly in the 2016/17 excise taxes and others) in Budget 201525 and Budget 2016, and
year. However, ART is not the only item for which spending growth Y T imposed spending ceilings, spending cuts (R25 billion in personnel
is required – wage pressures are substantial in the South African cuts across the whole-of-government Budget 2016) and undertook
A N
context in terms of the 2015 wage agreement which covers three reprioritisation to fund new priorities, such as the zero-increase in
years exceeding inflation by several percentages. Primary health tuition fees and increased student financial aid at higher education
M U
care volumes of patients are increasing and there are backlogs institutions. Despite these efforts, the indicators of debt sustainability
in improving conditions of health facilities, all of which require in South Africa appear to imply that fiscal space for increased
4 ED
additional resources. health, and specifically HIV and AIDS spending, is likely to be
further constrained.
Sustainability and government debt
O
50%
EM
40%
30%
Percentage of GDP
Interest/GDP
Deficit/GDP
20%
Interest/Exp
0%
-10%
/96 /98 /00 /02 /04 /06 /08 /10 /12 /14 /16 /18
95 97 99 01 03 05 07 09 11 13 15 17
Financial year
* The increase in interest payments/GDP ratio from 2.3% of GDP to 3.5% of GDP is somewhat lower than the increase of net loan debt from 22% to 46% of
GDP, because interest rates – although rising – are lower than in 2008/09, but could be at risk of rising further; debt payments take up 11.7% of the budget
in 2016/17.
S A H R 20 1 6 215
Potential to raise additional revenue through NHI further improvements in health outcomes could be achieved through
the constrained optimisation scenario, noting that HIV and TB still
Should funds not be sufficient for the 90-90-90 scenario, additional
contribute massively to the national burden of disease.
funding may become available over time through new financing
mechanisms through NHI or through other mechanisms to raise The budget process appears to have been proactive in considering
national revenue. The recently published White Paper on NHI26 and at least partially funding the proposed recommendations of
suggests that public funding for health services will rise by the HIV and AIDS Investment Case; this forms a good basis for the
approximately 2% of GDP over 15 years, from 4% of GDP to 6.2% adoption of the 90-90-90 strategy and progressive implementation
of GDP, mainly through increased taxation. This could, in the long of the HIV Investment Case.
term, raise sufficient funding to fully fund the 90-90-90 scenario
However, there will be various hurdles to overcome, such as
and for complete donor sustainability. However, NHI will take
managing the increase in health personnel costs due to the 2015
several years to be fully functioning and to generate the revenues
wage agreement, which is expected to result in an 7.4% annual
anticipated, particularly in the fiscal climate portrayed in Budget
growth in wages across government.19 In addition, there will be a
2016.19
need to reconcile rising HIV and AIDS budgets with the personnel
hiring limitations announced across government as part of the
PM
Technical and allocative efficiency
fiscal constraint in Budget 2016 – a specific exclusion for HIV
Achieving high levels of technical and allocative efficiency is critical and AIDS-related personnel may be required to address this. If this
to sustainability, especially in a constrained fiscal environment. is not achieved, there may be funds available, but not sufficient
Substantial savings have been achieved through a well-researched
16 6
human resources to implement the 90-90-90 strategy, noting also
and negotiated procurement process resulting in South Africa that South Africa has a significantly lower number of doctors than
20 IL
achieving among the lowest prices for ARVs globally, which, do most income-comparable upper middle-income countries.30
together with the shift to nurse-based treatment, has substantially More contracting with private general practitioners as well as public
lowered the unit costs of ART. There may be potential for even clinics, as envisaged in the NHI policy, might also assist.19 Rising
Y T
greater efficiencies through measures such as adherence clubs and
the Central Chronic Medicine Delivery and Dispensing programme
HIV and AIDS budgets in the context of low growth in health budgets
A N
represents somewhat of a dilemma, but may still be worthwhile
which will facilitate less-frequent facility visits, integration of services given the high proportion which HIV and AIDS contributes to the
M U
treatment being approached after many years of reducing costs. fiscal and other resource constraints. Comparing the investment case
Nonetheless, through improved chronic medicine delivery and scenarios (see Figures 1–3), the constrained optimisation scenario
dispensing, integration and other forms of efficiency savings and compares favourably with the unconstrained optimisation scenario
O
rationalisation, it is likely that future reforms could achieve greater for outcomes such as incidence, prevalence and lives saved, but is
technical efficiency and value for money in health service delivery cheaper in the long term and should therefore be considered the
G
platforms and for the HIV programme as well.27,28 most cost-effective option for Government. Although the investment
case suggests a degree of allocative efficiency at baseline,
R
(e.g. MMC, condoms and the sex worker programmes have only
N
216 S A H R 20 1 6
H IV and A IDS financing
experience of previous CD4 count threshold changes has been that NHI (and other related potential financing reforms) could potentially
they tend to lead to progressive and gradual rather than sudden, increase public health spending from 4% to approximately 6.2% of
large increases in uptake. GDP over a 15-year period26 (as envisaged in the NHI White Paper
assuming economic growth of 3.5%), once additional revenue
The constrained optimisation scenario involves an optimal allocative
sources have been put into place. NHI would have the effect both of
distribution that focuses funds on the most cost-effective interventions.
raising additional revenue and increasing the health sector’s share
Implementing this will not necessarily be easy, as there are always
of the budget above the current 13.1% and closer to the 15% called
calls (in some cases potentially justifiably) to implement a range
for in the Abuja Declaration.
of less cost-effective or proven interventions. Part of this dilemma
arises from the difficulty of proving effectiveness, particularly for
a potentially large set of enabling interventions. This is one of the Conclusions
methodological limitations of this investment case analysis. Many of
these other interventions make sense from other perspectives, but do The national budget, reflected in Budget 2016, is under fiscal con-
not meet the very rigorous criteria used here. As more interventions straint and has limited fiscal space. Attempts have been made to
are added and government and donor funds are used for additional create fiscal space by increasing taxation and reducing national
PM
interventions and purposes, the scenario moves closer to the more spending. Some of the additional funds sourced from the contingency
expensive unconstrained optimisation approach, with higher costs reserve and through reprioritisation have been allocated to the HIV
and a requirement for further additional funding. In addition, the investment case, including the UTT strategy, given its apparent cost-
costed model assumes that the current high degree of technical effectiveness and ability to make a substantial impact on national
16 6
efficiency in terms of medicine prices and staff distribution can be health outcomes.
sustained, and it is possible that the country may face changing
20 IL
However, for the 90-90-90 strategy to work, its human resource
cost pressures, e.g. increasing medicine prices following currency requirements will have to be addressed in a climate where
depreciation. restrictions on post-filling have been reported in several provinces.
Y T
Scaling up HIV and AIDS services at a time of fiscal constraint will be The annual additional costs of ART expansion consume a significant
A N
difficult. Confronting these kinds of challenges is consistent with the portion of the available additional funds in the national health
experience of health services in many OECD countries (e.g. Ireland, budget, which faces considerable limitations. The rising short-term
M U
Greece, England) which have been through a period of fiscal costs of the HIV programme (ART being the largest contributor to
constraint during the 2008 global recession and have introduced HIV and AIDS spending, accounting for between 56% and 77% of
4 ED
a wide and varied set of efforts to control costs, achieve technical total cost), together with ever-rising personnel costs resulting from
efficiency gains and source cheaper input costs. South Africa faces the 2015 wage agreement, imply pressure on the rest of the health
the added high quadruple burden of disease,32 an escalating HIV service with a likely continued focus on efficiency savings and more
and AIDS response, and less advanced health services. cost-efficient service platforms.
O
Affordability will also depend on the degree to which donor funding Given these pressures, the transition plan for donor-funding
G
will have to be replaced. In the context described here, where programmes will require scrutiny to make best use of limited and
increases in HIV and AIDS funding already comprise a significant declining donor funding. However, the level of donor funding in
R
share of total annual health budget increases, it is likely that South Africa is relatively small and compensating for the decline
simultaneous full replacement of donor funding will be difficult. Full would not incur huge fiscal pressure. Despite the PFIP, the two largest
BA
domestic sustainability, in the sense of fully replacing donor funding, donors, PEPFAR and GFATM, have committed to supporting HIV and
O
will become easier once economic growth becomes stronger or once AIDS service delivery in South Africa with substantial allocations in
the number of persons on ART levels off (as is projected for around the medium term. Over the past few years, Government has worked
EM
2026 in both optimisation scenarios). In this context, simultaneous closely with PEPFAR on the PFIP transition. It is evident that transition
replacement of donor funds is likely to imply greater scrutiny of planning and sustainability – both fiscal and programmatic – is a
the merit of the services to be absorbed into the public service. difficult process that requires close collaboration with all relevant
However, it is worth noting that the entire level of donor funding stakeholders, including the NGO sector.
for health is relatively small (0.11% of GDP). Even if donor funding
Given the constrained fiscal climate, it is important to achieve high
had to be replaced in its entirety, this does not imply a huge fiscal
levels of technical and allocative efficiency in the delivery of HIV
pressure. Complete replacement is not envisaged at the present
and AIDS services. The programme has already reached fairly high
time, with substantial PEPFAR and GFATM allocations continuing
levels of technical and allocative efficiency (e.g. substantial savings
through the medium term, noting the importance of the South
in ARV procurement, and nurse-initiated management of ART) with
African contribution to ending AIDS globally. Practical experience
real unit costs dropping substantially. It is important for Government
of the sustainability transition in South Africa within the first one to
and the private sector to continue to achieve greater efficiencies and
two years of reducing PEPFAR funds has shown the complexity of
value for money in HIV and AIDS service delivery and other parts of
handing over responsibility for a complex set of services and non-
the health service as an integral part of financing reforms.
governmental organisations (NGOs) widely distributed throughout
the country. This practical experience suggests that sustainability In summary, the total cost of the national HIV and AIDS programme
transitions should be carefully planned and managed. Fiscal will increase, notwithstanding the mix of interventions chosen,
sustainability has in several cases proven to be considerably simpler because of South Africa’s generalised epidemic and Government’s
than programmatic transition of services. pre-existing commitment to fund lifelong ART to existing patients.
S A H R 20 1 6 2 17
In the context of the current fiscal constraints, it is in the hands of
Government to decide when total costs should start to decrease –
bearing in mind that spending more now will lead to a decrease in
total spend.
Recommendations
The following recommendations arise from the research:
PM
should be implemented, which will entail implementation of
UTT, and scale-up of interventions that have been identified as
highly cost-effective, such as MMC and condom distribution.
However, it is uncertain whether some of the highly cost-
16 6
effective interventions can be logistically and practically
scaled up even faster.
20 IL
➢➢ The HIV investment case findings underscore the importance
of investing more now in HIV and AIDS to reduce overall
Y T
spending and to achieve greater impact over the next 20
A N
years. In the context of NHI and declining donor funding, it
is recommended that Government also intensify its efforts to
M U
Acknowledgements
The authors wish to acknowledge contributions from Teresa Guthrie,
Lise Jamieson, Gavin Surgey, Refiloe Thokoa and Shaneel Ragoo.
218 S A H R 20 1 6
H IV and A IDS financing
References
1 Joint United Nations Programme on HIV/AIDS (UNAIDS). 19 National Treasury (South Africa). Budget Review 2016.
90-90-90 – an ambitious treatment target to end the epidemic. Pretoria: National Treasury; February 2016.
Geneva: Joint United Nations Programme on HIV/AIDS; 20 National Treasury (South Africa). Budget Review 2010.
2014. Pretoria: National Treasury; 2010.
2 La Pelle NR, Zapka J, Ockene J. Sustainability of Public 21 World Health Organization. World Health Statistics. Geneva:
Health Programs: The Example of Tobacco Treatment World Health Organization; 2014.
Services in Massachusetts. Am J Public Health. 2006 August;
96(8):1363–9. 22 United States President’s Emergency Fund for AIDS Relief
(PEPFAR). Partnership Framework Implementation Plan in
3 Durairaj V, Evans D. Fiscal space for health in resource-poor Support of South Africa’s National HIV, STI & TB Response
countries. World Health Report (2010) Background Paper, 41. 2012/13–2016/17 between The Government of the
Geneva: World Health Organization; 2010. Republic of South Africa and The Government of the United
4 Heller P. Understanding fiscal space. International Monetary States of America. 2012. [Internet]. [cited 28 March 2016].
Fund, IMF Policy discussion paper. Washington, DC: URL: http://www.pepfar.gov/documents/
International Monetary Fund; 2005. organization/196651.pdf
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5 Venter F. HIV Treatment in South Africa: The challenges of an 23 European Commission. Economic stability and growth pact.
increasingly successful antiretroviral programme. In: Padarath 2016. [Internet]. [cited 28 March 2016].
A, English R, editors. South African Health Review 2012/13. URL: http://ec.europa.eu/economy_finance/economic_
Durban: Health Systems Trust; 2013. governance/sgp/corrective_arm/index_en.htm
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6 United Nations. Political Declaration on HIV/AIDS: 24 Sachs M. The new fiscal guidelines and a “rule-of-thumb”.
Intensifying our Efforts to Eliminate HIV/AIDS. Resolution National Treasury proposals in the 2015 Medium Term
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65/277 of the 65th Session of the UN General Assembly, Budget Policy Statement. Pretoria: National Treasury; 2015.
New York, 10 June 2011. [Internet]. [cited 28 March 2016].
URL: http://www.treasury.gov.za/comm_media/
7 Schwartländer B, Stover J, Hallet T, et al. Towards an
Y T presentations/Fiscal%20Principles.pdf.
improved investment approach for an effective response to
HIV/AIDS. Lancet. 2001;377:2031–41. 25 National Treasury (South Africa). Budget Review 2015.
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Pretoria: National Treasury; February 2015.
8 South African National Department of Health. National
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Strategic Plan for HIV, TB and STIs (2012–2016). Pretoria: 26 South African National Department of Health. White Paper
National Department of Health; 2012. on National Health Insurance for South Africa, Version 40.
December 2015. [Internet]. [cited 28 March 2016].
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10 South African National Department of Health, and South health for the money. In: World Health Report 2010. Geneva:
African National AIDS Council. South African HIV and TB World Health Organization; 2010.
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African National AIDS Council. South African HIV and TB health and finance perspectives. Paris: Organisation for
investment case – Reference Report Phase 1. March 2016. Economic Co-operation and Development; 2015.
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12 Johnson L. THEMBISA version 1.0: A model for evaluating 29 National Treasury (South Africa). Estimates of National
the impact of HIV/AIDS in South Africa – Working Paper. Expenditure. Pretoria: National Treasury; 2016.
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Towards a transparent pricing system in
South Africa: trends in pharmaceutical
18
logistics fees
Authors:
Varsha Bangalee i
Fatima Suleman i
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S 20 IL
outh Africa has instituted various mechanisms to render the pricing of Despite efforts to increase
pharmaceuticals more transparent, including the Single Exit Price (SEP) that
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clarifies the price at which a manufacturer may sell a medicine to logistics transparency in the supply
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service providers or medicine dispensers. The SEP consists of an ex-manufacturer chain, prices reflected in
price, a logistics fee and Value Added Tax. However, as more countries look to South
South African medicine price
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Africa for lessons from its pricing policies, an understanding of the manufacturer’s
price, logistics fees and their relationship has become increasingly necessary to registries may not be a true
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support the principle that the SEP leads to more transparent prices. reflection of prices negotiated
This chapter provides a descriptive analysis of the pricing dynamics between the between manufacturers and
ex-manufacturer’s price and the logistics fee; a determination of the logistics fee
logistics service providers or
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The findings reveal that despite efforts to increase transparency in the supply chain,
prices reflected in South African medicine price registries may not be a true reflection
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22 1
Introduction
The current landscape of the South African healthcare system has Fundamentally, the objectives of attaining price transparency are
to a large extent stemmed from the country’s previous political to improve economic efficiency; obtain accurate price information
dispensation. This history has resulted in gross inequality in access to assist policymakers and researchers; empower buyers to
to and affordability of health care in an already severely under- negotiate more strategically; and to hold pharmaceutical firms more
resourced system grappling with a high disease burden.1 Post- accountable for prices.11 Previous editions of the South African
apartheid efforts to resolve this tenuous situation revolved around the Health Review have covered the development and implications
restructuring of the South African healthcare sector, which resulted of pharmaceutical pricing policies.12–16 The most recent Health
in the publication of the National Drug Policy in 1996.2 Among Policy and Legislation chapter in the Review (2013/2014) also
the economic objectives of this policy has been the need to reduce briefly mentioned the progress of legislation in this area.17 Previous
the cost of medicines in both the private and public sectors.2 To Mediscor Medicines Reviews provide some information on generic
meet these objectives, the policy document importantly included medicine use, and the effect of newly launched and expensive
the establishment of a ‘Pricing Committee’ tasked to monitor and medicines in the private sector market, as well as changes in SEP
regulate medicine prices. The policy also highlighted the need for a basket of medicines.18,19 However, none of these reviews
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for “total transparency in the pricing structure of pharmaceutical examined the impact of policy implementation on the prices of
manufacturers, wholesalers, providers of services, such as dispensers medicines, or whether transparency has been achieved. Thus no
of drugs, as well as private clinics and hospitals”.2 Importantly, information exists as to the effect of SEP adjustments on logistics
these policies were intended to apply only to the private sector, as fees, or whether increases in SEP reflect an increase in both the
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medicines procurement in the public sector continued to be based on ex-manufacturer price and logistics fee increases, on an annual
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a national competitive tender process, limited to locally registered basis, as a result of increasing costs of doing business for both
products.3 manufacturers and wholesalers or distributors.
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Previously in the private sector, medicine price inflation, medicine
price transparency, and medicine price uniformity represented
South Africa has undergone a number of policy changes
pertaining to supply chain and pharmaceutical pricing.12–17
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significant problems in an unregulated medicines market.4 The loss Improved understanding and knowledge of the realities of the ex-
of benefits to consumers resulting from the high levels of discounting manufacturer price, and logistics fees and their relationship have
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and payment of incentives within the pharmaceuticals supply become increasingly necessary, especially in the light of published
chain had raised serious concerns in the National Department of policy, requesting comment for the regulation of the logistics fee
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Health (NDoH) and made it difficult to determine the true price component of the SEP.20 In addition, a Gazette notice has been
of a medicine.5 The introduction of government medicine pricing issued for comment on suggested changes to what is perceived as
interventions aimed at reducing the prices of medicines and a bonus or a perverse incentive,21 which could impact on what is
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controlling the mark-ups instituted by the various stakeholders along being charged as a logistics fee, and might actually be considered
the entire supply chain from the manufacturer to the final medicine a discount. Should this Gazette be implemented, logistics fees will
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dispenser, saw the prohibition of said discounts and rebates in the have to be disclosed and be non-discriminatory.
pharmaceutical sector; mandatory offering of generic substitution;
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being that the prices of the products in those countries were publicly
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After much challenge and repeated litigation in the South African available. Should other countries want to include South Africa in
courts, the SEP was introduced in 2004, and was determined for their basket of countries for benchmarking, South Africa would be
each medicine on the basis of the net value of sales, including an attractive option due to the availability of the Medicines Pricing
discounts from the previous year.3,8 Pharmaceutical manufacturers database.
make submissions to the NDoH for SEPs for new medicines. This
Finally, there is a move to introduce universal health coverage in South
price is determined by the manufacturer and signifies a fixed price
Africa through National Health Insurance (NHI).22 Currently, in the
at which manufacturers and importers have to sell medicines,
public sector, the government is responsible for providing essential
without an opportunity to offer discounts.9 The ex-manufacturer
medicines for the South African population. Essential medicines can
price, logistics fee and Value Added Tax (VAT) constitute the three
be defined as those medicines that satisfy the priority healthcare
components of the SEP. The SEP is adjusted on an annual basis and
needs of the population, developed with careful consideration of
these maximum annual increases are regulated.10
disease prevalence in South Africa, evidence of medicine efficacy
The final logistics fee, as submitted in the manufacturer application and safety, and comparative cost-effectiveness.23,24 Essential
for SEP or SEP adjustments, is available on a price list found medicines are not charged to patients as a separate fee in the public
on the NDoH website. The logistics fee is determined through sector. As mentioned, equity in health care for all South African
negotiation between the manufacturer or importer and the logistic citizens was of fundamental importance in developing the National
service provider.9 The process and contracts are not made Drug Policy, and the implementation of an Essential Medicine List
public. Wholesalers and distributors are paid a logistics fee by (EML) played a pivotal role in achieving this. Under NHI, the EML
manufacturers, from the SEP; however, whether all logistic service may not operate solely in the current public sector but be included
providers are able to negotiate the same fee or whether this fee is as under NHI-funded plans, which will incorporate a unified set of
reflected in the medicines database is not evident.3
222 S A H R 20 1 6
Pharmaceutical logistics
treatment guidelines and clinical pathways. While there is still The ex-manufacturer price, logistics fee and the SEP inclusive of
some way to go before the two sectors operate under a unified VAT for each sample medicine were recorded as at 20 December
NHI system, it would be interesting to understand how a medicine 2013. These results were investigated statistically using correlation
deemed essential in the public sector is priced in terms of the SEP analysis to determine the relationship between the number of
(including the logistics fee) in the private sector under the current manufacturers and the logistics fee as well as to make descriptive
system. comparisons in relation to medicine class and the logistics fee. The
essential medicine status as listed in the most recently published
As a surrogate to determine transparency, the primary objectives of
Standard Treatment Guidelines and Essential Medicines List (EML)
this study were therefore to examine pricing dynamics between the
for two levels,24,32,33 was recorded for each surveyed medicine to
ex-manufacturer price and the logistics fee; to determine the logistics
elaborate on this relationship to the logistics fee.
fee relationship to the number of manufacturers of a product; and
to examine logistics fees among different medicine classes, as well The annual logistics fee as a percentage of the SEP of the originator
as the relationship to the essential medicine status of a product and lowest priced generic was compared to the consumer price
within medicine classes. This investigation is also important for other index (CPI). This was done for the years 2009–2013. The CPIs in
African countries referring to South Africa’s experience and lessons percentage, as obtained from Statistics South Africa, were 7.26
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learnt in implementing pricing policies. African countries are seeking (2009); 4.1(2010); 5.01(2011); 5.75 (2012) and 5.77 (2013).34
to institute pricing interventions in order to improve the availability, The CPI “expresses the current prices of a basket of goods and
affordability and acceptability of medicine access,25,26 especially in services in terms of the prices during the same period in a previous
the supply and distribution chain.27 year, to show effect of inflation on purchasing power”.35 The CPI is a
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measure of inflation. In Canada, the Canadian Patented Medicines
Prices Review Board sets maximum introductory prices for newly
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Methodology patented medications, and regulates the prices of medicines by
A cross-sectional descriptive study was undertaken to examine calculating a consumer price index adjustment factor.36,37 The CPI is
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the SEPs for a basket of medicines over a five-year period. Data
used in the study were retrieved from the South African Medicine
also one of the measures that the Minister of Health should consider
when reviewing the SEP on an annual basis.38
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Price Registry on private sector prices for originator and generic
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Pricing Survey,29 plus medicines (in the same dosage form) in each
fee and SEP over the five-year period showed that the majority of
core medicine class in the South African Medicines Formulary,30
medicines surveyed could be grouped into one of two categories,
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VAT. VAT is charged at a standard 14% across the board and is differed with regard to changes in the ex-manufacturer price and
calculated from the sum of the ex-manufacturer price and the logistics fee components. Table 2, showing the trend observed for
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logistics fee and added to the combination of these two prices. 65.1% of medicines (of which 73.6% were originator medicines),
The ex-manufacturer price, logistics fee and the SEP for all selected revealed that it was common for the ex-manufacturer price to increase
medicines were collected and expressed in South African Rand. in proportion to the SEP, while the logistics fee remained constant or
These prices were obtained from the locked database and no further was slightly increased. Table 3, showing the trend apparent for only
price adjustments for that year were possible, i.e. all SEP adjustments 20.1% of medicines (of which 47.1% were originator medicines),
had been made for that year. The relationship between the three revealed that increases in the ex-manufacturer price were met with
variables over the five-year period was plotted for all originator proportional decreases in the logistics fee. The remaining 14.8%
medicines and the corresponding lowest-priced generic option, of medicines displayed trends that were different from both Table 2
where available in the dataset specific to that strength. To ensure and Table 3. These trends were not included as they also differed
commonality and consistency of results, the lowest-priced generic from each other, but they are available on request.
as at 10 December 2009 was chosen for each of the originator
medicines in order to display trends throughout the designated study
period. Data for the following originator medicines: indomethacin,
amoxicillin, trimipramine, cefotaxime and co-trimoxazole, were not
available for the entire study period and were therefore excluded.
The pricing data for paracetamol syrup (schedule zero) were not
included as schedule zero medications are currently exempt from
pricing regulations in South Africa.31
S A H R 20 1 6 223
Table 1: Summary of trends for 50 medicines surveyed from 10 December to 20 December 2013
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Acebutolol 200mg cap Originator x
Lowest-priced generic None available
Atenolol 50mg tab Originator x
Lowest-priced generic x
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Proton pump inhibitors Rabeprazole 20mg tab Originator x
Lowest-priced generic None available
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Pantoprazole 40mg tab Originator x
Lowest-priced generic x
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Esomeprazole 20mg tab Originator
Lowest-priced generic
x
None available
A N
Lansoprazole 30mg cap Originator x
Lowest-priced generic x
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Lowest-priced generic x
N
Lowest-priced generic x
Sulphonylureas Gliclazide 80mg tab Originator x
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Lowest-priced generic x
Glimepiride 4mg tab Originator x
Lowest-priced generic x
Glipizide 5mg tab Originator x
Lowest-priced generic None available
Glibenclamide 5mg tab Originator x
Lowest-priced generic x
Fluoroquinolones Ciprofloxacin 500mg tab Originator x
Lowest-priced generic x
Moxifloxacin 400mg tab Originator x
Lowest-priced generic x
Levofloxacin 250mg tab Originator x
Lowest-priced generic x
Gemifloxacin 320mg tab Originator x
Lowest-priced generic None available
Norfloxacin 400mg tab Originator x
Lowest-priced generic x
Ofloxacin 400mg tab Originator x
Lowest-priced generic x
224 S A H R 20 1 6
Pharmaceutical logistics
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Lowest-priced generic x
Quinapril 5mg tab Originator x
Lowest-priced generic x
Captopril 25mg tab Originator x
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Lowest-priced generic x
Benazepril 10mg tab Originator x
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Lowest-priced generic None available
Lisinopril 5mg tab Originator x
Lowest-priced generic x
Long-acting Benzodiazepines
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Diazepam 5mg tab Originator
Lowest-priced generic
x
x
A N
Flurazepam 30mg cap Originator x
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Lowest-priced generic x
Dosulepin 25mg tab Originator x
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Lowest-priced generic x
Imipramine 25mg tab Originator x
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Lowest-priced generic x
Lofepramine 70mg tab Originator x
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Lowest-priced generic x
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Table 2: Distribution of SEP, ex-manufacturer fee and logistics Table 3: Distribution of SEP, ex-manufacturer price and logistics
fee over five years, where the logistics fee is constant fee over five years, where there is an inverse relationship
(quinapril – originator) to the logistics fee (quinapril – generic)
Ex-manufacturer Ex-manufacturer
Year price Logistics fee SEP Year price Logistics fee SEP
2009 78.35 5.09 95.12 2009 41.02 4.35 51.72
2010 78.35 5.09 95.12 2010 41.02 4.35 51.72
2011 85.95 5.59 104.36 2011 41.02 4.35 51.72
2012 85.95 5.59 104.36 2012 43.72 2.62 52.83
2013 90.94 5.91 110.41 2013 46.25 2.78 55.89
S A H R 20 1 6 22 5
Table 4: Median SEP components as at 20 December 2013a
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Lansoprazole 30mg cap 7.90 79.83 9 N
Omeprazole 20mg cap 10.44 77.29 7 Y
Cardiovascular HMG CoA Reductase Inhibitors Simvastatin 20mg tab 8.78 78.95 18 Y
disease Atorvastatin 10mg tab 9.61 78.12 10 N
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Fluvastatin 80mg tab 6.22 81.5 1 N
Lovastatin 40mg tab 13.16 74.57 1 N
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Pravastatin 40mg tab 13.16 74.57 4 N
Rosuvastatin 5mg tab 8.78 78.95 3 N
Diabetes Sulphonylureas Y T Gliclazide 80mg tab 8.37 79.35 8 Y
Glimepiride 4mg tab 8.78 78.95 9 N
A N
Glipizide 5mg tab 5.36 82.37 1 N
Glibenclamide 5mg tab 11.19 76.54 4 Y
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Combination
Pain/inflammation Anilides Paracetamol 120mg/5mL syr 11.28 76.45 4 Y
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226 S A H R 20 1 6
Pharmaceutical logistics
Table 4 reflects the median logistics fees and median ex-manufacturer The findings revealed that for the majority of surveyed medicines
price expressed as a percentage of the SEP for each medicine in the (74.4%; n=61), the logistics fee/SEP percentage (as indicated in
selected class, together with the total number of manufacturers and the medicines price database) was generally above the CPI for each
EML status as at 20 December 2013. year. Of the remaining medicines that were below the CPI (25.6%,
n = 21), all except four were originator medicines.
The results reveal that there were large variations in the logistics fee
components between all classes of medicines, and that the median Of the 258 medicines surveyed, four medicines, namely fosinopril,
spread of the logistics fee increased as the number of medicines bisoprolol, pantoprazole and moxifloxacin, also had clones
available in each class increased. Overall, a weak correlation manufactured by the originator company. Table 5 shows the
exists between the number of manufacturers and the logistics fee for differences in the SEP components of these medicines as at 20
each medicine in a class (Pearson’s correlation coefficient r=0.09); December 2013.
however, this does not necessarily indicate that logistics fees are
not levied as a means of introducing final price competition. This Apart from bisoprolol, both the ex-manufacturer price and the
phenomenon may actually be class-dependent, as it was noted logistics fee for the originator medicine were higher than those for
that medicines with the highest logistics fee component were also the respective clone, but the percentage of logistics fee and ex-
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the medicines that had limited competition (1–2 manufacturers) manufacturer price of the SEP remained the same or quite similar.
in certain medicine classes only, i.e. short-acting beta2 agonists, The ex-manufacturer price and the logistics fee for the highest-priced
fluoroquinolones, tricyclic antidepressants and third-generation generics for each of the medicines in Table 5 were lower than those
cephalosporins. for the originator and the clone.
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Medicines on the EML represent those that had the highest number
Discussion
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of different manufacturers in every medicine class surveyed. In
most instances, they also had median logistics fees higher than the
The price of medicines has long been established as an important
logistics fee of other medicines in their group, with the exception
Y T measure in ensuring medicine accessibility.39 however, the pricing of
of the following medicine classes: tricyclic antidepressants,
medicines is reliant on policies unique to each country. South Africa’s
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fluoroquinolones, HMG CoA reductase inhibitors and short-acting
efforts in trying to achieve accessible and affordable medicines in
beta2 agonists.a
the private sector have been described as anticompetitive by several
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Overall, the ex-manufacturer price and logistics fees relative to the industry players.40,41 Despite the benefits of increased transparency,
SEP varied widely across all medicine classes studied. The results empirical evidence has shown that highly regulated markets with
4 ED
show that 54.4% of the median logistics fee segment were less than low medicine prices may have unintended consequences.42–44
10%. As a medicine class, third-generation cephalosporins had the Price regulation, specifically price ceilings, may result in perverse
highest median logistics fee segment at 12.3%.
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Table 5: Price component comparisons of originator, clones and the highest-priced generic medicines (20 December 2013)
G
Ex-
Logistics Log/ SEP Ex-man/SEP
Medicine manufacturerer’s VAT SEP Unit SEP
R
a INH – inhaler, tab – tablet, cap – capsule, susp – suspension, syr – syrup,
inj – injection, Log – logistics fee, Ex-man – Ex-manufacturer, EML – essential
medicines list.
All manufacturer medicines on the NDoH tender list were considered for
the study in the same strength, dosage form and pack size as the originator
medicine.
VAT averaged 14% of the SEP for all medicines surveyed
S A H R 20 1 6 227
economic effects for businesses.45 Consequently, business may be One would expect that both the ex-manufacturer price and the
forced to take other actions to recover their lost profits. This may have logistics fee would increase, as they are both exposed to the same
been the case in South Africa, post-SEP implementation, when firms CPI changes, while the ex-manufacturer prices might increase more
possibly altered the logistics fee to recover profits lost from changes due to international currency fluctuations. In 2014, the Pricing
in the ex-manufacturer price, or created market incentives by paying Committee considered various inflators for different medicines,
higher logistics fees to create an economic incentive to market whether these were generic medicines (fully imported or locally
their products. It was previously cited that originator companies produced) or originator medicines.38 The premise was that the cost
with no other generic competition often paid low or no logistics pressure for each of these medicines would be different and that
fees to wholesalers who were desperate to stock their products. This the extent to which each would be affected by inflation and the
placed generic companies at a disadvantage, as wholesalers would exchange rate would also differ.38 This is also evident when looking
often ‘squeeze’ them for higher logistics fees to make up for the at the differences in logistics fees between originator medicines and
loss sustained in dealings with originator companies.46 However, their clones as one would expect these to be identical; however, our
the occurrence of this may be class-dependent, as observed in the findings show that they do differ in certain instances. This could be
current study. to ensure that prices are more competitive than those being set by
the generic medicines.
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The results of this study indicate that the number of manufacturers
was not a determinant of the logistics fee component of the SEP for Results reveal that as a class, no particular medicine group
the majority of the medicine classes surveyed, and that EML status uniformly displayed high or low logistics fee components. Instead
generally resulted in higher logistics fee components. Furthermore, they displayed a spread of logistics fees depending on either the
16 6
the dynamics between the ex-manufacturer price and the logistics fee EML status of the medicine or the number of manufacturers. The
do not follow expected market trends, according to which they should differences in logistics fees could be attributed to a range of
20 IL
ideally increase collectively as they are both exposed to the same factors, including differences in product type, product categories in
inflationary pressures over time. These findings confirm arguments operation and labour requirements attached to different medicines.
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that the ex-manufacturer price and logistics fee reflected in the
medicines database are not the actual and accurate representation
However, this is a further illustration that the logistics fees disclosed
on the database are not the actual fees paid.
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of the fees negotiated by manufacturers and wholesalers.
There is room for greater transparency with regard to logistics fees
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The results reflected in Tables 2, 3 and 4 are consistent for a country for medicines in South Africa. Allegations of exploitation of the
like South Africa, where although the SEP is transparent, the ex- logistics fee by pharmaceutical companies have led to the proposed
4 ED
manufacturer price and the logistics fee component of this price are cap on the logistics fee as opposed to a fixed fee.49 This policy will,
not; therefore, the mark-ups in the distribution chain are not very however, require monitoring on implementation to ascertain whether
clear. Manufacturers could also be using a higher logistics fee to it is feasible. Transparency in this segment of the supply chain should
incentivise wholesalers and distributors to stock their products and be strived for, and could possibly be achieved through logistics fee
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thus create the push for their products down the chain. The logistics contracts being made public, or through negotiations between the
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fee has previously been quoted as generally being between 10% National Department of Health and wholesalers and distributors.7
and 15% of the final price in an unregulated market.43 Slightly more Considering all of the evidence on price transparency, the majority
R
than half of the medicines in this study had a reported logistics fee of of the empirical studies have found that greater price transparency
less than 10%. The results show that despite the similarity in the type leads to lower and more uniform prices.42 Furthermore, price
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of products (dosage form and storage conditions), medicines still do competition through discounts in the supply chain is not transparent
not attract the same logistics fees. or fair, as distributors are not rewarded for services rendered, but for
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228 S A H R 20 1 6
Pharmaceutical logistics
The actual contractual agreements for logistics fees are not in the
public domain and could not be used to compare reported trends
with actual trends.
Recommendations
Research on SEP reveals gaps in the literature regarding how
the various players in the supply chain have adjusted their daily
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practices to survive imposed policies. It is therefore recommended
that more qualitative research (documenting the views of the various
stakeholders) be undertaken, as well as quantitative research to
determine whether the logistics fees reflected on the NDoH website
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are a true reflection of the prices actually being paid.
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The results of this study foreground a dire need for more robust
information on medicine pricing in the South African pharmaceutical
sector to guide further policy decisions, gauge market changes in
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response to the various policies, and ensure transparent pricing.
A N
These results are important in that they aid policymakers in selecting
and implementing policies that will make medicines more inexpensive
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for patients, whilst ensuring the viability of the supply chain, rather
than merely instituting an umbrella policy that will interfere with
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S A H R 20 1 6 22 9
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8 Gray AL. Medicine pricing interventions – the South African White-Paper.pdf
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exit pricing for pharmaceuticals in South Africa. Master of adults: Standard treatment guidelines and essential drugs list.
Business Administration, University of the Witwatersrand, Pretoria: National Department of Health; 2012.
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Johannesburg. 2011.
25 Mhlanga BS, Suleman F. Price, availability and affordability of
11 Kemp K, Schondelmeyer S. Role of price transparency in the medicines. Afr J Prim Health Care Fam Med. 2014;6(1).
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URL: http://aspe.hhs.gov/health/reports/drug-papers/
Kemp1.htm#TOC 27 Tetteh E. Creating reliable pharmaceutical distribution
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12 Summers R, Suleman F. Drug Policy. In: Harrison D, Barron networks and supply chains in African countries:
P, Edwards J, editors. South African Health Review 1997. Implications for access to medicines. Res Social Adm Pharm.
Durban: Health Systems Trust; 1997. 2009;5(3):286–97.
13 Gray A, Eagles P. Drug policy. In: Barron P, editor. South 28 South African National Department of Health. South African
African Health Review 1997. Durban: Health Systems Trust; Medicine Price Registry. [Internet]. [cited 23 March 2016].
1997. URL: http://www.mpr.gov.za/.
14 Gray A. Equity and the provision of pharmaceutical services. 29 World Health Organization; Health Action International.
In: Ntuli A, editor. South African Health Review 1998. Measuring medicine prices,availability, affordability and price
Durban: Health Systems Trust; 1998. components. 2008. [Internet]. [cited 23 March 2016].
URL: http://www.haiweb.org/medicineprices/
15 Gray A, Suleman F. Drug policy – From macro development
to health district implementation. In: Crisp N, Ntuli A, editors. 30 Division of Clinical Pharmacology, Faculty of Health Sciences,
South African Health Review 1999. Durban: Health Systems University of Cape Town. South African Medicines Formulary.
Trust; 1999. Cape Town: Health and Medical Publishing Group; 2012.
16 Gray A, Matsebula T. Drug pricing. In: Crisp N, Ntuli A, 31 Republic of South Africa. Medicines and Related Substances
Clarke E, editors. South African Health Review 2000. Durban: Act 101 of 1965: Regulation No. 9965 – Exclusion of certain
Health Systems Trust; 2001. medicines from the operation of certain provisions of the Act.
Government gazette Vol. 575, No. 36507, 29 May 2013.
17 Gray A, Vawda Y. Health Policy and Legislation. In: [Internet]. [cited 23 March 2016].
Padarath A, English R, editors. South African Health Review URL: http://www.samed.org.za/Filemanager/userfiles/
2013/2014. Durban: Health Systems Trust; 2014. News/Regulation%20Gazette%20Medicines%20and%20
Related%20Substances%20Act.pdf
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Pharmaceutical logistics
32 South African National Department of Health. Hospital level 47 IMS Institute for Healthcare Informatics. Understanding the
paediatric: Standard treatment guidelines and essential drugs pharmaceutical value chain. IMS Health Incorporated and its
list. Pretoria: National Department of Health; 2013. affiliates. 2014. [Internet]. [cited 23 March 2016].
URL: http://www.imshealth.com/imshealth/Global/
33 South African National Department of Health. Primary health Content/Corporate/IMS%20Health%20Institute/Insights/
care level Standard Treatment Guidelines and Essential Drugs Understanding_Pharmaceutical_Value_Chain.pdf
List. Pretoria: National Department of Health; 2014.
48 Xiphu L, Mpanza N. Medicine prices survey in the Gauteng
34 Statistics South Africa. [Internet]. [cited 23 March 2016]. Province in South Africa. Pretoria: National Department of
URL: www.statssa.gov. Health; 2004. [Internet]. [cited 23 March 2016].
35 Business Dictionary.com. [Internet]. [cited 23 March 2016]. URL: http://www.haiweb.org/medicineprices/
URL: http://www.businessdictionary.com/definition/ surveys/200411ZAG/survey_report.pdf
consumer-price-index-CPI.html 49 Board of Healthcare Funders of Southern Africa. Health sector
36 Patented Medicines Prices Review Board. 2014 CPI-Based inquiry: Pharmaceutical task group’s response to third party
Price-Adjustment Factors. 2015. [Internet]. [cited 23 March submissions concerning the pharmaceutical sector. [Internet].
2016]. [cited 10 March 2016].
URL:http://www.pmprbcepmb.gc.ca/view. URL: https://www.google.co.za/?rlz=1W4CHBB_enZA577#
asp?ccid=1145&lang=en#a7 q=healthcare+sector+inquiry+pharmaceutical+task+group%E
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37 Lexchin J. The siren call of new drugs. Expert Rev
Pharmacoeconomics Outcomes Res. 2003;3(5):513–5.
38 Republic of South Africa. Medicines and Related Substances
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Act 101 of 1965: Regulations relating to a transparent pricing
system for medicines and scheduled substances: Comment
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notice on the annual adjustment of the single exit price of
medicines and scheduled substances for the year 2015.
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[cited 23 March 2016]. Y T
URL: http://www.gov.za/sites/www.gov.za/files/37816_
rg10231_gon536.pdf
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URL: http://www.healthpolicyunit.org/downloads/
logisitcs_fee.pdf
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March 2016].
URL: https://www.fas.org/sgp/crs/misc/RL34101.pdf
43 Ball D. The regulation of mark-ups in the pharmaceutical
supply chain. WHO/HAI Project on Medicine Prices and
Availability, Review Series on Pharmaceutical Pricing Policies
and Interventions, Working Paper 3. 2011. [Internet]. [cited
23 March 2016].
URL: http://www.haiweb.org/medicineprices/05062011/
Mark-ups%20final%20May2011.pdf
44 World Health Organization. WHO guideline on country
pharmaceutical pricing policies. Geneva: World Health
Organization; 2013. [Internet]. [cited 23 March 2016].
URL: http://www.ncbi.nlm.nih.gov/books/NBK258631/
45 Knittel CR, Stango V. Price ceilings as focal points for
tacit collusion: evidence from credit cards. Am Econ Rev.
2003;1703–29.
46 Ngozwana S. Policies to control prices of medicines: Does
the South African experience have lessons for other African
countries? In: Mackintosh M, Banda G, Tibandebage P,
Wamae W, editors. Making Medicines in Africa – The
political economy of industrializing for local health.
Basingstoke: Palgrave Macmillan; 2016. p.214.
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The development of a National Health
Research Observatory in South Africa:
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considerations and challenges
Authors:
Nobelungu J. Mekwa i Ashley Van Niekerk i,ii
Edith N . Madela-Mntla i,iii Mohammed Jeenah i
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Glaudina Loots i,iv Bongani M . Mayosi i,v
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ealth research observatories are globally recognised proactive institutions The National Health Research
that provide appropriate evidence-based information to guide policy-making
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decisions in a country, thereby improving health care. The World Health Committee has undertaken to
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Organization has recommended the development of national and regional research establish the National Health
and development observatories to ensure relevant, timeous and credible information
Research Observatory as a
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on current and emerging health research priorities and impact on health responses
and interventions, including allocation of resources and their scope and location. comprehensive information
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This chapter describes the vision, mandate, purpose, scope and benefits of a and translation system to
proposed health research observatory, as well as the key challenges, in order to enable the national co-
stimulate awareness and generate local interest among and participation by the
ordination and integration
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translation system to enable the national co-ordination and integration of research multiple research platforms
and health information from the country’s multiple research platforms.
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could limit the NHRC authority over public entities, and the autonomy of research
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institutions such as universities where conflicts of interest may cause and perpetuate
barriers to vital research-related information.
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Introduction
Health research observatories have emerged in a number of countries are purely passive is incorrect. Rather, observatories are proactive
such as the Lebanese Observatory for Research, Development and investigators, providing information to inform policy-making,
Innovation; the Lattes Platform in Brazil; and the National Institute for decisions and resource allocation.
Health Care and Excellence (NICE) in the United Kingdom. These
Three key terms should be defined in order to understand the
institutions function through the secondary use and integration of
concept of a health research observatory, namely: health research,
existing or routinely gathered research information towards the
health research system, and research for health.
support of public health policy decision-making.1 The World Health
Organization (WHO) AFRO Region Consultative Expert Working The Global Forum for Health Research (GFHR) defines ‘health
Group has recommended the development of national and regional research’ as a process for obtaining systematic knowledge and
research and development (R&D) observatories to member countries technology that can be used to improve the health of individuals or
to ensure relevant, timeous and credible information on current and groups to reduce inequalities in health.10
emerging health research priorities and impact on health responses
A ‘health research system’ is defined as a system for planning, co-
and interventions, including allocation of resources and their scope
ordinating, monitoring and managing health research resources and
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and location.2–5
activities, and for promoting research for effective and equitable
In response to its legislative mandate, South Africa’s National Health national development.
Research Committee (NHRC) convened a summit in July 2011 to set
The term ‘research for health’ connotes that improving health
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priorities for health research and to address the strategic priorities
outcomes requires the involvement of many sectors and disciplines.
of the National Department of Health (NDoH) and the government
The GFHR promotes a shift of focus from ‘health research’ to
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in South Africa. The summit brought together stakeholders from
‘research for health’, the latter referring to “research undertaken in
government, industry, academia and civil society to identify the
any discipline or combination that seeks to understand the impact on
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key priorities for strengthening health research, innovation and
development over the next three to five years. Notable among the
health of policies and programs; assist in developing interventions
that mitigate impact; and contribute to the achievement of better
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seven summit findings is the need:
health and equity”.10
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system, that has led to the proposal for the establishment of a The nature and function of health observatories
National Health Research Observatory (NHRO) in South Africa.
According to Pourmalek,11 the health observation concept and
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South Africa’s National Development Plan (NDP)7 has identified key practice relate closely to the evolution and maturation of health
health and social priorities with a far-reaching development and
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fields undermine research efforts to transform the country’s health about population health and health systems, in support of effective
profile. Based on these considerations, the NHRC has undertaken to
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Pourmalek further states that health observatories use information generation, sharing, dissemination and use, including web-related
from monitoring, evaluation and surveillance systems.11 However, activities at the Regional Office. This entails providing support to
he cautions that health observatories are not meant to be replicas member states to enhance the evidence for policies and strategies,
or replacements for any part of health information systems, nor and for monitoring health in the Africa Region, while strengthening
raw or intelligent repositories of health statistics or geographical the capacity of member states to improve the:
information systems. Health observatories contribute to the
➢➢ availability, quality and use of information;
identification of health information gaps and improvements in health
information systems.13 Most countries do not have established ➢➢ sharing, translation and application of information; and
national health observatories, while some developing countries have ➢➢ use of information and communication technology for health.3
national observatories or public health observatories and others
These support areas involve tasks that fall within the legislated
have thematic observatories, such as the National Human Resources
mandate of the NHRC and that necessitate action that is consistent
for Health Observatory in Sudan.14 In South Africa, the NHRO will
with the establishment of the proposed NHRO for the country.
come under the legislated mandate of the NHRC.8 Its core purpose
will be to strengthen the co-ordination and management of research Regionally, the Consultative Expert Working Group (CEWG) of the
within the health research system, thus it will fall into the category of WHO AFRO Region held a meeting in Brazzaville in the Republic of
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‘thematic observatories’. the Congo in 2013 to deliberate on their task assigned by the Sixty-
third World Health Assembly, namely to search for new, innovative
Co-ordination of research within the health research and sustainable sources of funding for research and development
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system in South Africa : the current situation (R&D) addressing the specific health needs of developing countries.
One of the five potential mechanisms identified for implementation
Health research co-ordination in South Africa falls under the mandate
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of the recommendations on R&D financing and co-ordination
of the NHRC which derives its authority from the National Health Act
pointed to a need for co-ordination of research through instituting a
(61 of 2003)15 as amended. In terms of this Act, the NHRC is tasked
Y T regional R&D observatory and relevant advisory mechanisms under
to determine the health research to be carried out by public health
the auspices of the WHO. In this respect, a network of research
authorities; to ensure that health research agendas and research
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institutions, regional experts and consulting councils would be
resources focus on priority health problems; to develop and advise
established. Such a network would ensure the implementation of
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for investment.3
the NHRC is the primary co-ordinator of health research activities in
South Africa.15 Sound co-ordination along with national health R&D observatories
will enable the WHO to play a central and more effective role in
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Does South Africa need a National Health Research improving the co-ordination and support of health R&D directed
Observatory? at the African Region.3 The establishment of a health research
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observatory has great potential for South Africa to improve not only
The NHRC has reported that there are deficiencies in the monitoring
its health system machinery, but also the regional and global health
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coverage, the degree to which public or private funding can be For the NHRO to be relevant to national needs and priorities, it
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assessed, and in some cases the absence of a standardised system is important that it be positioned in relation to all key national
for reporting research and development data.6 These limitations are strategies and initiatives, as well as other similar intersectoral
manifest within a setting characterised by insufficient information initiatives and existing strategies in South Africa’s public domain.
policies, formal agreements and data management protocols Advocacy for the observatory, which is a fairly new development
between the agencies that manage health information. Such in the country, should be strongly mobilised to secure the buy-in of
shortcomings in the information produced by routine national health all key stakeholders. Some of these initiatives and strategies may be
information systems with weak structures and performance profiles located in other sectors and driven by State and other entities, but
have negative effects on the country’s health research system. all contribute to research for health. Key among these is the National
Development Plan 2030.7
Global trends
South Africa is not alone in its attempt to establish a health research The National Development Plan 2030
observatory as a means to solve the problems facing the provision The National Development Plan (NDP 2030) sets out nine long-term
of healthcare delivery and the development of health systems. At health goals for South Africa. Five of these goals relate to improving
the global level, the African Health Observatory and Knowledge the health and well-being of the population. By 2030, South Africa
Management Unit of the WHO AFRO Region supports regional should have:
and country efforts towards strengthening health systems through
➢➢ Raised the life expectancy of South Africans to at least 70
the African Health Observatory and a network of national health
years
observatories.3 The Unit defines its purpose as being to support the
strengthening of the WHO’s capacity in knowledge acquisition, ➢➢ Progressively improved TB prevention and cure
S A H R 20 1 6 237
➢➢ Reduced maternal, infant and child mortality ventions to prevent or mitigate such impact, and will support the
achievement of international goals and targets. This covers the full
➢➢ Significantly reduced the prevalence of non-communicable
spectrum of research, spanning generic areas of activity: measuring
disease
the magnitude and distribution of the health problem, understanding
➢➢ Reduce injury, accidents and violence by 50% from 2010 the diverse causes or determinants of the problem, developing
levels. solutions or interventions that will help prevent or mitigate the
The remaining four goals deal with aspects of health systems problem, implementation or delivery of solutions through policies
strengthening, which are: and programmes, and evaluating the impact of these solutions on the
level and scale of the problem.2 In line with the call for a multisectoral
➢➢ Complete health system reforms
and multidisciplinary approach to the functioning of health research
➢➢ Primary health care teams to provide care to families and observatories, the NHRC will ensure that the proposed NHRO
communities will strengthen existing collaborations and draw on initiatives and
➢➢ Universal health care coverage research institutions that already provide information on research for
health. These include but are not limited to the following initiatives:
➢➢ Posts with skilled, committed and competent individuals.
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➢➢ The National Health Information Systems (NHIS), which
The planned observatory can add value towards the achievement of provides health information and undertakes monitoring
these goals. While the NDP 2030 explicitly acknowledges that there and evaluation of the health of the population and disease
are no easy solutions for achieving these nine goals, it identifies a set tendencies.
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of nine priorities that will contribute to the achievement of effective
➢➢ Research and Development plans developed by the NDoH
health systems. Table 1 sets out some of the possible contributions of
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which provide funding that is responsive to changes in the
the proposed NHRO to these priorities.
research environment and that aims to enhance skills levels
and address South Africa’s socio-economic objectives will also
Key initiatives and stakeholders Y T be drawn on.
The value of access to credible research information in the
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➢➢ The National Health Research Database (NHRD), developed
development of the health system is highlighted by the Director-
by the Health Systems Trust, serves as a repository of health-
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originating in any sector, will assist in the development of inter- currently being launched through the nine Provincial Health
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Table 1: Contribution of a National Health Research Observatory to the nine priorities of the National Development Plan 2030
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National Development Plan priority Possible contribution of a National Health Research Observatory
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Address the social determinants that affect health and diseases Provide an analysis of social factors that play a key role in determining health
status
Strengthen the health system Identify points of weakness in the health system and their underlying causes and
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Improve the health information system Collate data from a range of sources; stratify, repackage, translate and
disseminate the information in ways that make it accessible for use by different
stakeholders
Prevent and reduce the disease burden and promote health Contribute to the identification of the types and levels of the burden of disease;
make recommendations for their prevention, reduction and mitigation
Finance universal health care coverage Analysis of health care financing; assist in identifying sources, levels and types of
healthcare financing available, and identify gaps in universal coverage
Improve human resources in the health sector Analysis of the full-time equivalents for health sector human resources to reliably
determine the quality, qualifications and numbers needed for provision of
adequate health care
Review management positions and appointments, and strengthen Analyse data on management functions and infrastructure needs; map out trends
accountability mechanisms in skills availability and thus influence accountability and evidence-based policy-
and decision-making
Improve quality by using evidence Analyse all data received and provide feedback for translation of research into
practice; make findings accessible to all stakeholders for improved quality of
health care
Meaningful public-private partnerships Vigilance on events and trends leading to balanced feedback to all sectors will
enable development of meaningful partnerships between public and private
sector stakeholders to help parties engage in using synergies for mutual benefit
23 8 S A H R 20 1 6
Health Research Observatory
Research Committees and is a crucial first step undertaken by Proposed model for the NHRO in South Africa
the NDoH to facilitate the development of the NHRO.
It is envisaged that the NHRO will function directly under the authority
➢➢ The Research Information Management System (RIMS), of the NHRC but will be co-ordinated by a steering committee
funded by the Department of Science and Technology (DST) comprising identified experts as mentors and advisors and research
and hosted at the National Research Foundation (NRF) in institutions as feeders of information. There have been strong
Pretoria, allows users to view the total R&D investment in motivations for national observatories to be staffed with their own
specific areas of science and technology across agencies officials and to support the training of the requisite human resources
and to examine the details of research investments within a to ensure their core functioning.18 Securing skilled leadership would
specific agency. The system is a strategic tool for research be critical for the strategic management of the NHRO to ensure
development and support at institutional and national levels, that it serves its intended goals, and the NHRO should be armed
and facilitates internal and external monitoring of research with high-level technical expertise and capacity to achieve the initial
outputs and impact. It provides the country’s science councils implementation and full operation of the observatory. Specifically,
and higher education institutions with two key components of a the human resources complement should comprise a director; three
research information management system, namely a common senior managers to govern operations, data analysis and information
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application platform for publicly funded research institutions dissemination; two administrators; technicians; managers for data
to support their research administration processes, and the analysis and information dissemination; a biostatistician and an
information needed to establish a common platform for the DST epidemiologist. A hosting institution will provide operational staff
to distil data from publicly funded institutions that will inform for office administration and human resources support. Infrastructure
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strategic research-related decision-making. Additionally, the needs to include office space, information technology and communi-
National Bioportal being developed by the DST will focus cations facilities.
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on the research and development activities needed for the
implementation and expansion of the National Bio-economy Implementation, considerations and challenges
Strategy launched in 2014.18 Y T Some of the potential challenges include current legislative
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➢➢ The National Science and Technology Expenditure Plan is a inadequacies that may limit the NHRO’s authority to engage with
means of reporting projected national expenditure on scientific public or private health data repositories. The autonomous nature of
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and technological activities (STAs) over the Medium-term research partners, and the variations in and limitations of the existing
Expenditure Frameworks (MTEF). The National Department of approaches and standards for health research data, present further
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Health also feeds information on expenditure levels and trends possible challenges to the successful operation of the observatory.
at national, provincial and local levels.
The institutionalisation of a NHRO is considered a key prerequisite to
➢➢ The Department of Environmental Affairs (DEA) conducts
its effective operation and ability to function over time.3 The decision
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➢➢ The Safety in Mines Research Advisory Committee, under the policy and health sector needs within current legislative mandates,
auspices of the Department of Energy and Mineral Resources, specifically the National Health Act (61 of 2003)15 through the
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annually prepares comprehensive programmes for health NHRC mandate.8,19 Such alignments will support the administrative
and safety research, including a review of health and safety actions that are required to ensure the effective implementation of
performance in the various mining sectors, health and safety the observatory.19
research foci and priorities for these sectors, estimated costs of
However, ensuring that the NHRO will be aligned with the
specific programmes, and an evaluation of research proposals
information needs of policy- and decision-makers may be difficult,
made by the Mine Health and Safety Council or any of its
given the complex nature of health systems and services, the multiple
committees.
levels and requirements of government, the diverse management
There is therefore compelling evidence that South Africa has both a involved, and the types of decision-making that may need to be
critical need for and has already garnered much of the necessary conducted.19 The following measures are likely to consolidate this
information and technical capacities, resources and infrastructure alignment:
to implement a health research observatory.6,19 With this context
➢➢ Establishment of an observatory under a government policy
in mind, it is imperative that all stakeholders within the research
that extends beyond government administrations
community be brought on board to ensure proper understanding
of the processes for the establishment and maintenance of the ➢➢ A guarantee that the observatory has the necessary resources
proposed NHRO, and to engage actively in its development as a and an independent budget
tool for improving the yield of research for health outcomes. ➢➢ A transparent management system for both the use of
resources and the information gathered and processed by the
observatory.19,20
S A H R 20 1 6 239
Consensus on NHRO scope and functions
The proposed NHRO may generate many expectations from a range
of interest groups with regard to its purpose, objectives, functions
and responsibilities. The NHRO may therefore be mistakenly
perceived as an alternative or replacement for routine information,
monitoring and surveillance systems, thus generating concerns about
its implementation, especially among those groups already involved
in similar monitoring systems.19 The NHRO implementation plan
should therefore specify its key dimensions through some form of
engagement process with partners and stakeholders.3 The formation
of advisory meetings, task teams and technical collaboration
agreements is needed to aid the buy-in and sharing of accountability
or ownership of joint tasks. Such a plan should also consider and
where possible specify the extent and boundaries of the data
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system co-ordination, collation, analysis and liaison capacities, and
difficulties that may impede implementation. The plan should also
be framed around a phased implementation of an approach that
utilises existing and effective monitoring or surveillance systems.8,19
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Furthermore, the development and management of the NHRO may
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be perceived by partners, including government departments and
managers, as an additional activity for busy staff, implying increased
workloads with no added value. It is therefore imperative that a
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cost-benefit analysis of the observatory be generated to support the
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engagement with partners on its implementation.19
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The general launch of the NHRO and its capacity to compile and
analyse information and generate reports would be limited by
the difficulties inherent in operationalising a new structure of this
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Conclusion
The NHRC acknowledges the existence of gaps in available
information regarding South Africa’s health research system as a
whole. Such gaps include information pertaining to expenditure on
health and disease-related research and development as outlined
in the 2011 NHRC Summit Report.6 Efforts to track and map
health research investments may be restrained by the complexity,
incompleteness and resource-intensity of information systems;
however, the NHRC has carefully considered global experience and
WHO recommendations and is proposing the establishment of a
NHRO along lines that will be relevant to South Africa’s context
and needs. Driven by the NHRC’s mission, namely to elevate health
research that is aligned with both the NDP and the WHO’s global
interest in research for health, this chapter articulates the manifold
local, regional and global benefits to be rendered by the envisaged
NHRO. These benefits should generate lasting interest among the
research community to ensure a functional and sustainable structure
for co-ordination of South Africa’s health research system.
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G
13 April 2016].
URL: http://www.who.int/workforcealliance/members_
partners/member_list/gfhr/en/
11 Pourmalek F. National health observatories: Need for stepped-
up action. theHealth. 2012;3(3):63–64.
12 Richards T. European observatory will promote better health
policy. British Medical Journal. 1999;318:352.
13 Gattini CH. Implementing National Health Observatories:
Operational Approach and Strategic Recommendations.
Santiago de Chile. Office of the PAHO/WHO Representation
in Chile, Pan American Health Organization, Regional Office
of the World Health Organization. 2009. [Internet]. [cited 4
April 2012].
URL: http://new.paho.org/chi/images/PDFs/national%20
health%20observatories_final.pdf
14 The National Human Resources for Health Observatory –
Sudan. World Health Organization Global Health Workforce
Alliance. [Internet]. [cited 13 April 2016].
URL: http://www.who.int/workforcealliance/members_
partners/member_list/nhrhobs_sudan/en/
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Health and Related Indicators 20
Authors:
Candy Day i
Andy Gray ii
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Contents
Introduction 244
Data sources and collection
Y T 249
A N
Demographic indicators 250
Socio-economic and risk factor indicators 254
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Disability 260
Infectious disease 262
Malaria 264
Tuberculosis 266
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Nutrition 282
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Injuries 295
Health services indicators 297
Health facilities 297
Health personnel 300
Health financing 307
Conclusion 311
Acknowledgements 311
Appendices 311
Maps 311
Selected data sources and results for WHO Core indicators 320
Indicator definitions for data tables presented in this chapter 332
References 342
243
Introduction
Just as 2015 saw the target date set for the Millennium Development 3.b - Support the research and development of vaccines and
Goals (MDGs) being reached, with a global effort to track progress medicines for the communicable and non-communicable
towards achieving those ambitious goals, so 2016 is the first year diseases that primarily affect developing countries, provide
for a new series of such goals, with an even more ambitious scope. access to affordable essential medicines and vaccines, in
In September 2015, the United Nations General Assembly hosted accordance with the Doha Declaration on the TRIPS Agreement
the Sustainable Development Summit in New York, which endorsed and Public Health, which affirms the right of developing
a new set of Sustainable Development Goals (SDGs).a The range countries to use to the full the provisions in the Agreement on
of the SDGs has been expanded. A total of 17 SDGs have been Trade-Related Aspects of Intellectual Property Rights regarding
set, ranging from “end poverty in all its forms everywhere” (Goal flexibilities to protect public health, and, in particular, provide
1) to “promote peaceful and inclusive societies for sustainable access to medicines for all
development, provide access to justice for all and build effective,
3.c - Substantially increase health financing and the recruitment,
accountable and inclusive institutions at all levels” (Goal 16), with
development, training and retention of the health workforce in
a commitment to “strengthen the means of implementation and
developing countries, especially in least developed countries
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revitalize the global partnership for sustainable development” (Goal
and small island developing states
17). SDG3 is specific to Health: “Ensure healthy lives and promote
well-being for all at all ages”. As with the MDGs, each SDG has 3.d - Strengthen the capacity of all countries, in particular
a series of targets. The targets for SDG3 are extensive, and each developing countries, for early warning, risk reduction and
16 6
represents a complex set of sub-targets:b management of national and global health risks.
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3.1 - By 2030, reduce the global maternal mortality ratio to less There has been a robust debate about how best to set measurable
than 70 per 100 000 live births indicators for the health-related SDG targets. Murray has argued
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3.2 - By 2030, end preventable deaths of newborns and
children under 5 years of age, with all countries aiming to
that four major design features should be considered:1 that each
indicator should not only measure the intended effect, but also be
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important for population health (in order to avoid diverting scarce
reduce neonatal mortality to at least as low as 12 per 1 000
resources to an outcome that is only tangentially related to the
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3.3 - By 2030, end the epidemics of AIDS, tuberculosis, malaria measurements in an affordable manner; and that, wherever
and neglected tropical diseases and combat hepatitis, water- possible, each indicator should be disaggregated by age, gender,
borne diseases and other communicable diseases and sub-national location. Meeting these standards is incredibly
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from road traffic accidents visibility of major communicable diseases (and adding the politically
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a https://sustainabledevelopment.un.org/sdgs
b Target numbering is reproduced as it appears in the source.
c It is not clear why only this target is to be achieved by 2020, and the others
by 2030, but it is included as per the source.
24 4 S A H R 20 1 6
Health and Related Indicators
Work is still under way in South Africa to hone the local indicator set (HIV and AIDS, sexually transmitted infections, tuberculosis,
to match the new global imperative. The official 2015 country report malaria, neglected tropical diseases, outbreaks, epidemic diseases),
on the MDGs has been released by Statistics South Africa.4 This reproductive, maternal, newborn, child and adolescent health
showed that none of the MDG4 indicators (under-5 mortality) for (including sexual health, reproductive rights and immunisation),
which there were data were achieved. The same applied to MDG5 non-communicable diseases (including chronic disease, health
(maternal and reproductive health). However, some but not all of promotion, nutrition, mental health and substance abuse), injuries
the targets set for MDG6 (AIDS, tuberculosis, malaria) were met. and violence and the environment.
Interestingly, no data were provided on one of the most challenging
of the MDG8 targets, measuring access to essential medicines
(8E: In co-operation with pharmaceutical companies, provide
access to affordable essential drugs in developing countries). In
this regard, the global report stated that “global and regional data
are lacking”.5 It noted that “availability varies widely across the
countries surveyed”, and recommended improved monitoring of the
availability of essential medicines, as well as the prices actually paid
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by patients in developing countries. This example is illustrative of the
challenge facing the choice of indicators for the new SDGs.
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MDGs and their transition to the SDGs was provided by the WHO in
2015.6 This report clearly identifies the challenges facing countries
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as they re-orientate their programmes to add the focus on NCDs:
“Achieving the SDG target for NCDs will require major interventions
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to deal with a context characterized by ageing populations, rapid
unplanned urbanization and globalization of markets that promote
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inactivity and unhealthy diets, and will focus on the development and
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the SDGs, the WHO Global Reference List of 100 Core Health
G
reference for countries to use, “in accordance with their own health
priorities and capacity”. However, the List is also uniquely relevant to
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the SDGs. Table 1 shows those WHO 100 Core Health Indicators for
which South Africa currently does not have data readily available.
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S A H R 20 1 6 245
Table 1: WHO 100 Core Health Indicators for which South African data are not readily available or routinely reported
Financing Sub-domain
Health systems Domain
Input Level
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for health.8
Total capital expenditure on Total capital expenditure on health as a percentage of current + capital It should be possible to calculate this indicator
health as a share of current + expenditure on health. using data on government expenditure (National
capital expenditure on health Treasury) although this would not include all
sources (local government, private sector).
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Out-of-pocket payment on Share of total current expenditure on health paid by households out-of- Although some estimates exist, there does not
health as a percentage of pocket, expressed as a percentage of total current expenditure on health. appear to be a robust estimate of this indicator
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current expenditure on health for SA.
Birth registration coverage Percentage of births that are registered within one month of age in a civil Some information is available in Stats SA
Information
Death registration coverage Percentage of deaths that are registered (with age and sex). Some information on completeness of death
registration is available in Stats SA Causes
of death reports, but not for all age groups.
Completeness of adult death registration (15
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Completeness of reporting Percentage of facilities that submit reports within the required deadline. This can be calculated by NDoH based on
by facilities timeliness of reporting through DHIS. These
results do not however appear to be published
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or generally available.
Health service access Percentage of population living within 5 km of a health facility. Some GIS work on this topic has been done but
Infrastructure
Output training institutions Number of graduates from health workforce educational institutions Data are potentially available from training
Workforce
(including schools of dentistry, medicine, midwifery, nursing, pharmacy) institutions, but are not currently reported.
during the last academic year per 1 000 population.
Service-specific availability Number of health facilities offering specific services per 10 000 population A proxy measure may be based on the National
Output
Health systems
Access and
availability
and readiness and meeting minimum service standards on the basis of a set of tracer Core Standards Assessments and the Ideal
criteria for specific services. Clinic dashboard initiative:
Fixed PHC facilities scoring 80% and above on
ideal clinic dashboard
International Health Percentage of attributes of 13 core capacities that have been attained There are no available data for this indicator. So
Health security
Regulations (IHR) core at a specific point in time. The 13 core capacities are: (1) National far only the transfer of Port Health to National
capacity index legislation, policy and financing; (2) Coordination and National Focal Point control has been reported.
communications; (3) Surveillance; (4) Response; (5) Preparedness; (6)
Risk communication; (7) Human resources; (8) Laboratory; (9) Points of
entry; (10) Zoonotic events; (11) Food safety; (12) Chemical events; (13)
Radionuclear emergencies.
24 6 S A H R 20 1 6
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termination of pregnancy). disaggregated in this way.
Maternal death review Percentage of maternal deaths occurring in the facility that were audited. In theory, the NCCEMD audits all maternal
coverage (%) deaths in facilities that are reported to the
secretariat, but there are no specific data in this
regard. Few home deaths are noted and not all
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private sector facilities may be covered.11
ART retention rate Percentage of adults and children with HIV alive and on ART 12, 24, 36 Although these data are collected in Tier.Net,
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(etc.) months after initiating treatment among patients initiating ART during there are concerns about data quality. The
a specified time period. availability of data may vary between districts.
Intimate partner violence Percentage of currently partnered girls and women aged 15-49 years who No current data source in SA.
Outcome
Risk factors
Injury and
violence
prevalence (%) Y T
have experienced physical and/or sexual violence by their current intimate
partner in the last 12 months.
A N
Early initiation of Percentage of infants breastfed within 1 hour of birth in a specified time No current data source in SA.
Infectious disease NCDs and
nutrition
People living with HIV who Percentage of people living with HIV who have been diagnosed. Numerator: Number of people living with HIV
Service coverage
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have been diagnosed (%) This indicator is also one of the 90-90-90 global targets for AIDS who have been diagnosed.
(UNAIDS). Denominator: Estimated number of people living
with HIV.
The denominator could be estimated from
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receiving treatment.
HIV care coverage (%) Number and percentage of people living with HIV who are receiving HIV It is not clear whether the necessary data are
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care, as proxied by receipt of at least one of the following during the available in SA, which would allow for tracking
reporting period: clinical assessment (WHO staging) or CD4 count or viral of a unique identifier allowing for calculation of
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HIV viral load suppression Percentage of people on ART who are virologically suppressed (VL level Although these data are collected in Tier.
(%) ≤1000 copies/mL). net, there are concerns about data quality.
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Sub-domain
Domain
Level
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sleeping under insecticide- the previous night. this intervention has not been adopted as policy
treated nets (%) in SA.
Indoor residual spraying Percentage of population at risk protected by IRS during a specified time The World Malaria Report 2015 indicates that
(IRS) coverage (%) period. SA claimed 100% coverage for the population
at risk in 2014, although local data on this topic
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do not appear to be published; they may be
available on request from the NDoH malaria
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programme.
Coverage of preventive Percentage of the population living in endemic areas requiring No data collected in SA for this indicator.
chemotherapy for selected preventive chemotherapy that received treatment for at least one of the The DHIS does include an indicator ‘Deworming
neglected tropical diseases selected neglected tropical diseases (schistosomiasis, soil-transmitted
Y T dose 12-59 months coverage’.
(%) helminthiases, lymphatic filariasis, onchocerciasis).
A N
Demand for family planning Percentage of women of reproductive age (15-49 years) who are sexually Essentially the inverse of ‘Unmet need for family
Service coverage
satisfied with modern active and who have their need for family planning satisfied with modern planning’. Potentially available from surveys
methods (%) methods. such as the Demographic and Health Survey,
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suspected pneumonia taken a blocked nose) in the two weeks preceding the survey taken to an when included in a household survey.
to a health facility appropriate health facility or provider.
Children with diarrhoea Percentage of children under 5 years of age with diarrhoea in the last two These data are not currently collected by DHIS,
receiving oral rehydration weeks receiving ORS (fluids made from ORS packets or pre-packaged but some old data may be extracted from
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AIDS-related mortality rate Estimated number of adults and children who have died due to AIDS- Empirical data from different HIV surveillance
Health status
Impact
Infectious disease
(per 100 000 population) related causes in a specific year, expressed as a rate per 100 000 sources are consolidated to obtain estimates
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Source: Compiled from WHO 100 Core Health Indicators list and multiple data sources reviewed for this chapter.
24 8 S A H R 20 1 6
Health and Related Indicators
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for the intended purpose.13
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published. The 2015 edition has been prepared, but has not yet
been published.
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In addition to routine sources and annual surveys, several key
surveys will either be in the field during 2016, or are expected
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to release results this year. These data will contribute significantly
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to monitoring a range of demographic and health indicators. The
expected new sources include the:
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➢➢ SANHANES-2
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➢➢ TB prevalence survey
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Trends and time-series: For most indicators, data are given for
several years, often from multiple different sources. In most cases
these data can thus not be used to assess trends and changes
over time due to possible differences in methodology and data
presentation issues. Even data from regular surveys may not be
comparable over time, or revised data for a historical time series
may be released, as for example with the General Household
Surveys and mid-year population estimates. This may result in
different values being published compared to previous editions.
Therefore, when using time series data, the most recent revisions
should be obtained from the online database and not from
previous printed editions of this chapter.
S A H R 20 1 6 249
Demographic indicators
Context Demographic indicators provide the critical denominator data for many other indicators. A periodic census allows
for the recalibration of such figures. However, later projections from the census struggle to take account of the
effects of large-scale migration, especially where such movements occur over the short-term, or are exacerbated
by crises, either natural or man-made. The Community Survey 2016 is in the field, with a planned increase in the
sample size, and will provide interim demographic indicators.
New data sources Some of the key new sources of national data included in this section are:
• Stats SA Census 2011 series of analytical publications on population dynamics, migration dynamics and
fertility
Internationally, new reports include:
• The State of World Population 2015
• World Report on Ageing and Health
Key issues and trends A key report from the Census 2011 was that dealing with fertility, which provided new estimates of total fertility
PM
rate (TFR), and in particular data on the adolescent fertility rate. Although South Africa is moving through a
demographic transition, it still has to deal with the health issues of a large youth cohort, even as it starts to deal
with the non-communicable disease burden associated with an aging population.
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In 2015, the United Nations Population Fund (UNFPA) report “The altered the population structure of the country, except perhaps
State of the World Population” drew attention to the issue of those in relation to the Indian ethnic group. Although exact figures are
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requiring humanitarian assistance.14 The report pointed out that not reported, the trends over time show increasing international
more people were displaced by crises in 2015 than at any time migration, with approximately 100 000 female and 140 000 male
since the Second World War. It estimated that 59.5 million were Y T international migrants recorded in 2011 (Figure 1). This appears
displaced, more than 100 million were in need of humanitarian to be a significant under-recording of the phenomenon. Based on
A N
assistance, and that natural disasters affected 200 million people data from a long-term panel study undertaken in five relatively
a year. Based on data from the Census 2011, Stats SA issued a impoverished Johannesburg neighbourhoods, the health status of
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report on population dynamics in South Africa.15 The age and sex international migrants and South African respondents is similar.16
structure of any given population is a function of the three major If, as is expected, non-documented international migrants are not
4 ED
demographic phenomena: migration, fertility and mortality. That evenly distributed between provinces, but are accessing health
age and sex structure has a major impact on demands for health services, this calls into question the population data used in the
services, as well as other services (such as education). Migration equitable share calculation, as well as the denominators used for
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occurs both internally (such as from province to province) and many indicators. In addition, international migrants do pose some
internationally. Although acknowledging that a Census only particular health challenges, as shown by the increased incidence
G
captured those international migrants who declare themselves as of imported malaria, including in provinces other than those which
such, Stats SA concluded that migration does not appear to have are malaria endemic.
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160 000
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140 000
120 000
100 000
Migrant population
Male
80 000
60 000
Female
40 000
20 000
0
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
Year
250 S A H R 20 1 6
Health and Related Indicators
The Stats SA Population Dynamics report noted that fertility seems to occurred after the age of 30 years. It also showed that African
have been the “main contributing factor to the change in population and coloured women experienced their first birth earlier than white
age-sex structure over time”. Declining fertility has resulted in a “shift mothers, irrespective of province, residence or education. The
from child population to youth population aged 20–29”, creating adolescent fertility rate (per 1 000 girls aged 15–19 years) is a
a potential “demographic dividend”. However, it also notes that new indicator, included in Table 2 and Table 3. The national figure
“youth unemployment rates, uncertainties about quality of education is 70 per 1 000 adolescents, varying from 60 in Gauteng and the
and the scourge of HIV and AIDS” may result in the country not Western Cape to 80 in other provinces. Differences per population
enjoying the benefits of this ‘dividend’. The overall shift in the group are far wider, ranging from 14 in white adolescents to 76 in
population age-sex structure between 1985 and 2011 is depicted African adolescents.
in the population pyramids provided by Stats SA (Figure 2).
Globally, there is great interest in the effects of ageing populations
on health and thus the need for healthcare services. A World
Figure 2: Population of South Africa, 1985 and 2011
Health Organization report in 2015 has, however, challenged the
Age
prevailing stereotypes, supporting the contention that “70 is the
80+ new 60”.18 However, this contention has also been challenged as
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70-74 Males potentially placing vulnerable older people at risk, and perhaps as
60-64 Females
ill-fitting to low- and middle-income countries. The WHO report also
50-54
included data on changes in national total fertility rates by economic
strata. Although South Africa is an upper middle-income country,
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40-44
its national TFR is still closer to that of low middle-income or even
30-34
low-income countries (Figure 3).
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20-24
10-14
Figure 3: Fertility rates in low-, middle- and high-income countries,
0-4
8.0 6.0 4.0 2.0 0.0
Y T
2.0 4.0 6.0 8.0
1960–2011
A N
% Population 1985 7
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Age
6
80-84
Males
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70-74
Females 5
60-64
Births per woman
50-54 4
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40-44
30-34 3
G
20-24
2
10-14
R
0-4
1
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0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Source: ASSA2008 and Census 2011 as cited in Stats SA Census 2011:
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Note: Axes adjusted so that each age-sex bar represents the percentage of High-income Organisation for Economic Co-operation and Development
the total population.
High-income
Upper-middle-income
Stats SA has also issued a specific report on fertility, based on the
Lower-middle-income
Census 2011 data,17 which recorded a national total fertility rate
Low-income
(TFR) of 2.67. Although data quality issues could not be ruled out,
SA TFR
the Census 2011 showed an increase in the TFR for the coloured
population from 2.41 in 2001 to 2.57 in 2011. As before, the TFR
Source: Adapted from Census 2011 Fertility17 and World Report on
for the African population was highest (2.82), while the values for Ageing.18
both the white (1.70) and Indian (1.85) population groups were
below the replacement level. As expected, TFRs were lowest in the
most developed provinces (Gauteng, Western Cape) and highest
in the more rural provinces (Limpopo, Eastern Cape), reflecting the
combined effects of differences in socio-economic status and the
dominance of specific population groups. The Stats SA report also
provided insights into the age of mothers at first birth. It showed
that the majority of first births occurred when women were aged
between 18 and 20 years, and that less than 5% of all first births
S A H R 20 1 6 251
Table 2: Demographic indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Adolescent fertility rate (per 1000 girls aged 15–19 years)
2011 80.0 70.0 60.0 80.0 80.0 80.0 80.0 80.0 60.0 70.0 a
Ageing index
2011 Census 20 19 18 15 18 15 19 19 23 18 b
2015 mid-year 15 20 22 14 15 14 23 17 23 17 c
Age dependency ratio
2011 Census 66.0 52.9 39.0 58.5 67.3 56.0 55.7 54.5 45.0 52.7 d
Annual population growth rate
2011 2001–2011 0.44 0.14 2.68 0.69 0.79 1.83 1.44 1.62 2.52 1.44 b
2015 2014–2015 - - - - - - - - - 1.65 c
Area (square km)
2011 168 966 129 825 18 178 94 361 125 754 76 495 372 889 104 882 129 462 1 220 813 b
Area as a % of total area of South Africa
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2011 13.8 10.6 1.4 7.7 10.3 6.3 30.5 8.7 10.6 100.0 b
Average household size
2011 Census 3.7 3.2 3.0 3.9 3.7 3.7 3.7 3.2 3.4 3.4 b
Crude death rate (deaths per 1 000 population)
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2014 unadjusted - - - - - - - - - 8.4 e
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2015 mid-year - - - - - - - - - 9.6 f
Population – Census and Stats SA mid-year estimates
2011 Census 6 562 053 2 745 590 12 272 263 10 267 300 5 404 868 4 039 939 1 145 861 3 509 953 5 822 734 51 770 561 b
2015 mid-year
Population – DHIS estimates
6 916 200 Y T
2 817 900 13 200 300 10 919 100 5 726 800 4 283 900 1 185 600 3 707 000 6 200 100 54 956 900 c
A N
2015 DHIS 6 692 803 2 763 018 13 267 544 10 688 165 5 654 033 4 235 606 1 182 278 3 702 970 6 245 836 54 432 253 g
2016 DHIS 6 731 182 2 768 642 13 543 184 10 806 538 5 724 448 4 290 010 1 191 995 3 757 769 6 362 257 55 176 026 g
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2017 DHIS 6 773 280 2 765 819 13 820 215 10 924 776 5 789 938 4 344 144 1 202 801 3 809 367 6 478 871 55 909 212 g
2018 DHIS 6 815 094 2 773 543 14 088 410 11 039 740 5 849 604 4 395 703 1 212 630 3 858 959 6 589 734 56 623 417 g
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Population % by province
2011 Census 12.7 5.3 23.7 19.8 10.4 7.8 2.2 6.8 11.2 100.0 b
2015 mid-year 12.6 5.1 24.0 19.9 10.4 7.8 2.2 6.7 11.3 100.0 c
Population density (people per km2)
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2011 Census 38.8 21.1 675.1 108.8 43.0 52.8 3.1 33.5 45.0 42.4 b
G
2015 mid-year 40.9 21.7 726.2 115.7 45.5 56.0 3.2 35.3 47.9 45.0 c
Public sector dependent population – based on medical scheme coverage reported in the General Household Survey (GHS)
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2014 GHS 6 097 394 2 296 119 9 292 722 9 358 755 5 149 542 3 587 874 942 269 3 112 069 4 493 087 44 274 032 h
2015 GHS 6 189 999 2 313 496 9 477 815 9 521 455 5 234 295 3 645 599 950 851 3 158 364 4 569 474 45 009 701 h
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Public sector dependent population – based on population minus number of beneficiaries reported by Council for Medical Schemes
2014 non med scheme 6 115 606 2 394 063 9 959 696 9 430 704 5 196 166 3 626 168 982 490 3 127 784 4 785 456 45 244 189 i
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Census 2011 Fertility.17 National value estimated from graph since not included in report. Values multiplied by 1 000 to convert from rate per individual
adolescent.
b Census 2011.19
c Stats SA Mid-year Estimates. 2015 mid-year estimates.20
d Census 2011 Population dynamics.15
e Stats SA Causes of death 2014.10 Data have been updated with late registrations processed in 2015. Not adjusted for under-reporting - completeness of
death registration for children uncertain, completeness for adults estimated at 94%.
f Stats SA Mid-year Estimates. 2015 mid-year estimates.20 CDR assumption used in population projections.
g DHIS Population Estimates 2002–2018.
h Stats SA GHS 2014.21 Calculated using provincial medical scheme coverage (GHS 2014) and Stats SA mid-year estimates for the relevant year.
i Medical Schemes 2014–15.22 Calculated from total number of beneficiaries subtracted from total population (Stats SA mid-year estimates for the relevant
year).
j Census 2011 Fertility.17
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2014 GHS 38 778 133 3 811 882 689 310 1 052 479 - 44 274 032 d
2015 GHS 39 539 832 3 851 821 698 706 1 047 354 - 45 009 701 d
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
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a Census 2011 Fertility.17 National value estimated from graph since not included in report. Values multiplied by 1 000 to convert from rate per individual
adolescent.
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b Census 2011.19
c Stats SA Mid-year Estimates. 2015 mid-year estimates.20
d Calculated using medical scheme coverage (Stats SA GHS 2013 and 2014)21,23 and Stats SA mid-year estimates for the relevant year.
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A N
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G
R
BA
N
O
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S A H R 20 1 6 2 53
Socio-economic and risk factor indicators
Context Although a focus on the determinants of health has been central to the Primary Health Care approach, which is
entrenched as underpinning South African health policy, this focus has been given even more prominence by the
Sustainable Development Goals (SDGs), and its renewed attention to intersectoral action.
New data sources Nationally, new data have been reported in the:
• Stats SA Quarterly Labour Force surveys, 2015 (Q3)
• Stats SA Education and Gender, 2004–2014
• Stats SA Census 2011 Profile of Educational Attainment
• Stats SA Census 2011 Income Dynamics
• Department of Water Affairs 2014 Blue Drop Report
Internationally, data of interest have been reported in the:
• UNDP Human Development Report 2015
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• UNICEF Unless we act now: The impact of climate change on children
Key issues and trends Although an updated Blue Drop Report (with data from the 2014 audit) was finally released, no Green Drop
Report has yet been issued. The Blue Drop Report is poorly constructed and difficult to interpret. Similarly,
updated data on air pollution are difficult to access and interpret.
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Key socio-economic indicators, such as the unemployment rate, provide evidence of the persistent gaps that exist
between population groups and provinces and also the impact of lower than expected economic growth.
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The United Nations Development Programme’s annual Human A key measure of socio-economic status is the unemployment rate,
Y T
Development report places countries in a hierarchy, based on the
Human Development Index.24 In 2015, South Africa was placed in
reported on a quarterly basis by Stats SA. The most recent figures
show that unemployment increased by 626 000 in quarter 1 of
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the ‘medium development’ strata, at position 116, together with El 2015, decreased by 305 000 in quarter 2, but then increased
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Salvador and Viet Nam. The Human Development Index value for again by 188 000 in quarter 3.27 Overall, the national official
South Africa continues to improve steadily. unemployment rate in quarter 3 was 25.5%, but 34.4% when
measured by the expanded definition. It is against this sustained
4 ED
services. Severe storms, resulting in floods and landslides, can also further analyses of the Census 2011 data. This includes reports on
affect access to safe water and sanitation. After considerable delay, income dynamics and education attainment.29-31 These provide
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the Department of Water and Sanitation released the Blue Drop compelling evidence of the persistence of poverty in South Africa,
Report 2014 in early 2016.26 The report claimed that the National where 15.5% of households in 2011 (down from 23.2% in the 2001
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Blue Drop score (measuring the performance of individual potable Census) reported no income at all. They also showed persistent
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water suppliers) has “improved substantially” since 2009; but also gaps between the educational attainment status of Whites and both
that the “drop in performance in general in 2014 is perturbing and Coloureds and Africans. Lack of educational attainment has an
water services authorities and their providers need to regain the increasingly important effect on employment status, as unskilled and
progress made in 2012”. The 2014 audit assessed 152 Water semi-skilled jobs are lost from the economy.
Service Authorities, providing services via 1 036 treatment systems.
Only 44 Blue Drops (indicating excellence) were awarded to 20 of Air quality is also a focus on the SDGs (target 3.9 reads: “By
the 152 Water Service Authorities. Overall, it was claimed that 60% 2030, substantially reduce the number of deaths and illnesses
of the water supplied daily was supplied with Blue Drop excellence. from hazardous chemicals and air, water and soil pollution and
Critically, no updated report on waste water treatment (the Green contamination”) and a measure of air pollution is included in the
Drop report) was issued. Stats SA has reported on sanitation and WHO 100 Core Health Indicators (defined as “Annual mean
refuse removal as part of the General Household Survey 2014.21 concentration of particulate matter of less than 2.5 microns of
The percentage of households with access to ‘improved sanitation’ diameter (PM2.5) [μg/m3] (or of less than 10 microns [PM10] if
(i.e. a flush toilet connected to a public sewerage system or septic PM2.5 is not available) in cities”). Recent data on this indicator are
tank, or a pit toilet with a ventilation pipe) is one of the WHO difficult to access. The 2012 PM10 data presented here are from
100 Core Health Indicators and was 79.5% nationally in 2014. the WHO Global Health Observatory, although trend information
Nationally, only 4.9% of households had no sanitation or relied on by city areas is available in the 2014 Department of Environmental
the bucket system in 2014, but the percentage was still high in the Affairs Annual Air Quality Governance Lekgotla.32
Northern Cape (9.1%), Eastern Cape (8.5%), Free State (7.9%) and
Mpumalanga (7.1%).
254 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Air pollution level in cities (particulate matter [PM])
2012 PM10 - - - - - - - - - 56.0 a
Drinking Water System (Blue Drop) Performance Rating
2012 82.1 73.6 98.1 92.1 79.4 60.9 68.2 78.7 94.2 87.6 b
2014 72.0 75.0 92.0 86.0 62.0 69.0 68.0 63.0 89.0 79.6 c
Education level: percentage of population 20 years and older with no schooling
2013 no schooling 5.9 4.4 2.0 7.8 10.4 10.6 7.8 8.3 1.2 5.5 d
2014 no schooling 5.5 4.2 2.0 7.1 10.1 9.3 6.9 7.4 2.1 5.2 e
Human development index (high value = best)
2013 - - - - - - - - - 0.663 f
2014 - - - - - - - - - 0.666 f
Human development index rank (1 = best)
2013 - - - - - - - - - 117 f
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2014 - - - - - - - - - 116 f
Literacy rate
2014 90.4 92.3 97.6 89.8 84.8 85.8 89.4 89.6 97.9 93.1 g
Percentage of households by type of housing
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2014 formal 64.3 83.8 78.9 74.8 93.6 88.1 83.6 78.0 82.5 79.4 e
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2014 informal 7.8 14.3 19.2 8.1 3.9 7.6 10.8 21.0 14.8 12.9 e
2014 traditional 27.7 1.8 0.3 17.0 2.4 4.3 1.9 0.9 0.0 6.8 e
Percentage of households using electricity for cooking (%)
2013 GHS
2014 GHS
71.5
74.9
Y T
88.8
89.4
84.6
84.9
75.5
77.5
53.6
57.0
75.6
76.6
83.9
85.3
81.1
81.9
88.3
89.2
78.4
79.8
d
e
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Percentage of households with access to piped water
2013 GHS 80.5 95.9 95.9 86.2 77.5 86.7 96.1 88.3 98.7 89.9 d
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2014 GHS 78.5 95.3 96.4 86.5 79.6 87.1 95.8 87.2 98.9 90.0 e
Percentage of households with no toilet / bucket toilet
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2013 GHS 10.0 7.7 1.8 5.5 7.2 6.3 7.4 5.0 3.6 5.1 d
2014 GHS 8.5 7.9 1.9 4.8 5.4 7.1 9.1 5.1 4.5 4.9 e
Percentage of households with telephone (telephone in dwelling or cell phone)
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2013 GHS 89.4 94.1 98.0 95.5 95.7 96.8 86.4 94.0 93.0 95.0 d
2014 GHS 91.1 95.1 98.2 96.9 96.4 96.8 89.8 93.8 94.8 95.9 e
Population using safely managed sanitation services (%)
G
2013 GHS 71.2 83.3 90.2 73.9 50.0 62.7 81.7 70.0 94.8 77.9 d
R
2014 GHS 78.1 83.8 90.9 75.7 54.0 64.3 83.7 66.7 94.6 79.5 e
Poverty prevalence (%)
BA
2011 Census food poverty line 40.5 31.6 26.8 37.4 41.5 35.3 28.2 33.4 23.2 32.7 h
2011 FPL rebased - - - - - - - - - 21.7 i
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Global Health Observatory. http://gamapserver.who.int/gho/interactive_charts/phe/oap_exposure/atlas.html [accessed 11/2/2016].
b Blue Drop 2012.33
c Blue Drop 2014.26 No report has been produced for 2013.
d Stats SA GHS 2013.23
e Stats SA GHS 2014.21
f Human Development Report 2015.24
g Gender & Education Vol 2.31
h Census 2011 Poverty.29 Census results considered less accurate compared to specific income/poverty surveys. Income data from Census 2011 significantly
overestimated the proportion of households that claimed to have no income, resulting in higher levels of poverty.
i Poverty Trends 2006–2011.34 Derived from the Income and Expenditure Survey (IES) 2010/2011. The food poverty line (FPL) is the level of consumption
below which individuals are unable to purchase sufficient food to provide them with an adequate diet. Food poverty line rebased – equates to 10.9 million
people in 2011.
j Poverty Trends 2006–2011.34 Lower-bound poverty line – equates to 18.6 million people in 2011.
k Poverty Trends 2006–2011.34 Upper-bound poverty line – equates to 27.1 million people in 2011.
l Stats SA Labour Force Survey.35 Quarter 3, 2013 Report.
m Stats SA Labour Force Survey.35 Quarter 3, 2014 report.
n Stats SA Labour Force Survey.27 Quarter 3, 2015 report.
S A H R 20 1 6 2 55
Table 5: Socio-economic indicators by population group
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Unemployment rate (official definition)
2014 Q3 27.2 22.9 11.9 7.7 24.3 e
2015 Q3 28.8 22.8 12.5 5.9 25.5 f
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2014.21
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b Gender & Education Vol 2.31
c Census 2011 Poverty.29 Census results considered less accurate compared to specific income/poverty surveys. Income data from Census 2011 significantly
overestimated the proportion of households that claimed to have no income, resulting in higher levels of poverty.
d Y T
Poverty Trends 2006–2011.34 Derived from the Income and Expenditure Survey (IES) 2010/2011. The lower-bound poverty line (LBPL) includes non-food
items, but requires that individuals sacrifice food in order to obtain these, while individuals at the upper-bound poverty line (UBPL) can purchase both
adequate food and non-food items. The Rand value of each line is updated annually using CPI prices data.
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e Stats SA Labour Force Survey.35 Quarter 3, 2014 report.
f Stats SA Labour Force Survey.35 Quarter 3, 2015 report.
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256 S A H R 20 1 6
Health and Related Indicators
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from overall improvements in health status, but are perhaps most closely related to expanded access to ART.
Mortality data are increasingly available at district municipality level rather than only at provincial level, and
can even be disaggregated by local municipality. However, the completeness and quality of data may vary
substantially between areas, complicating the comparison of mortality rates.
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A recent issue from the Global Burden of Disease Study 2013 (GDB) 21.8% of deaths. This included 779 deaths specifically recorded as
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has reported on the causes of mortality among adolescents and due to multidrug-resistant tuberculosis (MDR-TB) and 77 deaths due
children.36 It showed that, in 2013, the leading causes of death to extensively drug-resistant tuberculosis (XDR-TB). The data were
Y T
were lower respiratory tract infections (among younger children),
diarrhoeal diseases (among older children) and road injuries
presented not only by province, but also by district municipality. The
report stated that disaggregated data by local municipality were
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(among adolescents). The persistence of some of these causes in available on request.
particular locales was striking: Nigeria was responsible for 12%
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to be biased.
Similar changes were seen for those aged younger than 5 years,
which are a testament to the global attention paid to child health Although now somewhat dated, the estimates of mortality in South
BA
in the MDG era. The Institute for Health Metrics and Evaluation Africa derived from the Census 2011 are still interesting, especially
(IHME) has provided intriguing graphical representations of the as they reflect changes in relation to AIDS-related mortality over
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GBD data for individual countries, showing the changes in causes time.39 The report also provided estimates of the under-5 mortality
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of morbidity and mortality.37 Figure 4 shows the changes between rate (44.0 per 1 000 live births) and maternal mortality ratio (580
1990 and 2013 in the number of years lived with disability (YLD) per 100 000 live births), but these differed markedly from estimates
due to leading causes (disaggregated by communicable, maternal, prepared from civil registration data. Nonetheless, Stats SA were
neonatal, and nutritional diseases, non-communicable diseases and of the opinion that, overall, “the findings suggest that the country
injuries). Over that time period, the most dramatic change was in has made significant progress towards achievement of the MDG
HIV and AIDS, which moved from position 70 to position 1, a shift targets”.
in excess of 12 000%. Other notable shifts include a 35% increase
The fourth annual report of data from the Rapid Mortality
in YLDs due to diabetes and a 29% decrease in YLD due to iron-
Surveillance (RMS) database was released in December 2015 and
deficiency anaemia.
tracks several high-level indicators of mortality, after correcting for
The 2014 update to the Stats SA report “Mortality and causes the incompleteness of reporting.40 A steady improvement in birth
of death in South Africa” (P0309.3) was released in December and identity registration has improved the completeness of the
2015.10 These data are drawn from the civil registration system population register, although this has exposed apparent under-
and are based on 453 360 reported deaths, showing a sustained recording in the vital registration (cause of death) data.
downward trend since the peak in 2006 (Figure 5). Of these, 78.4%
were reported within 72 hours of the death. The overall leading cause
of death remained infections and parasitic diseases, responsible for
S A H R 20 1 6 2 57
Figure 4: Leading causes of YLDs in South Africa, 1990 and 2013, and percent change, 1990–2013
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Migraine 10 10 Diabetes 35%
11 11 Migraine 6%
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Diabetes
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Communicable, maternal, neonatal and
Non-communicable diseases Injuries
nutritional diseases
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A N
Source: IHME Global Burden of Disease 2013 Country Profile for South Africa (healthdata.org).
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Notes: YLDs are years lived in less than ideal health. This includes conditions that may last for only a few days, as well as conditions that can last a lifetime.
Rankings are based on YLDs per 100 000, all ages, not age-standardised.
The small burden of HIV and AIDS in 1990 accounts for the dramatic relative increase in burden from this cause.
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700 000
G
600 000
R
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500 000
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Number of deaths
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400 000
300 000
200 000
100 000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Stats SA 317 727 366 477 382 530 417 042 456 054 503 160 558 258 578 217 599 267 614 014 605 949 597 781 582 956 550 401 514 938 492 062 473 384 453 360
Year of death
258 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Adult mortality (45q15 – probability of dying between 15–60 years of age)
2010 BoD 52.2 53.7 33.9 52.8 37.7 47.4 43.9 44.5 26.6 42.6 a
2010 Census both - - - - - - - - - 37.4 b
2010 Census female - - - - - - - - - 31.2 b
2010 Census male - - - - - - - - - 43.6 b
2010 RMS 2014 both - - - - - - - - - 43.0 c
2010 RMS 2014 female - - - - - - - - - 38.0 c
2010 RMS 2014 male - - - - - - - - - 48.0 c
2011 RMS 2014 both - - - - - - - - - 40.0 c
2011 RMS 2014 female - - - - - - - - - 35.0 c
2011 RMS 2014 male - - - - - - - - - 46.0 c
2012 RMS 2014 both - - - - - - - - - 38.0 c
2012 RMS 2014 female - - - - - - - - - 32.0 c
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2012 RMS 2014 male - - - - - - - - - 44.0 c
2013 RMS 2014 both - - - - - - - - - 36.0 c
2013 RMS 2014 female - - - - - - - - - 30.0 c
2013 RMS 2014 male - - - - - - - - - 42.0 c
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2013 GBD 2013 female - - - - - - - - - 35.3 d
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2013 GBD 2013 male - - - - - - - - - 45.2 d
2014 RMS 2014 both - - - - - - - - - 34.0 c
2014 RMS 2014 female - - - - - - - - - 28.0 c
2014 RMS 2014 male
Life expectancy at birth (e0)
- Y T- - - - - - - - 40.0 c
A N
2010 BoD 53.8 53.4 63.2 52.9 63.6 56.6 59.3 58.0 68.0 58.8 a
2010 Census - - - - - - - - - 57.9 b
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Burden of Disease SA 2010.41
b Census 2011 Mortality.39
c RMS 2014.40 Estimates for 2013 are based on RMS data rather than VR data because of apparent significant under-recording of the VR (cause of death)
data.
d Global Burden of Disease 2013.42
e Stats SA Mid-year Estimates. 2015 mid-year estimates.20
S A H R 20 1 6 2 59
Disability
Context Although no new data on disability are available, this section is retained for the sake of completeness.
New data sources Nationally, no new data have been reported.
Internationally, media reports have focused on the gap between life expectancy at birth and the proposed
measure of ‘healthy life expectancy’ (HALE)
Key issues and trends The data shown below are repeated from the previous issue of the Health Review.
Data from the Global Burden of Disease Study 2013 (GBD 2013) lived with illness and disability. The gap between HALE and life
have been used to calculate the gap between life expectancy at expectancy at birth is on average 9.2 years (with 62.3 years lived
birth and another summary measure, health life expectancy (HALE) in a healthy state out of a life expectancy of 71.5 years (Figure 6).
proposed by the University of Washington’s Institute for Health In South Africa the gap is 8.4 years (with 52 years lived in a healthy
Metric and Evaluation (IHME).43,44 The latter takes into account the state out of a life expectancy of 60.4 years). South Africa was one
number of years lived with illness and disability. On average, while of a few countries which experienced a reduction in life expectancy
life expectancy at birth has increased, so have the number of years and HALE between 1990 and 2013 (Figure 7).
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Figure 6: The gap between HALE and life expectancy, highlighting the position of South Africa, 2013
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Years
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35 40 45 50 55 60 65 70 75 80 85 90
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expectancy expectancy
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Source: GBD 2013 DALYs and HALE collaborators, Lancet 2015 and Noack et al. 2015.43,44
Note: The gap between healthy life expectancy (HALE) and life expectancy grows as life expectancy rises. The gap is greatest in Switzerland at 12.8 years,
and narrowest in Papua New Guinea, at six years.
26 0 S A H R 20 1 6
Health and Related Indicators
Figure 7: Change in HALE and life expectancy for South Africa, 1990–2013
Years
40 50 60 70 80 90
2013
HALE LE
52 60.4
56 64.5
1990
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Source: GBD 2013 DALYs and HALE collaborators, Lancet 2015 and Noack et al. 2015.43,44
Note: The majority of countries experienced a rise in life expectancy, with some exceptions: Botswana, Namibia, South Africa, Gabon, Zimbabwe, Swaziland,
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Lesotho, Belarus, Belize, Paraguay and Guyana.
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Table 7: Disability indicators by province
EC
Cataract surgery rate (per million population)
FS Y T GP KZN LP MP NC NW WC SA Ref
A N
2012 DHIS 962.5 471.2 412.8 685.4 737.4 662.1 448.9 426.4 - 553.2 a
2013 DHIS 882.9 387.4 620.3 700.1 568.8 563.3 993.7 661.4 1 272.4 732.0 b
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2014 DHIS 1 052.4 608.1 846.4 758.2 751.1 630.5 883.4 594.3 1 287.3 849.7 c
Prevalence of disability (%)
4 ED
2012 GHS 6.0 7.6 3.5 5.0 5.0 5.4 7.1 7.2 4.6 5.1 d
2012 WHODAS score 2.6 3.1 2.0 3.1 3.2 3.9 3.0 2.4 1.4 2.5 e
2013 GHS 6.2 7.1 3.9 5.9 4.7 5.3 8.3 8.1 4.6 5.4 f
2014 GHS 6.0 7.0 3.7 4.7 4.6 4.6 7.5 7.4 4.6 4.9 g
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
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a DHIS.45 2012/13 financial year. WC data were not available in the national DHIS datamart as extracted at the time.
b DHIS.45 2013/14 financial year.
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years are often mistakenly categorised as being unable to walk, remember, communicate or care for themselves when it is due to their level of development
rather than any innate disabilities they might have.
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e SANHANES-1.47 The WHO–Disability Assessment Scale (DAS) score provides an indication of the overall level of self-reported disability in the 30 days
preceding the interview at the time the survey was conducted. It is expected that the level of disability will increase with age. In SANHANES-1, a very low
level of disability was reported at all ages, including the middle and older age group although the results show a trend of increasing disability with age.
f Stats SA GHS 2013.23
g Stats SA GHS 2014.21
h SANHANES-1.47 Self-reported prevalence of wearing a hearing aid.
S A H R 20 1 6 26 1
Infectious disease
Context Even though the SDGs can be perceived as shifting focus to non-communicable diseases, they also broaden the
focus on communicable diseases beyond the ‘Big Three’ (AIDS, tuberculosis and malaria).
New data sources Nationally, new data have been reported in the:
• Surveillance data, surveillance bulletins and other reports issued by NICD
Internationally, there have been many reports on the Ebola virus disease outbreak, and also on the emerging
threat of Zika virus. However, these have not been covered in the Health Review as their direct and immediate
relevance to South Africa is limited. A national response has been mounted though, especially following the
declaration of Zika as a Public Health Emergency of International Concern (PHEIC), in terms of the International
Health Regulations.
Key issues and trends Significant changes in the way prevalence and incidence data on infectious diseases are collected, analysed and
reported is expected with the creation of the National Public Health Institute of South Africa (NAPHISA). A draft
Bill in this regard has been published for comment, but not yet tabled in Parliament.
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As has been noted for some years, no updated notifiable disease other target conditions are diphtheria, pertussis, neonatal tetanus,
data have been issued by the National Department of Health. The total tetanus, measles, rubella, congenital rubella syndrome, mumps,
role currently filled by the National Health Laboratory Service diarrhoea, pneumonia, Japanese encephalitis, and yellow fever.
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(NHLS), and in particular the National Institute for Communicable The intention is to provide data disaggregated by age, geographic
Diseases (NICD), is expected to be taken on by the proposed location (such as by district), sex, and vaccination status. Available
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National Public Health Institute of South Africa (NAPHISA). The data on prevalence of hepatitis B are either dated50 or based on
most recent report on laboratory-confirmed cases of diseases under small sample sizes.51 The latter study, based on only 201 serum
September 2015.48
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surveillance by NICD covered the period 1 January 2014 to 30 samples, showed a decline in occult hepatitis B infection in the post-
vaccination era in South Africa (after the introduction of the vaccine
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to the Expanded Programme on Immunisation in April 1995), but
An example of the expanded scope of global attention is provided
significant disease burden in those who are HIV co-infected. Occult
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received treatment for at least one of the selected neglected tropical surface antigen (HBsAg) by current available assays. The WHO 100
diseases (schistosomiasis, soil-transmitted helminthiases, lymphatic Core Indicator set also contains a specific measure of the prevalence
filariasis, onchocerciasis)”). In South Africa, more than 4 million of hepatitis B surface antigen.
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people are estimated to be infected with either Schistosoma The September 2015 edition of the NICD Communicable Diseases
haematobium or Schistosoma mansoni.49 About a quarter of the
G
Only one case was identified in Gauteng during this period, and
public health response in this regard.
none in the Western Cape. The January 2016 edition showed that
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The WHO 100 Core Health Indicators also include a composite eight laboratory-confirmed human rabies cases had been identified
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262 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Reported cases of cholera
2013 NICD lab confirmed cases - - - - 1 - - - - 1 a
2014 NICD lab confirmed cases - - 2 - - - - - - 2 b
2015 NICD lab confirmed cases 0 0 0 0 0 0 0 0 0 0 c
Reported cases of measles
2013 NICD lab confirmed cases 2 0 3 1 0 0 0 1 1 8 a
2014 NICD lab confirmed cases 2 1 16 6 0 3 35 0 6 69 b
2015 NICD lab confirmed cases 2 1 2 2 0 0 3 1 4 15 c
Reported cases of rabies
2013 NICD lab confirmed cases 0 2 0 1 3 1 0 0 0 7 a
2014 NICD lab confirmed cases 4 0 0 0 1 0 0 1 0 6 b
2015 NICD lab confirmed cases 1 1 0 1 2 0 0 0 0 5 c
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a NICD surveillance. Communicable Diseases Surveillance Bulletin April 2015.54 Data for Jan–Dec 2013.
b NICD surveillance. Communicable Diseases Surveillance Bulletin April 2015.54 Data for Jan–Dec 2014.
c NICD surveillance. Communicable Diseases Surveillance Bulletin November 2015.48 Data for Jan–Sep 2015.
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Malaria
Context Although malaria transmission only occurs in KwaZulu-Natal, Mpumalanga and Limpopo, imported cases
present to health facilities in other provinces. South Africa has yet to decide on the provision of chemoprophylaxis
through the public health sector, and in particular for those migrant workers who return to neighbouring countries
over holiday periods, and are at increased risk of contracting malaria.
New data sources Nationally, new data have been reported in the:
• NDoH malaria surveillance
Internationally, reports of interest include:
• WHO World Malaria Report 2015
• Global Technical Strategy for Malaria 2016–2030
Key issues and trends South Africa is committed to eradicating malaria by 2030. As always, it is difficult to reconcile the different
figures reported locally and in global reports. The WHO World Malaria Report now includes the number of
local versus imported cases for some countries; the NDoH figures for 2015 classify cases as local, imported or
unknown.
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The World Health Organization’s World Malaria Report 2015 confirmed by microscopy, the number of rapid diagnostic tests
showed that, globally, the number of malaria cases fell from about (RDT) performed, and the number of cases confirmed with an RDT.
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262 million (range: 205–316 million) in 2000 to about 214 million Surprisingly, the estimated number of malaria deaths in 2014 in
(149–303 million) in 2015.55 Globally, malaria incidence fell by South Africa (120) was lower than the reported number of deaths
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37% over the same period, and by more than 75% in 57 of 106 (174) in the global report. South African surveillance data recorded
affected countries. The number of malaria deaths globally also fell 136 deaths due to malaria in 2015, including deaths that have
by 48% (from 839 000 (653 000–1.1 million) in 2000 to 438 000
Y T occurred in provinces other than KwaZulu-Natal, Mpumalanga and
(236 000–635 000), in 2015. WHO therefore concluded that “the Limpopo, as shown in Table 9. Of the 11 238 cases recorded in
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target of Millennium Development Goal (MDG) 6 ‘to have halted 2015, 5 597 were classified as imported, 5 235 as local and the
and begun to reverse the incidence of malaria’ (Target 6C) has remaining 406 of unknown origin (Figure 8). This Figure shows a
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been achieved”. Nonetheless, even though the number of malaria marked difference in the relative proportion of local and imported
deaths in children aged under 5 years in the WHO African Region cases between Limpopo and Mpumalanga.
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shows that, of a population of 54 million, it was estimated that in and to prevent re-establishment of malaria in all countries that are
2014 just over 2 million South Africans lived in high transmission now malaria-free. The indicators for the Strategy include some that
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areas (where there is more than 1 case per 1 000 population), are also in the WHO 100 Core Indicator set, but which South Africa
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and 3.2 million in low transmission areas (0–1 cases per 1 000 does not report (specifically where the interventions are not adopted
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population). The report provided figures from 2000 to 2014 on locally, such as the proportion of the population at risk who slept
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the number of malaria cases presumed and confirmed in South under an insecticide-treated net the previous night).
Africa, the number of microscopy samples examined, the number
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EC FS GP KZN LP MP NC NW WC SA Ref
Case fatality rate: malaria
2013 DoH surveillance 10.0 2.8 1.4 2.3 1.0 1.0 0.0 2.9 1.2 1.2 a
2014 DoH surveillance 0.0 0.0 1.5 1.2 1.6 0.6 6.7 0.0 2.3 1.2 a
2015 DoH surveillance 4.2 2.4 1.7 1.0 1.5 0.5 5.6 1.8 2.4 1.2 a
2013 DoH surveillance 0.05 0.07 0.19 0.12 0.43 0.87 0.00 0.08 0.02 0.20 b
2013 VR 0.06 0.29 0.53 0.30 1.05 1.11 0.00 0.61 0.12 0.47 c
2014 DoH surveillance 0.00 0.00 0.22 0.07 1.62 0.78 0.09 0.00 0.07 0.31 b
2014 DoH surveillance 33 54 1 929 687 5 679 5 280 15 73 175 13 925 a
2015 DoH surveillance 24 41 1 524 606 5 352 3 494 18 55 124 11 238 a
26 4 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Reported cases of malaria (per 100 000)
2013 DoH surveillance 0.5 2.6 13.8 5.5 43.6 92.0 1.7 2.8 1.4 16.7 b
2014 DoH surveillance 0.5 1.9 14.9 6.4 100.9 124.8 1.3 2.0 2.9 25.8 b
2015 DoH surveillance 0.3 1.5 11.5 5.5 93.5 81.6 1.5 1.5 2.0 20.4 b
2013 VR 4 8 67 31 58 46 0 22 7 247 c
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
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a DoH Malaria Statistics. Data for Jan–Dec.
b DoH Malaria Statistics. Calculated using Stats SA mid-year population estimates for the relevant year.
c Stats SA Causes of death 2013.57-59 Calculated from Stats SA Causes of Death online database using ICD-10 codes B50–B54 as underlying cause of
death. Includes deaths not recorded by province. Although the 2014 Causes of death report has been released, it does not contain details on deaths due
to malaria and therefore this indicator will be updated once the unit records are made available through Nesstar online database.
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d Murray et al. 2014.60 Modelled estimate as part of the Global Burden of Disease Study 2013.
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Figure 8: Monthly cases and deaths due to malaria by province, 2015
1500
Number per month
Malaria 1000
cas es
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500
0
30
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Number per month
20
Malaria
G
deaths
10
R
0
April
April
April
April
April
April
April
April
Augus t
April
Augus t
Augus t
Augus t
Augus t
Augus t
Augus t
Augus t
Augus t
J une
J une
F ebruary
October
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October
December
J une
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J une
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October
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J une
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October
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J une
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E lement_type
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S A H R 20 1 6 265
Tuberculosis
Context Although tuberculosis remains a key target for the Sustainable Development Goals (SDGs), there is also increased
awareness of the potential linkages with non-communicable diseases, and in particular, diabetes. In the same
way that HIV fuelled the tuberculosis epidemic, so could the increasing incidence of diabetes.
New data sources Nationally, new data have been reported in the:
• Stats SA Mortality and causes of death in South Africa, 2014: Findings from death notification
Internationally, reports of interest include:
• WHO Global Tuberculosis Report 2015
• Stop TB Partnership Global Plan to End TB 2016–2020
Key issues and trends The Stop TB Partnership’s Global Plan to End TB 2016–2020 has set ambitious 90-(90)-90 targets: to reach 90%
of all people who need TB treatment, including 90% of people in key populations, and to achieve at least 90%
treatment success. Monitoring the first two of these targets requires estimation of the total number of patients with
TB in the general population and then, specifically in ‘key’ populations. Target 2 is therefore a subset of Target 1.
In South Africa, the ‘key’ populations would include people living with HIV, miners and prisoners. The targets
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have been articulated somewhat differently by the South African National Department of Health, as screening
90% of vulnerable groups, diagnosing and starting 90% on treatment, and then achieving at least 90% treatment
success.
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Improved diagnostic capacity is still needed for children, and in particular those who are HIV-TB co-infected.
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Globally, the World Health Organization’s Global Tuberculosis The 90-(90)-90 targets pose significant challenges to routine data
Report 2015 showed that the Millennium Development Goal (MDG) systems. It has also been argued that a TB elimination strategy
target in terms of TB incidence had been met.61 The target was met
Y T requires considerable investment in local data systems, which
in all six WHO regions, and in 16 of 22 high-burden countries would allow for targeted interventions to address ‘hot spots’ of
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(including South Africa). South Africa did not meet the MDG transmission.63 Barnhart does point out, however, that targeted
targets for TB prevalence or TB mortality. In 2014, the number of approaches and disease-specific initiatives and funding can be
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incident cases in South Africa was only exceeded by those in India, self-defeating, in that they can draw resources away from some
Indonesia, China, Nigeria and Pakistan (in that order). However, areas and weaken the health system, potentially resulting in poorer
4 ED
from 550 000 in 2011 to 4.8 million in 2014, of which 51% were 2014 case findings are shown in Table 11 and the 2013 treatment
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procured by South Africa. South Africa was also responsible for outcomes in Table 12. Historical data can, as always, be accessed
59% of all people living with HIV who were treated with isoniazid from the HST website.
preventive therapy (IPT) in 2014.
26 6 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Case detection rate (all forms)
2012 Global TB - - - - - - - - - 69 a
2013 Global TB - - - - - - - - - 68 a
2014 Global TB - - - - - - - - - 68 a
HIV prevalence in TB incident cases
2012 Global TB - - - - - - - - - 64.0 a
2013 Global TB - - - - - - - - - 62.0 a
2014 Global TB - - - - - - - - - 61.0 a
Incidence of TB (all types) (per 100 000)
2012 Global TB - - - - - - - - - 892 a
2013 Global TB - - - - - - - - - 860 a
2014 Global TB - - - - - - - - - 834 a
Prevalence of multidrug resistance among new TB cases (%)
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2012 NHLS Xpert 6.9 6.2 6.8 8.9 6.6 11.2 5.5 7.1 5.1 7.1 b
2013 NHLS Xpert 6.2 5.7 6.5 8.9 4.9 9.5 5.6 5.4 5.0 6.6 b
2014 NHLS Xpert 6.0 5.6 5.7 8.3 4.9 8.6 5.0 5.2 5.2 6.4 b
Tuberculosis death rate per 100 000 (in HIV-positive people)
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2012 Global TB - - - - - - - - - 130 a
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2013 Global TB - - - - - - - - - 129 a
2014 Global TB - - - - - - - - - 134 a
Tuberculosis mortality rate per 100 000
2012 vital registration
2013 vital registration
109
95
Y T 120
103
62
56
129
96
77
66
108
90
107
91
106
86
52
44
93
77
c
d
A N
2014 vital registration 87 99 49 81 62 80 88 84 40 69 e
Tuberculosis mortality rate per 100 000 (excluding HIV)
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Global TB Report 2015.61
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b DHB 2014/15.67 Percentage of positive TB tests that are RIF resistant (based only on tests done using GeneXpert technology).
c Stats SA Causes of death 2012.58 Calculated from deaths due to TB (ICD10 A15–A19), plus ICD10 U51 (MDR) and ICD10 U52 (XDR TB) and Stats SA
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mid-year population estimates for the relevant year. No adjustment has been made for under-reporting or ill-defined causes. The rate for South Africa
includes deaths that are not allocated to a specific province and will therefore be higher than the average provincial value. Based on the recorded province
of death.
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d Stats SA Causes of death 2013.59 Calculated from deaths due to TB (ICD10 A15–A19), plus ICD10 U51 (MDR) and ICD10 U52 (XDR TB) and Stats SA
mid-year population estimates for the relevant year. No adjustment has been made for under-reporting or ill-defined causes. The rate for South Africa
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includes deaths that are not allocated to a specific province and will therefore be higher than the average provincial value. Based on the recorded province
of death.
e Stats SA Causes of death 2014.10 Includes 779 deaths due to MDR TB and 77 deaths due to XDR TB. Calculated from deaths due to TB (ICD10 A15-A19),
plus ICD10 U51 (MDR) and ICD10 U52 (XDR TB) and Stats SA mid-year population estimates for the relevant year. No adjustment has been made for
under-reporting or ill-defined causes. The rate for South Africa includes deaths that are not allocated to a specific province and will therefore be higher than
the average provincial value. Based on the recorded province of death.
S A H R 20 1 6 267
Table 11: TB case-finding indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Bacteriological coverage rate (%)
2014 TB register 66 65 63 69 72 57 54 50 69 65 a
Proportion of extra-pulmonary TB
2014 TB register 6 12 13 14 13 8 4 8 11 11 a
Reported cases of MDR-TB
2012 Lab diagnosed 2 205 390 1 198 6 630 266 760 373 267 2 072 14 161 b
2014 Lab diagnosed - - - - - - - - - 18 734 c
Reported cases of XDR-TB
2012 Lab diagnosed 477 31 50 754 3 3 72 10 145 1 545 b
Reported cases of TB (PTB new Sm+)
2014 TB register 22 026 5 157 11 944 21 657 4 907 5 150 2 502 4 229 12 530 90 102 a
Reported cases of TB (PTB new Sm+) (per 100 000)
2014 TB register 330.9 187.0 91.9 204.9 87.9 123.2 213.4 115.9 204.4 167.8 a
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Reported cases of TB (PTB)
2014 TB register 49 696 15 543 40 845 78 169 15 069 17 309 8 635 19 106 38 615 282 987 a
Reported cases of TB (all types)
2014 TB register 52 734 17 584 46 995 91 382 17 355 18 820 9 001 20 759 43 563 318 193 a
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Reported cases of TB (all types) (per 100 000)
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2014 TB register 792.3 637.6 361.6 864.4 310.7 450.1 767.6 568.8 710.6 592.5 a
Retreatment ratio (percentage of Sm+ cases that are retreatment)
2014 TB register 4 5 4 5 4 4 10 6 19 7 a
42
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Smear positivity (percentage of PTB cases which are new Sm+)
2014 TB register 29 25 24 28 27 28 20 29 28 a
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
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a DoH TB. Based on analysis of patient-level records in ETR.Net as received from NDoH 2013–2015.
b MDR Overview 2014.68
c Global TB Report 2015.61
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EC FS GP KZN LP MP NC NW WC SA Ref
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2013 TB register 7.6 5.6 6.3 4.9 4.2 5.0 7.9 7.3 8.6 6.3 a
TB death rate (all TB)
2013 TB register 9.3 11.1 6.3 6.4 11.0 7.5 9.0 10.2 3.8 7.4 a
TB treatment failure (all TB) (%)
2013 TB register 0.4 0.3 0.1 0.2 0.5 0.3 0.3 0.3 0.3 0.3 a
TB treatment success rate (all TB) (%)
2013 TB register 77.0 76.8 82.6 81.8 57.6 76.1 71.8 65.8 82.6 77.9 a
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DoH TB. Based on analysis of patient-level records in ETR.Net as received from NDoH in 2015.
26 8 S A H R 20 1 6
Health and Related Indicators
Context Although the dominance of HIV, TB and malaria indicators has not been retained in the Sustainable Development
Goals (SDGs), the impact of HIV in high-burden countries remains important.
New data sources Nationally, new data have been reported in the:
• 2013 National Antenatal Sentinel HIV Prevalence Survey
• National Health Laboratory Service data
Internationally, reports of interest include:
• The One Campaign Tracking Global Commitments on AIDS
• UNAIDS Focus on location and population
• UNAIDS Global Plan Progress Report 2015
• UNAIDS AIDS by the numbers 2015
• HIV Worldwide 1990–2013 Visualization created by IHME for the Journal of the American Medical
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Association
Key issues and trends The UNAIDS 90-90-90 targets pose considerable challenges for routine data systems, especially with regard to
the first of these targets.
Delays in the release of key HIV survey data continue to hamper efforts to track progress. The results of the
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October 2013 antenatal HIV survey were released in January 2016. This is a key starting point for many
modelled estimates of the burden of HIV.
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Timely access to key survey results is invaluable, not only for AIDS by 2030” focused on what is termed the ‘location-population
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researchers, but also to guide local practice. In this regard the
continued delay in releasing the results of the most recent annual
approach’ to implementing the Fast-Track interventions.75 An
example of a population that is routinely missed by HIV programmes
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antenatal HIV survey is regrettable. The results of the 2013 National is men. Data from the Hlabisa demographic surveillance site have
Antenatal HIV Prevalence Survey were only published in January shown growing male-female disparities in adult life expectancy,
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2016. The national antenatal HIV prevalence was shown to be related to lack of utilisation of HIV testing and treatment among
29.7% (95% confidence interval 28.9–30.2%).69 No statistically men.76
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significant change in this figure has now been recorded for the
The WHO 100 Core Health Indicators have introduced a number of
last six reported surveys. However, there are persistent differences
measures that require integrated HIV and TB data systems, including
in antenatal HIV prevalence between provinces, and between
the provision of TB preventive therapy for HIV-positive people newly
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in Table 14. Detailed data on the testing and treatment cascade are
Some data from a survey of HIV prevalence in sex workers in difficult to gather. The design of a household survey to be conducted
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Johannesburg, Cape Town and Durban was released in December in two sub-districts of the uMgungundlovu Municipality has shown
2015.70 The report was finally made available in March 2016.71 It that two sequential cross-section surveys of 10 000 randomly
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was announced in March 2016 that pre-exposure prophylaxis with selected individuals aged 15–49 years will be needed in order to
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tenofovir-based antiretrovirals would be provided to sex workers, identify two cohorts to be followed for one year in order to detect a
marking an important intervention for this key group.72 30% reduction in the HIV incidence rate between surveys with 84%
power.77
Globally, UNAIDS continues to issue summary data on the HIV
pandemic. The 2015 Progress Report on the Global Plan towards Modelled estimates show that South Africa was diagnosing 76% of
the elimination of new HIV infections among children by 2015 HIV-positive adults by 2012.78,79 In 2014/15, 9.6 million HIV tests
and keeping their mothers alive showed that, among the 21 target were performed, almost achieving the target of 10 million.80 These
countries, 1.2 million paediatric infections had been averted since data provide further support for expanded access to different testing
1996 through the provision of antiretrovirals to pregnant women options, including home-based testing and self-testing. However,
living with HIV (PMTCT).73 In this regard, the greatest progress ensuring that the necessary data are captured from such testing
had been made by South Africa, which reduced such infections by modalities in order to track progress towards the 90-90-90 targets
76%. Early (4–8 weeks post-partum) population-level effectiveness will be challenging.
of South Africa’s PMTCT programme showed a 91% reduction in The methods for modelling population prevalence have had to be
mother-to-child transmission of HIV by 8 weeks.74 This assessment updated, to take account of the effects on prevalence and incidence
also showed high levels of HIV testing during pregnancy (95.5%), of increasing access to ART.81 Increasingly, such models will rely
of access to such results (99.8%) and of early infant HIV testing on accurate service provision data, disaggregated by all of the
(98.7%). In 2015, the UNAIDS report on the “Fast-Track to end covariates of interest.
S A H R 20 1 6 269
Table 13: HIV prevalence and incidence indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
AIDS sick (number of people with AIDS-defining conditions)
2015 ASSA2008 80 652 41 238 152 552 187 299 46 526 55 965 9 432 51 915 34 743 665 502 a
Antenatal client HIV 1st test positive rate (%)
2014 DHIS 13.1 15.3 16.8 20.4 10.6 21.0 7.6 14.6 6.1 15.2 b
HIV incidence (%)
2012 HSRC age 15-49 - - - - - - - - - 1.7 c
2012 THEMBISA age 15-49 1.5 d
2012 EPP/Spectrum age 15-49 1.5 d
2013 ASSA2008 total population 0.8 0.7 0.5 1.0 0.5 0.8 0.4 0.8 0.3 0.7 a
2013 GBD 2013 total population - - - - - - - - - 0.7 e
HIV prevalence (%) (age 15-49)
2015 ASSA2008 17.3 18.4 16.4 22.8 11.5 19.5 10.4 18.6 8.0 17.0 a
2015 mid-year - - - - - - - - - 16.6 f
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HIV prevalence (%) (antenatal)
2012 29.1 32.0 29.9 37.4 22.3 35.6 17.8 29.7 16.9 29.5 g
2013 15-49 years 31.4 29.8 28.6 40.1 20.3 37.5 17.5 28.2 18.7 29.7 h
2013 15-19 years - - - - - - - - - 12.7 h
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2013 15-24 years - - - - - - - - - 19.9 h
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2013 20-24 years - - - - - - - - - 24.0 h
2013 25-29 years - - - - - - - - - 34.9 h
2013 30-34 years - - - - - - - - - 42.5 h
2013 35-39 years
2013 40-44 years
-
-
Y T -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
42.5
35.3
h
h
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2013 45-49 years - - - - - - - - - 24.4 h
HIV prevalence (%) (total population)
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2012 ASSA2008 10.8 12.1 11.2 15.1 7.1 12.7 6.8 12.5 5.2 11.1 a
2012 HSRC all ages - - - - - - - - - 12.2 c
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2013 4-8 weeks 0.7 1.0 0.7 1.3 0.5 0.6 0.5 1.7 0.4 0.9 i
2015 mid-year - - - - - - - - - 11.2 f
2015 ASSA2008 11.4 12.3 11.1 15.4 7.5 13.0 7.0 12.6 5.2 11.3 a
People living with HIV
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2012 ASSA2008 736 404 355 466 1 222 605 1 602 236 423 400 492 287 78 711 436 670 278 889 5 685 424 a
2015 ASSA2008 796 634 366 895 1 229 068 1 680 200 461 927 520 480 82 723 451 339 289 915 5 967 061 a
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a ASSA2008.82
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b DHIS.45
c HIV Household Survey 2012.83
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EC FS GP KZN LP MP NC NW WC SA Ref
AIDS orphans (maternal orphans <18 years)
2015 ASSA2008 187 391 90 079 284 602 416 265 111 858 140 340 15 365 112 672 58 905 1 400 267 a
ANC clients tested for HIV (%)
2012 DHIS 98.6 98.2 89.1 106.8 101.7 103.8 96.1 97.3 96.4 98.2 b
2013 PMTCT survey 91.5 94.6 97.3 95.4 95.1 94.3 95.3 97.3 97.0 95.5 c
Antenatal client initiated on ART rate
2013 79.0 80.8 63.1 85.4 78.6 74.2 80.3 79.2 68.5 76.3 b
2013 PMTCT survey 86.1 93.0 93.2 91.0 83.4 83.4 89.0 88.3 95.9 90.3 c
2014 91.7 88.7 87.4 95.2 92.9 92.9 89.8 90.2 82.8 91.2 b
270 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Antiretroviral coverage (%)
2012 THEMBISA children - - - - - - - - - 44.7 d
2012 THEMBISA female 15+ - - - - - - - - - 62.7 d
2012 THEMBISA male 15+ - - - - - - - - - 51.5 d
2012 THEMBISA total - - - - - - - - - 57.0 d
2012 children 0-14 - - - - - - - - - 43.0 e
2013 children 0-14 - - - - - - - - - 47.0 e
2014 children 0-14 - - - - - - - - - 49.0 e
Antiretroviral treatment exposure (%)
2012 age 0-14 - - - - - - - - - 45.1 f
2012 all ages female - - - - - - - - - 34.7 f
2012 all ages male - - - - - - - - - 25.7 f
Early infant diagnosis coverage
2013 NHLS in DHB 80.8 86.2 96.6 93.9 82.0 90.5 82.8 74.8 80.6 88.3 g
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HIV testing coverage (%)
2012 NiDS - - - - - - - - - 65.2 h
2014 DHIS 36.0 26.2 23.3 39.0 40.8 30.0 29.5 35.2 31.9 32.1 b
2014 MSM - - - - - - - - - 73.0 i
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2014 Non-MSM - - - - - - - - - 65.1 i
HIV-positive new and relapse TB patients on antiretroviral therapy (ART) during TB treatment (%)
20 IL
2012 TB register 66.9 78.8 65.5 50.4 53.2 60.4 63.5 63.2 69.8 60.6 j
2013 DHIS 35.7 20.4 3.5 59.0 48.6 60.9 0.0 40.0 - 29.9 k
2013 TB register 87.5 Y T 78.4 75.4 66.1 59.7 61.8 73.9 69.1 77.8 72.0 j
2014 DHIS 43.8 43.5 2.7 61.5 45.7 54.6 34.2 47.9 - 32.8 k
A N
2014 TB register 89.1 76.2 77.5 74.8 75.3 90.4 83.5 75.4 77.4 78.9 j
Infant 1st PCR test around 6 weeks uptake rate (%)
M U
2012 DHIS 84.2 101.2 97.3 114.6 91.5 102.2 94.0 103.0 55.0 98.7 l
2013 DHIS 91.7 103.0 97.8 113.1 94.9 106.1 87.1 109.4 94.7 102.5 l
4 ED
2014 DHIS 95.2 91.3 98.6 107.9 93.9 106.0 90.8 100.1 96.5 100.6 l
Infant 1st PCR test positive around 6 weeks rate (%)
2012 DHIS 3.0 2.3 2.4 2.2 2.4 3.0 2.7 2.8 1.7 2.5 b
2013 DHIS 2.0 2.8 2.0 1.6 2.6 2.1 2.5 2.3 1.9 2.0 b
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2014 DHIS 1.7 1.3 1.3 1.3 2.0 1.7 2.1 1.8 1.4 1.5 b
Male circumcision (% of men who are circumcised)
G
2012 HSRC age 15+ 74.0 36.0 48.2 23.2 72.6 49.9 20.3 36.7 41.0 46.4 m
2012 NCS 2012 - - - - - - - - - 48.1 n
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2013 PMTCT survey 2.4 2.8 2.2 2.9 2.1 1.5 2.2 5.4 1.9 2.6 p
Number of patients receiving ART
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2015 Adults (Mar) 301 782 158 909 700 357 897 270 219 851 269 866 39 921 179 729 172 856 2 940 541 q
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2015 Children (Mar) 18 280 9 968 30 219 54 192 12 655 15 118 3 133 11 883 7 913 163 361 q
2015 Total (Mar) 320 062 168 877 730 576 951 462 232 506 284 984 43 054 191 612 180 769 3 103 902 q
TB cases with known HIV status (%)
2012 TB register 86.3 87.1 89.8 83.9 90.4 85.3 78.8 83.1 94.5 86.9 j
2013 TB register 88.4 89.1 92.8 88.8 93.1 90.1 77.3 89.5 95.6 90.3 j
2014 TB register 92.3 89.6 93.7 92.5 94.1 92.5 84.6 91.7 95.9 92.8 j
Percentage of deaths due to AIDS
2013 ASSA2008 27.0 31.8 35.5 38.1 25.6 36.6 20.9 36.2 16.7 31.9 a
2013 GBD 2013 - - - - - - - - - 51.6 r
2015 ASSA2008 28.5 32.0 35.4 39.0 27.2 37.4 21.9 36.4 17.6 32.8 a
2015 mid-year - - - - - - - - - 30.5 s
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a ASSA2008.82
b DHIS.45
c PMTCT Survey 2012-13.74 Among self-reported HIV-positive mothers 54.8% received maternal ART during or before pregnancy and 35.5% received
maternal and infant ARV prophylaxis.
d THEMBISA 1.0.86
e Global Plan 2015 Progress.73
f HIV Household Survey 2012.83
g DHB 2013/14.87 2013/14 financial year. Numerator: NHLS PCR tests under 2 months of age. Denominator: Live births from Stats SA x antenatal HIV
prevalence from antenatal surveys to estimate HIV-exposed infants.
S A H R 20 1 6 27 1
h Maughan-Brown et al. 2015.88 Proportion of adults having ever received an HIV test.
i HEAIDS 2014.89 Defined in survey as ‘Have had HIV test’. MSM = men who have sex with men.
j DoH TB.
k DHIS.45 Data appear to be incomplete and under-reporting treatment coverage. WC use a different routine information system and data had not been
successfully imported into the national DHIS datamart at that time of extraction.
l DHIS.45 Due to problems with recording the denominator of live births to HIV positive women and also uncertainty about whether the numerator may also
include tests in older infants, this indicator substantially over-estimates coverage of early infant diagnosis for HIV.
m HIV Household Survey 2012.83 Self-reported circumcision.
n NCS 2012.90 Survey sampled men aged 16–55. Among the 5 471 890 men who said they were not circumcised: Almost a million said they definitely
intended to get circumcised in the next 12 months. Of those that say they will definitely get circumcised, 80.5% (803 690) intend to have a medical
circumcision.
o DHB 2013/14.87 2013/14 financial year.
p PMTCT Survey 2012-13.74
q DHIS.45 As at March. Based on DHIS data element ‘Adult remain on ART total’ or ‘Child remain on ART total’ derived from aggregated TIER.Net data.
r Murray et al. 2014.60 Calculated from estimated deaths due to HIV of 251 912 divided by 458 933 registered deaths (adjusted for estimated completeness
of registration of 94%).
s Stats SA Mid-year Estimates.20 2015 mid-year estimates.
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N
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272 S A H R 20 1 6
Health and Related Indicators
Reproductive health
Contraception, sexual behaviour, sexually transmitted infections and termination of pregnancy
Context Apart from the usual maternal indicators, the WHO 100 Core Health Indicators have also included two key
measures of reproductive health: “demand for family planning satisfied with modern methods” and “contraceptive
prevalence rate”.
New data sources No new data have been found, either nationally or internationally.
Key issues and trends The National Adolescent Sexual and Reproductive Health and Rights Framework 2014–2019 was published in
February 2015.
The National Adolescent Sexual and Reproductive Health and ➢➢ gender-based violence among adolescents;
Rights Framework 2014–2019 has been issued by the Department ➢➢ adolescent age at sexual debut;
of Social Development. The Framework proposed a number of
➢➢ uptake of condom usage and levels of consistent condom
indicators for monitoring and evaluation, including:
usage during sex; and
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➢➢ incidence of STIs, HIV and AIDS and other sexual and
➢➢ level of medical male circumcision in adolescents.
reproductive health (SRH) illnesses such as cervical and breast
cancer; However, the Framework does not define these indicators, nor
does it explain where the data would be sourced. As the tables
16 6
➢➢ incidence of under-18 years childbirths;
below show, much of the data in this regard is dated, or is not
➢➢ maternal mortality ratio among adolescents; disaggregated in the way desired by the Framework.
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➢➢ termination of pregnancy among adolescents;
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A N
Table 15: Contraception and sexual behaviour indicators by province
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EC FS GP KZN LP MP NC NW WC SA Ref
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Age of first sex under 15 years (% having first had sex at age 14 or younger)
2012 age 15-24 16.8 10.3 9.5 7.6 11.8 7.7 10.1 9.8 14.2 10.7 a
2014 MSM under 16 - - - - - - - - - 24.4 b
2014 Non-MSM under 16 - - - - - - - - - 15.9 b
O
2014 DHIS 39.4 43.7 38.7 57.8 49.2 39.8 44.9 42.7 60.0 46.8 d
N
HIV knowledge: correct knowledge about prevention and rejection of major misconceptions
O
2012 age 15+ 25.6 34.7 31.7 24.4 19.3 21.9 28.0 20.8 29.5 26.8 a
Male condom distribution coverage (condoms per male 15 years and older)
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2014 DHIS 33.6 34.1 25.8 58.9 38.2 34.3 20.3 28.1 55.3 38.4 d
Male condoms distributed (thousands)
2014 DHIS 68 783 32 872 131 322 196 002 66 161 48 371 8 271 37 170 123 436 712 387 d
Teenage pregnancy (%)
2012 NiDS female 15-19 14.5 7.4 12.0 14.1 10.5 15.2 16.2 10.1 6.7 12.4 e
2014 GHS age 15-19 9.0 8.5 6.5 7.0 9.6 9.1 10.3 10.1 8.1 8.0 f
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a HIV Household Survey 2012.83
b HEAIDS 2014.89 MSM = student men who have sex with men – those who report first having had sex at age younger than 13 or 16 years.
c HEAIDS 2014.89 Defined in survey as ‘Condom use by participants during last sex act’. MSM = men who have sex with men.
d DHIS.45 Financial year.
e NiDS Wave 3 v1.2.91 Based on answering ‘Yes’ to the survey question ‘Ever given birth?’
f Stats SA GHS 2014.21 Survey asked females whether they were pregnant during the 12 months before the survey (different to the usual definition of ever
having been pregnant while aged 15–19).
S A H R 20 1 6 273
Table 16: STI indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Percentage men with painful urination, genital symptoms
2014 MSM - - - - - - - - - 26.5 a
2014 Non-MSM - - - - - - - - - 33.3 a
STI treated new episode incidence (per 1 000)
2014 DHIS 45.0 24.8 18.5 61.7 24.0 23.8 20.1 16.8 19.5 31.0 b
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a HEAIDS 2014.89 Defined in survey as ‘Have you ever had burning or pain when you urinated?’ MSM = student men who have sex with men.
b DHIS.45 Financial year.
EC FS GP KZN LP MP NC NW WC SA Ref
ToP rate (%)
PM
2014 DHIS 8.7 10.8 7.8 3.6 5.5 2.3 6.4 9.8 16.8 7.4 a
ToPs (Terminations of Pregnancy)
2014 DHIS 14 096 6 144 18 465 9 590 8 387 2 405 1 756 8 294 19 989 89 126 b
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
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a DHIS.45 ToPs as % of all expected pregnancies in catchment population. Data extracted June 2012. Data for financial year from April of the year to March
of the following year (not calendar year).
b DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
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Health and Related Indicators
Maternal health
Context Although subsumed in Sustainable Development Goal (SDG) 3, maternal health remains a key priority for global
action and measurement. Target 3.1 is to reduce the global maternal mortality ratio to less than 70 per 100 000
live births by 2030.
New data sources Nationally, new data have been reported in the:
• Stats SA Census 2011: Estimation of Mortality in South Africa
• Rapid Mortality Surveillance Report 2014
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maternal mortality ratio may be a better indicator for monitoring trends and health systems improvements, although
it does not quantify outcomes for those delivering outside of the healthcare system.
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As indicated before, the continuing analysis of the Census 2011 data satisfied with modern methods) and the contraceptive prevalence
has provided an additional estimate of the maternal mortality ratio rate (defined as the percentage of women aged 15−49 years,
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for 2010.39 However, the figure provided (580 per 100 000 live married or in union, who are currently using, or whose sexual
births) is very different from those calculated from vital registration partner is using, at least one method of contraception, regardless
data and reported internationally, as shown in Table 18. Dorrington
Y T of the method used). Another indicator of relevance to maternal
and Bradshaw have drawn attention to the high levels of uncertainty health is the anaemia prevalence in women of reproductive age (the
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in estimates of South Africa’s maternal mortality ratio.92 They have percentage of women aged 15−49 years with a haemoglobin level
pointed out that successive estimates from the same sources (such as less than 120 g/L for non-pregnant women and lactating women,
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WHO and IHME) do not lie within the 95% uncertainty bounds of and less than 110 g/L for pregnant women, adjusted for altitude
previous estimates. Such variation calls into question the validity of and smoking). Based on data from only one regional hospital in
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these measures as indicators of progress over time. The 1990–2015 KwaZulu-Natal, the prevalence of anaemia among 2 000 antenatal
trends in maternal mortality recently published by WHO illustrates presenters over the period 2012 to 2014 was shown to be 42.7%
this again.93 Although methodological changes to “optimise use of overall, but 71.3% in HIV-positive women.96 In 68.9% of cases,
country-level data” have brought the results for South Africa closer the anaemia was mild, normocytic and normochromic. This is
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to national estimates in recent years, there are still substantial higher than the KZN provincial value for anaemia in all women of
differences in the trends. reproductive age reported by SANHANES-1 (Table 24).
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An updated Global Strategy for Women’s, Children’s and Adole- Another new indicator added to Table 18 is that on postnatal visits.
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scents’ Health 2016–2030 was issued by the United Nations The WHO 100 Core indicator definition for “postpartum care
in 2015.94 The updated Strategy has a focus on equity, which coverage” is the “percentage of mothers and babies who received
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demands sex-disaggregated data and gender-sensitive indicators. postpartum care within two days of childbirth (regardless of place
In this regard, the Strategy calls for specific action around health of delivery)”. The locally accessible data are on the percentage of
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information gathering and analysis: for example, that “by 2020, all mothers making a postnatal visit within six days of delivery.
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S A H R 20 1 6 27 5
Table 18: Maternal health indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
ANC coverage (%)
2013 DHIS 82.3 87.8 104.5 89.5 83.0 81.0 88.3 86.5 81.7 88.8 a
2014 DHIS 79.3 89.6 109.7 87.9 89.0 85.2 87.9 86.7 82.7 90.4 a
Caesarean section rate (%)
2013 DHIS 26.3 25.5 25.6 29.9 16.5 17.6 18.9 19.2 28.6 24.4 a
2013 NCCEMD 26.2 25.1 25.5 30.0 16.2 17.4 18.6 18.3 28.1 24.2 b
2013 Private sector - - - - - - - - - 67.5 c
2014 Private sector - - - - - - - - - 70.8 c
2014 DHIS 26.9 25.2 25.5 29.5 17.2 17.3 19.4 21.4 29.1 24.7 a
Delivery rate in facility (%)
2013 DHIS 75.2 81.6 93.7 77.2 86.8 75.7 84.4 72.2 84.7 82.0 a
2014 DHIS 77.2 88.2 96.8 82.4 91.0 80.5 88.1 74.8 87.9 85.9 a
Maternal mortality ratio (MMR)
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2010 Census - - - - - - - - - 580 d
2010 RMS 2014 - - - - - - - - - 267 e
2010 WHO (2015 estimates) - - - - - - - - - 154 f
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2011 RMS 2014 - - - - - - - - - 200 e
2012 RMS 2014 - - - - - - - - - 166 e
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2013 RMS 2014 - - - - - - - - - 155 e
2013 IHME (2014 estimates) - - - - - - - - - 174 g
2015 WHO (2015 estimates) - Y T -
Maternal mortality ratio in facility / institutional (iMMR)
- - - - - - - 138 f
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2010 DHIS 147.9 237.2 93.8 196.9 142.1 161.1 90.7 204.6 - 138.5 h
2010 NCCEMD 197.0 263.5 159.2 208.7 166.7 218.6 267.4 256.1 88.0 186.2 i
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2011 DHIS 114.9 199.1 123.3 192.2 184.6 135.0 147.7 189.7 28.6 144.9 h
2011 NCCEMD 179.4 246.8 136.4 197.6 196.4 199.7 193.6 173.0 62.6 169.2 j
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2012 DHIS 109.5 132.7 116.5 165.5 177.9 175.8 144.6 166.6 8.7 132.9 h
2012 NCCEMD 153.7 149.3 163.7 170.2 192.9 177.4 166.5 164.8 81.8 160.2 j
2013 DHIS 156.2 143.4 104.5 148.4 152.0 149.1 118.9 184.9 68.6 133.3 h
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2013 NCCEMD 172.7 185.1 115.0 146.5 201.2 150.3 158.3 168.5 83.9 147.7 j
2014 DHIS 148.3 217.8 112.6 124.9 165.2 115.4 254.1 167.1 54.4 132.5 h
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2011 48.5 82.0 72.0 57.3 65.2 51.9 42.7 76.4 - 56.4 a
2012 55.5 82.3 85.1 69.4 73.0 61.6 51.7 78.9 - 65.2 a
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2013 54.6 83.9 86.5 72.2 72.3 53.9 51.2 74.0 82.8 73.0 a
2014 58.0 80.8 85.5 66.4 72.4 59.7 56.5 74.7 100.5 74.3 k
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2010 DHIS 172 112 185 365 172 113 19 111 - 1 249 a
2010 NCCEMD 232 120 293 385 198 150 52 134 82 1 646 l
2010 WHO (2015 estimates) - - - - - - - - - 1 700 f
2011 DHIS 137 94 250 366 236 101 30 107 26 1 347 a
2011 NCCEMD 210 124 270 360 249 148 40 99 60 1 560 j
2012 DHIS 128 64 242 314 226 135 32 97 64 1 302 a
2012 NCCEMD 183 72 339 326 245 136 33 96 75 1 508 j
2013 DHIS 183 64 217 280 193 114 26 106 66 1 249 a
2013 IHME (2014 estimates) - - - - - - - - - 1 925 g
2013 NCCEMD 200 85 240 278 256 115 34 97 79 1 384 j
2014 DHIS 174 100 236 252 211 90 57 97 53 1 270 a
2015 WHO (2015 estimates) - - - - - - - - - 1 500 f
PM (proportion of deaths among women of reproductive age that are due to maternal causes)
2010 WHO (2015 estimates) - - - - - - - - - 1.5 f
2015 WHO (2015 estimates) - - - - - - - - - 1.7 f
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b Saving Mothers 2011–13b.11
c Medical Schemes 2014–15.22
d Census 2011 Mortality.39 The estimated MMR is very different from the 269 estimated using vital registration data for SA by Dorrington et al. 2014.
276 S A H R 20 1 6
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e RMS 2014.40 The MMR is calculated (according to the method proposed by HDACC) from adjusted vital statistics by proportional redistribution of the
ill-defined natural causes (ICD codes R00–R99) among the specified natural causes. Thereafter, the number is adjusted to allow for the fact that about 7%
of deaths are not registered. These estimates have been adjusted for an increase in under-registration of deaths which appear to have become significant
since 2011.
f Maternal Mortality 1990-2015.93
g Kassebaum et al. 2014.99
h DHIS.45 Institutional (facility) MMR based only on maternal deaths in facilities. Data for financial year from April of the year to March of the following year
(not calendar year). Data from WC for 2010 were not included in the national DHIS datamart at the time of extraction.
i Saving Mothers 2012.100
j Saving Mothers 2011–2013.101 Institutional MMR using live births from DHIS as denominator.
k DHIS.45 Rates over 100% are possible due to data quality problems or simply because there is a time lag between the collection of the numerator (post
natal visits) and the denominator (deliveries in facility).
l Saving Mothers 2008-10.102
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Child health
Context Child health, which was a key focus of the MDG era, will continue to be an important target for intervention as
part of the Sustainable Development Goals (SDGs)
New data sources Nationally, new data have been reported in the:
• South African Child Gauge 2015
• Stats SA Census 2011: Estimation of Mortality in South Africa
• Rapid Mortality Surveillance Report 2014
Internationally, reports and data sources of interest include:
• Lancet series on breastfeeding
• Lancet series on stillbirths
• UNICEF For every child, a fair chance
• The Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030
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• Global and National Burden of Diseases and Injuries among children and adolescents (GBD 2013)
Key issues and trends Globally, increased attention is being paid to the prevention of stillbirths. There is also global attention being
given to the question of immunisation coverage, not only because of outbreaks of diseases such as measles in
affluent communities, but also because of public demands for access to new vaccines (such as that for meningitis
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B). Locally, there are concerns that complacency caused by consistently high coverage figures at an aggregated
level may be obscuring low levels of vaccine uptake in some areas (not only in underserved communities but also
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in those served by the private sector).
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Globally, there have been calls for increased attention to be paid
to the issue of stillbirths.103 The WHO 100 Core Indicator definition
The WHO 100 Core Health Indicators includes a measure of
excusive breastfeeding (percentage of infants 0–5 months of age
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is the “number of stillbirths per 1 000 births (live and stillbirths)”, (<6 months) who are fed exclusively with breast milk). It has been
with the explanatory note that “for purposes of international estimated that scaling up breastfeeding to near universal levels could
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comparison, stillbirths are defined as third trimester foetal deaths prevent 823 000 deaths in children under 5 annually at a global
(≥1000 g or ≥28 weeks)”. Stillbirths were not mentioned in the level, as well as 20 000 deaths from breast cancer.108 Although
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Millennium Development Goals, nor were they counted in the measured in younger infants, aged 4–8 weeks, the PMTCT survey
Global Burden of Disease studies. A Lancet Series on the issue found an increase in breastfeeding from 2010, with 57.5% overall
called for the development of indicators to measure the effect of being exclusively breastfed in 2013.74
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interventions, programmatic progress and quality of care.104 In Estimates from the Census 2011 have been added to the infant and
addition to measures of stillbirth itself, progress can also be tracked under-5 mortality figures in Table 21. The national estimates for
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via indicators of contraceptive coverage and access to antenatal 2010 based on the Census are not that different from the modelled
and peri-partum care.105 Globally, it is feared that less than 5% Stats SA mid-year estimates, but are 10% (U5MR) and 25% (IMR)
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of neonatal deaths and even fewer stillbirths are captured in vital higher than estimates based on the Rapid Mortality Surveillance
registration records.106
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child, a fair chance” agenda,107 is also the main underpinning 2014 figures are shown in Table 23. In 2015, Africa as a continent
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principle behind the annual South African Child Gauge.28 The 2015 celebrated one year without a wild-type polio case.109
edition reports on the development of a Youth Multidimensional
Poverty Index (MPI), which specifically targets those aged 15–24
years. Based on the Census 2011, it was shown that 33% of young
South Africans were multi-dimensionally poor at that time. Over half
of the South African population is under the age of 25 years, so the
overall burden of disease often falls heavily on this age group.
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Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Child under 5 years diarrhoea with dehydration incidence (per 1 000)
2013 DHIS 16.1 24.4 8.1 15.0 14.2 13.0 18.5 14.3 15.6 14.1 a
2014 DHIS 11.6 19.1 6.8 11.7 13.1 11.7 10.1 8.9 14.8 11.3 a
Child under 5 years pneumonia incidence (per 1 000)
2013 DHIS 42.3 84.4 37.3 92.2 34.2 18.5 67.6 25.7 66.5 53.2 a
2014 DHIS 32.7 81.4 31.7 86.1 27.7 13.5 42.5 18.7 89.4 49.3 a
Child under 5 years severe acute malnutrition incidence (per 1 000)
2013 DHIS 5.4 9.1 2.4 5.6 4.2 2.6 4.2 8.1 2.0 4.5 a
2014 DHIS 5.1 8.7 1.9 6.3 4.9 2.9 4.5 6.7 2.4 4.5 a
Children living far from their usual health facility (%)
2013 GHS 36.6 21.8 9.4 32.9 23.5 23.1 18.5 29.4 8.0 23.4 b
2014 GHS 36.3 20.1 7.9 27.3 23.7 22.4 20.2 25.5 8.4 21.5 b
Exclusive breastfeeding rate (%)
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2010 HIV-exposed 4-8 weeks - - - - - - - - - 20.4 c
2010 HIV-unexposed 4-8 weeks - - - - - - - - - 31.3 c
2011 HIV-exposed 4-8 weeks - - - - - - - - - 35.5 c
2011 HIV-unexposed 4-8 weeks - - - - - - - - - 43.6 c
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2013 HIV-exposed 4-8 weeks - - - - - - - - - 54.1 c
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2013 HIV-unexposed 4-8 weeks - - - - - - - - - 59.2 c
2013 all 4-8 weeks old - - - - - - - - - 57.5 c
Number of orphans
2014 GHS double
2014 GHS maternal
121 604
97 102
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54 496
28 458
77 435
88 314
197 273
157 631
55 253
56 521
69 928
46 364
14 665
12 792
49 702
41 041
13 348
30 459
653 704
558 681
d
d
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2014 GHS paternal 313 938 102 633 254 479 491 085 205 561 182 531 39 182 138 842 92 036 1 820 287 d
2015 ASSA2008 maternal/double 249 084 112 728 350 770 495 337 152 965 167 040 24 124 136 669 101 947 1 779 248 e
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Orphanhood (%)
2014 GHS double 4.6 6.0 2.2 4.8 2.5 4.6 3.6 3.9 0.7 3.5 d
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2014 GHS maternal 3.7 3.1 2.5 3.9 2.6 3.0 3.1 3.2 1.6 3.0 d
2014 GHS paternal 11.9 11.3 7.2 12.1 9.4 12.0 9.6 11.0 4.9 9.9 d
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
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a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b SA Child Gauge 2014.110 Based on GHS; Stats SA. Children are defined as people aged 0–17 years.
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e ASSA2008.82
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2014.21 Among children under 18 years of age.
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Table 21: Child mortality and related indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Child mortality (deaths between 1–4 years per 1 000 live births)
2013 GBD 2013 - - - - - - - - - 8.2 a
Infant mortality rate (deaths under 1 year per 1 000 live births)
2010 Census 40.3 53.2 23.8 46.8 27.6 39.0 37.0 46.8 20.4 35.0 b
2011 RMS 2014 - - - - - - - - - 28.0 c
2012 RMS 2014 - - - - - - - - - 27.0 c
2013 RMS 2014 - - - - - - - - - 29.0 c
2013 mid-year - - - - - - - - - 36.4 d
2014 RMS 2014 - - - - - - - - - 28.0 c
2014 mid-year - - - - - - - - - 35.3 d
2015 mid-year - - - - - - - - - 34.4 d
2015 ASSA2008 42.8 37.8 22.9 40.3 25.8 34.3 22.9 28.0 16.5 31.3 e
2015 Inter-agency group (2015) - - - - - - - - - 34.0 f
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Live birth under 2500g in facility rate (%)
2013 DHIS 13.4 13.5 15.1 12.5 10.5 11.6 18.0 14.1 15.1 13.4 g
2014 DHIS 13.5 13.1 12.8 11.7 10.4 11.4 18.5 14.0 14.7 12.6 g
Neonatal death rate (NNDR) (deaths <28 days old per 1 000 live births)
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2011 RMS 2014 - - - - - - - - - 13.0 c
2012 RMS 2014 - - - - - - - - - 11.0 c
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2013 DHIS 16.6 15.2 12.2 11.8 13.6 10.0 15.1 11.6 5.7 12.2 g
2013 GBD 2013 - - - - - - - - - 14.6 h
2013 PPIP all levels
2013 RMS 2014
-
-
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-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
10.6
11.0
i
c
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2014 RMS 2014 - - - - - - - - - 11.0 c
2014 DHIS 18.2 12.4 12.9 13.2 13.0 9.3 16.9 13.9 6.2 12.8 j
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2014 DHIS 26.9 33.1 29.4 27.0 31.5 24.5 37.1 26.2 20.9 27.7 g
Post-neonatal mortality rate (deaths 28–365 days age per 1 000 live births)
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28 0 S A H R 20 1 6
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Wang et al. 2014.111
b Census 2011 Mortality.39
c RMS 2014.40
d Stats SA Mid-year estimates 2015. 2015 mid-year estimates.20
e ASSA2008.82
f Child Mortality 2015 IGME.112 Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME) in 2015.
g DHIS.45 Financial year.
h Wang et al. 2014.111 Total of early neonatal (0–6 days: 11.4) and late neonatal (7–28 days: 3.2).
i NaPeMMCo 2010–13.113 Data for 2012–2013.
j DHIS.45 Inpatient neonatal death rate using live births in facility for denominator. 2014/15 financial year.
k Child Mortality 2014 IGME.114 Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME) in 2014.
l Stats SA Causes of death 2013.59 Data have been updated with late registrations processed in 2014. Not adjusted for under-reporting – completeness of
death registration for children uncertain.
m Perinatal deaths 2011–13.115 Not adjusted for under-registration of deaths. Number of births given is substantially incomplete for 2013 (approximately
140 000 late registrations in 2014).
n Perinatal deaths 2011–13.115 Not adjusted for under-registration of deaths. Updated denominator of total births given in publication using Stats SA live births
published in September 2015.
o Global Burden of Disease 2013.42 Both genders.
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Table 22: Child mortality indicators by population group
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Infant mortality rate (deaths under 1 year per 1 000 live births)
2010 Census 38.5 20.3 10.1 8.3 35.0 a
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Census 2011 Mortality.39 Y T
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Table 23: Immunisation indicators by province
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EC FS GP KZN LP MP NC NW WC SA Ref
BCG coverage (%)
2014 DHIS 88.5 100.8 119.0 81.9 95.2 84.9 95.2 79.6 97.0 94.5 a
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2014 DHIS 80.9 90.1 107.7 89.9 82.2 80.1 85.4 82.1 90.9 89.8 a
Measles 1st dose coverage (%)
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2014 DHIS 88.3 93.5 110.2 91.8 92.3 84.2 86.5 86.0 94.1 94.1 a
2014 UNICEF/WHO - - - - - - - - - 70.0 b
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2014 DHIS 85.2 91.7 107.8 91.7 91.3 83.0 87.6 84.2 93.6 92.8 a
2014 UNICEF/WHO - - - - - - - - - 65.0 b
RV 2nd dose coverage (%)
2014 DHIS 83.3 98.6 109.7 93.6 94.2 90.4 91.5 88.2 95.2 95.2 a
2014 UNICEF/WHO - - - - - - - - - 64.0 b
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b Immunization 2015.116 Estimates derived by review of available data (including routine service delivery data and surveys), informed and constrained by a
set of heuristics.
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Nutrition
Context Nutrition represents an opportunity for intersectoral action, but also shows how a ‘health indicator’ may represent
the net effects of many non-health issues, such as poverty (SDG1), climate action (SDG13) and life on land
(SDG14) and below the water (SDG13). SDG2 sets the specific goal to “end hunger, achieve food security and
improved nutrition and promote sustainable agriculture”.
New data sources Nationally, new data have been reported in the:
• NDoH Strategy for the Prevention and Control of Obesity in South Africa 2015–2020
• Who is getting fat in South Africa: Obesity trends and risk factors in the South African adult population
(analysis of National Income Dynamics Study data)
• Obesity trends and risk factors paper (analysis of National Income Dynamics Study data)
• SALDRU working paper on Multidimensional food insecurity measurement 2015
Internationally, reports of interest include:
• The State of Food Insecurity in the World 2015 (FAO)
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• Global Hunger Index 2015 (IFPRI)
• Global Food Security Index 2015 (The Economist Intelligence Unit)
• 2015 Global Nutrition Report (IFPRI)
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• Report of the Commission on Ending Childhood Obesity
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• Global Burden of Disease Study 2013 – comparative risk assessment
Key issues and trends Although malnutrition, including obesity, is well recognised as a public health problem in South Africa, effective
intervention has been difficult. One of the more recent proposals has been for the introduction of a tax on sugar-
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sweetened beverages.
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Measuring achievement of food security, as included in SDG2, is The Global Nutrition Report 2015 provides baseline data on a range
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a complex exercise. Data from South Africa have been used to of nutritional indicators, as well as identifying the ‘levers’ that are at
derive a Multidimensional Food Insecurity Index (MFII), based on the hand if countries wish to address malnutrition in all its forms.128 The
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methodology of the Multidimensional Poverty Index (MPI).117 Based Report also draws attention to the World Health Assembly Global
on this measure, which takes into account dietary diversity and Targets 2025 to improve maternal, infant and young child nutrition,
subjective food consumption adequacy, close to half of the South which are:
African population can be considered to be “multidimensionally food
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and Gauteng. Globally, reports on food insecurity have also been ➢➢ a 50% reduction of anaemia in women of reproductive age;
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issued by the United Nations Food and Agriculture Organization118 ➢➢ a 30% reduction in low birth weight;
and the Economist Intelligence Unit.119,120 The former rates South
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least food-secure nations narrowing. South Africa is ranked 42nd, months up to at least 50%; and
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with a Global Food Security Index of 64.5 (the highest being 89.0
➢➢ to reduce and maintain childhood wasting to less than 5%.
and the lowest 25.1).
The Global Hunger Index (based on the proportion of undernourished
The National Budget 2016 floated the idea of introducing a ‘sin’
in the population, the prevalence of wasting in children under 5
tax on sugar-sweetened beverages.121,122 Globally, this has been
years, the prevalence of stunting in children under 5 years, and
identified as a suitable target for intervention.123 This fiscal measure
the under-5 mortality rate) for South Africa in 2015 was 12.4 (a
is also mentioned in the Strategy for the Prevention and Control of
moderate value, and down by 8.6 points since 2005).129
Obesity in South Africa 2015–2020, published in 2015.124 The
targets set in the strategy are no increase in the prevalence of obesity In 2016, the World Health Organization issued a report from the
in 2016, a 3% decrease in all age groups by 2017, and a 10% Commission on Ending Childhood Obesity.130 The Commission’s
decrease in all age groups by 2020. The scale of the challenge is recommendations focus on promoting the intake of healthy foods
underlined by the data from the National Income Dynamics Study and reducing the intake of unhealthy foods and sugar-sweetened
(NiDS) Waves 1–3, which showed increasing body mass index and beverages by children and adolescents. The Commission endorsed
obesity in South Africa, particularly among women.125,126 Data the monitoring indicators included in the Global Monitoring
from the Global Burden of Disease Study 2013 have been used to Framework for Non-communicable Diseases and the Global
show that behavioural, environmental, occupational and metabolic Monitoring Framework for Maternal, Infant and Young Child
risks can explain half of global mortality and more than one-third Nutrition (as shown above). In addition, the Commission called on
of global DALYs.127 In particular, this analysis showed that the governments to “ensure data collection on BMI-for-age of children
attributable burden of high body mass index (BMI) has increased in – including for ages not currently monitored – and set national
the past 23 years, globally. targets for childhood obesity”. Secondary data analysis from the
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in South Africa has called for the creation of a national nutrition
monitoring system, in order to identify specific dietary deficiencies
in different population groups.134 Such deficiencies will most likely
affect communities in poorer urban and rural areas, where access to
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affordable, healthy foods is a challenge.
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Table 24: Nutrition indicators by province
EC Y T FS GP KZN LP MP NC NW WC SA Ref
Anaemia prevalence in children (%)
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2012 under 5 years - - - - - - - - - 10.7 a
Anaemia prevalence in women of reproductive age (%)
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2012 16-35 years 19.9 17.6 18.6 35.9 - 29.5 - 16.9 16.1 23.1 b
Iron deficiency anaemia prevalence (%)
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2011 NYRBS 12.4 7.1 6.1 6.5 4.0 3.4 4.3 3.8 11.3 6.9 c
2012 NiDS female <15 14.6 14.3 14.8 11.6 9.9 12.7 7.4 16.2 21.6 13.9 d
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2012 NiDS male <15 14.8 7.3 13.9 16.7 9.8 15.1 4.8 8.2 16.1 13.6 d
2012 NiDS <15 years 14.7 11.0 14.4 14.2 9.9 14.0 6.2 12.4 18.8 13.7 d
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2012 boys 2-14 years 3.7 4.1 5.3 6.1 3.3 6.1 3.9 2.7 4.1 4.7 a
2012 female 15+ 41.8 43.0 39.9 44.0 32.6 35.8 38.6 31.7 37.9 39.2 a
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2012 girls 2-14 years 6.7 4.7 10.0 8.5 4.3 5.5 3.5 4.3 7.2 7.1 a
2012 male 15+ 7.2 5.8 12.9 7.9 11.5 13.0 7.2 7.3 16.1 10.6 a
2013 boys <20 years - - - - - - - - - 7.0 f
2013 female 20+ - - - - - - - - - 42.0 f
2013 girls <20 years - - - - - - - - - 9.6 f
2013 male 20+ - - - - - - - - - 13.5 f
Overweight (%)
2011 NYRBS 31.1 20.9 22.6 26.8 14.0 17.8 13.0 15.5 31.5 23.1 g
2012 NiDS female <15 19.9 22.4 20.5 22.9 18.6 23.5 14.0 15.4 14.2 19.9 d
2012 NiDS male <15 21.0 18.7 17.0 20.3 16.2 13.2 11.0 14.4 14.3 17.3 d
2012 NiDS <15 years 20.5 20.6 18.8 21.6 17.5 17.7 12.6 14.9 14.3 18.6 d
2012 NiDS female 15+ - - - - - - - - - 27.6 e
2012 NiDS male 15+ - - - - - - - - - 25.2 e
2012 NiDS total 15+ - - - - - - - - - 26.5 e
2012 boys 2-14 years 12.4 10.8 11.0 15.1 4.8 10.6 2.9 6.4 18.2 11.5 a
2012 female 15+ 21.7 20.7 28.1 25.2 24.0 26.2 23.4 22.3 24.5 24.8 a
2012 girls 2-14 years 12.4 17.7 20.3 20.3 9.1 14.1 8.3 15.2 19.1 16.5 a
2012 male 15+ 17.1 19.5 21.0 23.7 16.3 17.4 17.8 9.0 26.9 20.1 a
2013 boys <20 years - - - - - - - - - 11.8 h
2013 female 20+ - - - - - - - - - 27.3 h
S A H R 20 1 6 28 3
EC FS GP KZN LP MP NC NW WC SA Ref
2013 girls <20 years - - - - - - - - - 16.7 h
2013 male 20+ - - - - - - - - - 25.3 h
Stunting (%)
2011 NYRBS 19.6 14.4 7.1 12.7 10.9 12.6 19.4 12.1 14.8 12.9 i
2012 NiDS <15 years 21.8 19.6 19.8 21.6 26.4 23.4 22.0 21.3 14.3 21.2 d
2012 NiDS female <15 21.2 16.5 17.7 20.5 27.4 18.6 17.9 23.7 14.1 20.1 d
2012 NiDS male <15 22.3 23.0 22.0 22.8 25.3 27.1 26.5 18.9 14.5 22.3 d
2012 female <15 years 15.6 22.1 10.0 14.4 9.4 13.0 15.0 17.8 13.9 13.7 a
2012 male <15 years 21.6 19.4 11.9 13.5 13.7 23.1 22.8 23.7 17.5 16.7 a
Underweight (%)
2011 NYRBS 5.8 9.1 6.0 6.2 7.1 7.6 17.2 12.6 5.0 7.0 i
2012 NiDS female <15 7.0 9.6 6.5 5.6 8.4 7.9 11.0 15.3 4.6 7.4 d
2012 NiDS male <15 8.2 6.0 8.8 7.4 12.0 10.5 18.7 16.9 8.0 9.5 d
2012 NiDS <15 years 7.6 7.9 7.7 6.5 10.1 9.5 14.6 16.1 6.3 8.5 d
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2012 NiDS female 15+ 1.4 3.6 1.4 1.5 2.1 2.0 4.3 2.6 3.3 2.0 e
2012 NiDS male 15+ 4.1 8.8 3.8 3.2 6.4 4.0 10.2 7.2 6.8 5.0 e
2012 NiDS total 15+ 2.6 6.1 2.6 2.2 3.9 2.9 7.1 4.8 4.8 3.4 e
2012 female 15+ 5.2 3.5 1.7 5.3 4.0 5.2 8.4 7.8 3.5 4.2 a
16 6
2012 female <15 years 5.6 6.9 1.2 1.5 2.4 3.7 10.8 7.9 4.6 3.6 a
2012 male 15+ 13.5 13.9 9.0 13.8 20.7 8.7 15.1 23.6 8.1 12.8 a
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2012 male <15 years 1.9 2.2 8.7 3.4 9.1 10.4 23.8 15.2 7.2 7.4 a
Vitamin A coverage children 12-59 months (%)
2012 DHIS 40.1 Y T 59.3 45.6 41.4 35.8 34.8 34.7 32.2 37.8 40.5 j
2013 DHIS 44.7 54.8 49.9 47.8 33.8 36.0 38.7 39.3 44.4 44.3 j
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2014 DHIS 53.0 58.7 56.6 54.5 44.4 50.0 45.3 52.2 47.4 52.2 j
Vitamin A deficiency (%)
M U
2012 female 15+ 46.1 43.1 43.3 50.0 44.7 49.6 46.7 50.9 51.5 47.1 l
2012 male 15+ 3.9 6.3 6.7 9.0 5.2 5.3 2.7 10.1 8.2 6.8 l
Wasting (%)
2011 NYRBS 1.6 4.6 3.6 2.2 4.9 5.3 10.8 6.0 1.3 3.5 i
O
2012 NiDS female <15 3.7 4.1 6.6 4.3 4.2 9.1 6.9 5.9 4.9 5.3 d
2012 NiDS male <15 4.2 2.3 7.5 5.6 2.3 7.3 11.5 5.0 5.3 5.5 d
G
2012 NiDS <15 years 4.0 3.2 7.1 4.9 3.3 8.1 9.1 5.5 5.1 5.4 d
2012 female <15 years 3.2 1.4 0.4 - 2.8 1.8 5.1 5.2 1.3 1.7 a
R
2012 male <15 years 1.6 1.7 3.6 2.4 6.5 2.8 18.5 8.5 2.0 3.8 a
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a SANHANES-1.47
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28 4 S A H R 20 1 6
Health and Related Indicators
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2012 NiDS <15 years 19.5 12.2 5.9 17.3 - 18.6 c
2012 NiDS female 15+ 27.7 22.7 28.8 31.2 - 27.6 d
2012 NiDS male 15+ 23.4 21.2 36.6 42.3 - 25.2 d
2012 boys 2-14 years 11.9 8.0 - - - 11.5 e
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2012 female 15+ 24.9 24.4 22.8 - - 24.8 e
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2012 girls 2-14 years 16.2 14.6 - - - 16.5 e
2012 male 15+ 19.1 22.1 32.2 - - 20.1 e
Stunting (%)
2011 NYRBS
2012 NiDS <15 years
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13.4
22.6
13.9
17.8
8.8
13.5
3.3
4.8
19.7
-
12.9
21.2
g
c
A N
2012 female <15 years 13.6 16.1 - - - 13.7 e
2012 male <15 years 16.7 18.6 - - - 16.7 e
M U
Underweight (%)
2011 NYRBS 7.0 9.7 11.0 2.0 5.6 7.0 g
4 ED
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Wentzel-Viljoen et al. 2013.133 Citing Charlton et al. study, Cape Town circa 2005. Data only reported for African and White groups. Not age-standardised.
b NYRBS 2011.135 Obese according to the age-dependent BMI cut-offs suggested by Cole (30kg/m2 by age 18)
c NiDS Wave 3 v1.2.91
d NCD Trends 2015.136
e SANHANES-1.47
f NYRBS 2011.135 Overweight according to the age-dependent BMI cut-offs suggested by Cole (25 kg/m2 by age 18)
g NYRBS 2011.135
h SANHANES-1.47 Of participants 15 years and older.
S A H R 20 1 6 285
Non-communicable diseases
Context Tracking non-communicable disease (NCD) prevalence and associated mortality poses significant challenges for
the health information system. The Sustainable Development Goals (SDGs) have paid more attention to NCDs
than did the Millennium Development Goals (MDGs), but the range of conditions to be tracked is also far wider.
New data sources Nationally, new data have been reported in the:
• National Cancer Registry summary statistics on histologically diagnosed cancer up to 2010
• Stats SA Causes of Death 2014 report (unit records not available at time of writing)
• South African NCD Alliance Civil Society Status Report 2010–2015
Internationally, reports of interest include:
• IDF Diabetes Atlas 2015
• PRB Non-communicable diseases in Africa Policy Brief
• Global Burden of Disease study 2013 global estimates of cardiovascular and ischaemic heart disease
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Key issues and trends Measures of non-communicable disease incidence, prevalence and associated mortality are difficult to extract
from routine service data. Over time, more data will be available from the National Income Dynamics Study
(NiDS) and the South African National Health and Nutrition Examination Surveys (SANHANES). There will
always be a differences between self-reported cases and clinically-confirmed cases, but longitudinal studies
16 6
can also provide insights into treatment gaps and the adequacy of treatment, at least for conditions such as
hypertension. Assessing the adequacy of care for other conditions is far more challenging.
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The WHO 100 Core Health Indicators include a number of measures exploration of the correlation between hypertension and various
of NCD incidence, prevalence and associated mortality, including: risk factors. Across the three waves of NiDS, for instance, mean
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➢➢ age-standardised prevalence of raised blood pressure among
systolic and diastolic blood pressures increased as BMI increased.
Self-reported treatment coverage in those self-reporting hypertension
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persons aged 18+ years;
did not vary between the three waves of NiDS (73.4%, 77.5%,
➢➢ age-standardised prevalence of raised blood glucose/
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➢➢ mortality between ages 30 and 70 years from cardiovascular with measured elevated blood pressure (35.9%, 34.1%, 38.4%)
diseases, cancer, diabetes or chronic respiratory diseases; and were on treatment. In addition, of those on treatment, at least half
(50.0%, 54.0%, 53.8%) were uncontrolled (i.e. had an elevated
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Each of these indicators poses significant challenges for routine data were reported in the 2008, 2010 and 2012 waves of NiDS. The
collection. However, cross-sectional surveys and longitudinal studies
R
reported hypertension and actual hypertension can be gleaned from the adequacy of treatment are not as easily performed. Cancer,
the three waves of the National Income Dynamics Study (NiDS) and in particular, represents a daunting list of very different conditions,
O
from the South African National Health and Nutrition Examination for which treatment is not continuous. Yet another challenge facing
Surveys (SANHANES). Self-reported data on hypertension can also
EM
the SDG targets for NCDs is the extent to which they address
be extracted from the annual General Household Surveys (GHS). The issues of equity. It has been suggested, for instance, that target 3.4
prevalence of self-reported hypertension in females aged 15 years be reworded by adding the text in italics: “by 2030, reduce by
and older varied from 14% in GHS 2012, to 21% in both NiDS one-third premature mortality from NCDs through prevention and
2012 and SANHANES 2012. The corresponding figures for men treatment and promote mental health and well-being, with particular
were 7% (GHS 2012), 11% (NiDS 2012) and 12% (SANHANES emphasis on improving the status of the worst off”.138 This would
2012).136 However, when actually measured by fieldworkers, require disaggregation of survey data by some measure of socio-
differences in the prevalence of hypertension by sex are negligible. economic status. In South Africa, consideration would also need
Prevalence of elevated blood pressure in females was 26.0% in to be given to the particular needs of those on long-term treatment
NiDS 2012 and 26.9% in SANHANES 2012. The corresponding for HIV, as some of the antiretroviral medicines used have negative
figures for men were 27.0% and 26.4%. Hypertension prevalence implications for cardiometabolic disease.139
by district is shown in the appendix (Map 2). Over the three waves
The value of spot measurements of blood pressure should not,
of NiDS, between 2008 and 2012, prevalence of elevated blood
however, be accepted without caution. A study in 101 employees
pressure increased slightly in white females and African males, and
of a large North West firm (50% male) showed that clinic blood
decreased slightly in coloured males. Prevalence remained almost
pressure measurements revealed 18% as hypertensive, but 24-hour
unchanged in African females, coloured females and white males.
measurements revealed 63% to be hypertensive.140
The prevalence of elevated blood pressure in those self-reporting
no hypertension was higher in males, and increased steadily The second wave of the Study on global AGEing and adult health
with age for both sexes. NiDS and SANHANES also allow for (SAGE) was due to be completed in China, Ghana, India, Mexico,
28 6 S A H R 20 1 6
Health and Related Indicators
and South Africa by the end of 2015, with the Russian Federation necessary insights that will allow for programme design, adaptation
to follow. Data are expected to be available in the public domain and management.
starting in the first half of 2016.e
Much of the battle against NCDs will rely on changing behaviours,
Data from the Global Burden of Disease Study 2013 have been which in turn will rely on being able to provide high-quality
used to trace global and regional trends in cardiovascular mortality information to the public. It has been shown, for example, that
between 1990 and 2013,141 as well as to estimate the contribution combining the provision of information with human papilloma
of cardiovascular disease to premature mortality by 2025.142 The vaccination at school can help to improve knowledge about cervical
data suggest that there are higher rates of cardiovascular disease cancer symptoms, screening and the role of vaccination among
in eastern and central Africa compared with West and Southern mothers of adolescent girls.147 However, the scale of the effort
Africa, but there is considerable uncertainty around the estimates. dedicated to public knowledge of HIV will need to be replicated
Premature mortality due to cardiovascular disease has fallen in in respect of the wider range of NCDs, including mental health. In
South Africa, but not sufficiently to meet the 25% reduction that Africa, with its youthful population, adolescents and young adults
was targeted. For Southern Africa as a region, a modest 4 to 8% need to be prioritised in this regard.148
reduction is expected between 2013 and 2025 if current risk factors
In 2015 the Rural Mental Health Campaign Report drew attention
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are not addressed. Hypertension is regarded as the most important
risk factor for such premature mortality in this region. Specifically to the parlous state of mental health services in rural areas of South
with reference to ischaemic heart disease, age-standardised death Africa.149 The report called for provinces to take deliberate steps to
rates in sub-Saharan Africa have seen one of the highest relative implement the National Mental Health Policy Framework, including
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increases between 1990 and 2013.143 setting targets, indicators, budgets and timelines. As can be seen
in Table 26, data on the prevalence and treatment of mental health
Globally, the International Diabetes Federation has published a
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conditions are generally lacking. The underlying source of the data
seventh edition of its Atlas, which estimates that 193 million people
on suicide in South Africa, which was obtained from the Global
with diabetes are undiagnosed, that 1 in 15 adults has impaired
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glucose tolerance, and that 1 in 7 births is affected by gestational
diabetes.144 The total number of people living with diabetes was Although more data on the incidence of cancer cases diagnosed
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estimated to be between 7.2% and 11.4% of the global population, histologically are now available from the National Health Laboratory
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or between 339 and 536 million people. The highest number of Service, the most recent data presented in Table 28 are from 2010.
undiagnosed patients with diabetes was expected to be in Africa,
where between 9.5 million and 29.3 million people were estimated
4 ED
e http://www.who.int/healthinfo/sage/cohorts/en/index3.html
f http://philanthropy.medtronic.com/who-we-are/about-us/index.htm
S A H R 20 1 6 287
Table 26: Chronic disease indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Cervical cancer screening coverage (%)
2014 DHIS 56.3 40.9 43.6 70.3 47.9 63.3 30.0 65.8 56.8 54.5 a
Diabetes prevalence (%)
2012 age 15+ 8.5 10.1 7.9 10.0 4.6 5.6 21.7 12.5 11.2 9.5 b
2013 age 20-79 - - - - - - - - - 8.3 c
2013 age 20-79 (age-standardised) - - - - - - - - - 9.3 c
2014 age 20-79 - - - - - - - - - 8.4 d
2014 age 20-79 (age-standardised) - - - - - - - - - 9.4 d
2015 age 20-79 - - - - - - - - - 7.0 e
2015 age 20-79 (age-standardised) - - - - - - - - - 7.6 e
Diabetes prevalence (per 1 000)
2013 all beneficiaries - - - - - - - - - 26.9 f
Hyperlipidaemia prevalence (per 1 000)
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2013 all beneficiaries - - - - - - - - - 35 f
Hypertension prevalence (%)
2012 NiDS female 15+ - - - - - - - - - 33.5 g
2012 NiDS female 15-24 - - - - - - - - - 7.9 g
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2012 NiDS female 25-34 - - - - - - - - - 18.9 g
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2012 NiDS female 35-44 - - - - - - - - - 33.2 g
2012 NiDS female 45-54 - - - - - - - - - 52.4 g
2012 NiDS female 55-64 - - - - - - - - - 66.6 g
2012 NiDS female 65+
2012 NiDS male 15+
-
-
Y T -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
78.7
29.8
g
g
A N
2012 NiDS male 15-24 - - - - - - - - - 11.8 g
2012 NiDS male 25-34 - - - - - - - - - 21.1 g
M U
Mortality between 30-70 years from cardiovascular, cancer, diabetes or chronic respiratory disease
2012 - - - - - - - - - 26.8 h
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2012 male serum chol >5 mmol/L 20.8 20.3 14.7 18.7 10.9 14.6 15.4 17.5 34.8 18.9 b
Prevalence of mental disorders
2012 current (depression) total 15.2 - - - - - - - - - i
2012 lifetime (depression) total 31.4 - - - - - - - - - i
Prevalence of raised blood pressure (%)
2012 NiDS female 15+ - - - - - - - - - 26.1 j
2012 NiDS female 15-24 - - - - - - - - - 7.6 j
2012 NiDS female 25-34 - - - - - - - - - 18.1 j
2012 NiDS female 35-44 - - - - - - - - - 26.5 j
2012 NiDS female 45-54 - - - - - - - - - 40.7 j
2012 NiDS female 55-64 - - - - - - - - - 46.1 j
2012 NiDS female 65+ - - - - - - - - - 55.3 j
2012 NiDS male 15+ - - - - - - - - - 26.5 j
2012 NiDS male 15-24 - - - - - - - - - 11.8 j
2012 NiDS male 25-34 - - - - - - - - - 20.6 j
2012 NiDS male 35-44 - - - - - - - - - 31.5 j
2012 NiDS male 45-54 - - - - - - - - - 39.0 j
2012 NiDS male 55-64 - - - - - - - - - 42.9 j
2012 NiDS male 65+ - - - - - - - - - 58.0 j
2012 NiDS total 15+ - - - - - - - - - 26.3 j
28 8 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
2012 raised SYS and DIA 10.4 17.3 11.4 8.4 6.6 9.1 10.8 13.0 9.4 10.2 k
2012 raised SYS or DIA or both 27.1 30.5 27.3 26.4 20.7 20.9 23.5 29.9 30.7 26.6 l
Suicide rate (per 100 000 population)
2012 age-standardised - - - - - - - - - 3.0 m
2012 age-standardised female - - - - - - - - - 1.1 m
2012 age-standardised male - - - - - - - - - 5.5 m
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b SANHANES-1.47
c Diabetes Atlas 2013.150 Modelled estimates based on best published studies. Estimated number of cases of diabetes = 2 646 050 of which 1 217 180
estimated to be undiagnosed.
d Diabetes Atlas 2014.151 Modelled estimates based on best published studies. Estimated number of cases of diabetes = 2 713 380 of which 1 248 160
estimated to be undiagnosed.
e Diabetes Atlas 2015.144 Estimated number of cases of diabetes = 2 286 000 of which 1 396 800 estimated to be undiagnosed.
f Medical Schemes 2014–15.22 Diagnosed and treated.
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g NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of hypertension was defined as those with BP equal or above
140/90 mmHg and/or taking anti-hypertensive medication.
h Global NCD 2014.152
i Andersson et al. 2013.153 Cross-sectional population-based survey of persons aged 18–40 living in the EC.
j NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of raised BP was defined as those with BP equal or above
16 6
140/90 mmHg regardless of medication usage.
k SANHANES-1.47 Restrictive definition of both parameters raised. Of participants 15 years and older.
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l SANHANES-1.47 Calculated from (raised SYS) + (raised DIA) – (both SYS and DIA raised). Age 15+.
m Global Health Observatory.154 Downloaded 14-02-2016 http://apps.who.int/gho/data/view.main.2485
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Table 27: Chronic disease indicators by population group
A N
African Coloured Indian White All Ref
Diabetes prevalence (%)
M U
2012 male serum chol >5 mmol/L 15.3 27.2 41.2 - 18.9 c
Prevalence of raised blood pressure (%)
G
2012 raised SYS and DIA 9.9 11.8 7.3 12.2 10.2 e
BA
2012 raised SYS or DIA or both 25.6 33.2 25.9 29.3 26.6 f
N
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Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a SANHANES-1.47
EM
b NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of hypertension was defined as those with BP equal or above
140/90 mmHg and/or taking anti-hypertensive medication.
c SANHANES-1.47 Too few observations in White population group.
d NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of raised BP was defined as those with BP equal or above
140/90 mmHg regardless of medication usage.
e SANHANES-1.47 Restrictive definition of both parameters raised. Of participants 15 years and older.
f SANHANES-1.47 Calculated from (raised SYS) + (raised DIA) – (both SYS and DIA raised). Age 15+.
S A H R 20 1 6 289
Table 28: Cancer incidence for leading types of cancer (per 100 000 population) for South Africa, 2010
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Cancer incidence 2010.155 Age-standardised incidence (World Standard Population). Rates are also given by gender and population group in the source
tables.
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A N
M U
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O
G
R
BA
N
O
EM
290 S A H R 20 1 6
Health and Related Indicators
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risk behaviours, in addition to smoking and unsafe alcohol use.
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The International Study of Childhood Obesity, Lifestyle and the
Environment (ISCOLE), which included children from South Africa,
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confirmed the association of exercise with avoidance of obesity.156
Data from the three waves of NiDS and from SANHANES 2012 have
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shown that the prevalence of overweight and obesity is consistently
higher in South African women than men at all ages. Mean body
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mass index (BMI) has increased between 1998 and 2012, for all
ages, sexes and population groups. In all three waves of NiDS, men
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and women, of all ages and all population groups, whether living
in urban or rural settings, and regardless of educational level, have
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S A H R 20 1 6 291
Table 29: Behaviour and awareness indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Alcohol dependence (%)
2014 MSM - - - - - - - - - 43.4 a
2014 Non-MSM - - - - - - - - - 32.5 a
Currently drink alcohol (%)
2011 NYRBS 25.7 46.2 43.7 25.8 21.1 31.9 49.2 38.5 44.4 32.3 b
Ever drank alcohol (%)
2011 NYRBS 42.6 60.5 66.7 42.8 30.2 46.1 67.1 58.9 66.2 49.2 c
Ever smoked cigarettes (%)
2011 GYTS Grade 8-11 - - - - - - - - - 31.3 d
2011 NYRBS 21.4 35.0 41.8 22.6 18.5 20.8 38.7 27.6 42.9 27.6 e
2012 NiDS total 15+ - - - - - - - - - 22.5 f
2012 age 15+ 22.5 32.2 16.0 20.8 14.4 17.6 33.2 14.9 38.5 20.8 g
2012 female age 15+ 9.3 14.6 7.3 7.0 2.9 3.9 26.4 6.5 31.7 10.1 g
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2012 male age 15+ 36.8 50.4 24.6 38.1 29.4 33.6 40.2 25.2 46.0 32.8 g
Ever used drugs (%)
2011 NYRBS 10.3 11.7 7.9 8.3 12.5 10.1 7.9 9.1 9.3 9.7 h
2014 MSM – injected drugs - - - - - - - - - 2.1 i
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2014 Non-MSM – injected drugs - - - - - - - - - 1.2 i
Frequent smokers (%)
20 IL
2011 NYRBS 3.4 8.8 7.9 3.6 3.5 3.1 8.7 3.7 7.6 4.9 j
2012 female 18+ 5.6 8.4 3.0 3.6 2.0 3.4 23.1 4.9 25.6 6.5 k
2012 male 18+
2012 total 18+
27.1
15.9
Y T 39.3
23.6
20.6
11.8
31.5
15.6
23.0
11.0
27.3
14.6
34.7
28.8
21.2
12.1
38.0
31.4
26.6
15.9
k
k
A N
Number of admissions for alcohol and other drug abuse
2012 Jul-Dec 316 - 3 552 831 - - - - 3 178 9 190 l
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2 92 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Smoking age of initiation <10 years (%)
2011 NYRBS 4.6 7.9 8.2 6.5 5.0 6.2 8.5 6.1 10.2 6.6 j
Total alcohol per capita (age 15+ years) consumption (litres per year)
2010 drinkers only - - - - - - - - - 27.1 x
Watch TV more than 3 hours per day (%)
2011 NYRBS 24.2 33.8 41.0 27.1 24.6 29.6 35.8 30.4 37.5 30.3 j
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a HEAIDS 2014.89 Moderate to high use measured on a multi-item measure of alcohol and drug use. MSM is men who have sex with men students.
b NYRBS 2011.135 Defined in survey as ‘Used alcohol in the past month’.
c NYRBS 2011.135 Defined in survey as ‘Ever used alcohol’.
d GYTS 2011.157
e NYRBS 2011.135 Defined as ‘Ever smokers’ in survey.
f NCD Trends 2015.136
g SANHANES-1. 47 Indicated as ‘have ever smoked tobacco’ in SANHANES survey.
h NYRBS 2011.135 Defined in survey as ‘Ever taken drug like heroin, mandrax, sugars, tik’.
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i HEAIDS 2014.89 Defined in survey as ‘Have you or your sex partner used needles to inject drugs?’ MSM is men who have sex with men students.
j NYRBS 2011.135 Learners in grades 8–11.
k Reddy et al. 2015.158 SANHANES-1. Adults 18 years and older. Data reported as ‘Current daily smoking’
l SACENDU. 159 Update June 2013. Data for Jul – Dec 2012. The total figure includes patients from MP and LP (Northern Region) and from FS, NW and NC
16 6
combined (Central Region).
m SACENDU. 159 Update Dec 2013. Data for Jan – Jun 2013. The total figure includes patients from MP and LP (Northern Region) and from FS, NW and NC
combined (Central Region).
20 IL
n SACENDU. 159 SACENDU Phase 35 report. The total figure includes patients from MP and LP (Northern Region).
o SACENDU. SACENDU Nov 2015 Update.160 The total figure includes 1076 patients from MP and LP (Northern Region).
p Reddy et al. 2013.161 Smoked cigarettes on 1 or more days in the past 30 days.
Y T
q GYTS 2011.157 Results quite different to those published by Reddy et al. from same survey.
r NYRBS 2011.135 Defined in survey as ‘Current smokers’.
A N
s Smoking 1980–2012.162 Age-standardised prevalence.
t Reddy et al. 2015.158 SANHANES-1. Adults 18 years and older.
M U
w SACENDU. SACENDU Nov 2015 Update.160 Note grouped results for MP and LP (Northern Region) and from FS, NW and NC combined (Central Region)
not presented here.
x Global Alcohol 2014.164
O
G
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BA
N
O
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S A H R 20 1 6 2 93
Table 30: Behaviour and awareness indicators by population group
PM
2012 female 18+ 2.6 32.1 4.8 12.8 - 6.5 c
2012 male 18+ 25.5 45.1 35.6 17.3 - 26.6 c
2012 total 18+ 13.3 38.0 20.1 14.9 - 15.9 c
Percentage participating in insufficient physical activity
16 6
2011 NYRBS 42.9 47.2 38.7 29.2 45.5 42.8 a
Prevalence of smoking (%)
20 IL
2011 GYTS 15.4 31.4 26.5 12.4 - 16.9 d
2011 NYRBS 15.9 31.9 25.3 24.2 14.9 17.6 a
2012 female 18+
2012 male 18+
Y T
3.3
28.5
34.4
47.0
7.5
36.8
12.9
18.0
-
-
7.3
29.2
c
c
A N
2012 total 18+ 15.1 40.1 22.1 15.3 - 17.6 c
Smoking age of initiation <10 years (%)
M U
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a NYRBS 2011.135 Learners in grades 8–11.
O
d Reddy et al. 2013.161 Smoked cigarettes on 1 or more days in the past 30 days.
R
BA
N
O
EM
2 94 S A H R 20 1 6
Health and Related Indicators
Injuries
Context Injuries are perhaps the most neglected component of the quadruple burden of disease in South Africa.
New data sources Nationally, new data have been reported in the:
• Stats SA Victims of Crime Survey (VOCS) 2014/15
• South African Child Gauge 2015
Internationally, data of interest have been reported in the:
• WHO Global Status Report on Road Safety 2015
• Global Burden of Disease 2013 Study results on injuries among children and adolescents
• Global Burden of Disease 2013 report on injury (incidence, mortality, DALYs)
Key issues and trends No new data on road safety have been issued by the Road Traffic Management Corporation (RTMC) since 2011.
Alternative sources, such as the cause of death statistics issued by Stats SA, are incomplete because of a lack of
adequate coding of injuries.
PM
Although there is some evidence, at least for the Western Cape, that reported data on homicide rates are
accurate, it would be useful to have the means to triangulate and confirm such data from alternative sources in
all provinces.
16 6
The Global Burden of Disease Study 2013 reported that, while The Statistics South Africa Victims of Crime Survey 2014/15 also
injuries are still “an important cause of morbidity and mortality in makes for sober reading.168 Although the VOCS is not intended
20 IL
the developed and developing world”, the data do show that the to replace police statistics, it is described as “a rich source of
“world is becoming a safer place to live”. As always, such data information which will assist in the planning of crime prevention as
hide significant variations.165 In younger adults (15 years to 49
Y T well as providing a more holistic picture of crime in South Africa”. The
years), for instance, high DALYs due to injury are mostly attributable VOCS 2014/15 is being used to “pilot the possibility of integrating
A N
to road injuries and interpersonal violence in Latin America and sub- the crime statistics obtained from administrative data with those of a
Saharan Africa, but to drowning and self-harm in Eastern Europe sample survey in order to maximise our understanding of the extent
M U
and Central Asia. Although the WHO 100 Core Indicator measure of crime and the under-reporting of crime”. The VOCS 2014/15
of suicide rate per 100 000 population is classified as an outcome shows that most households were of the opinion that the levels for
4 ED
measure for injury and violence, it has been retained in the mental both violent and non-violent crimes had increased in their areas of
health (NCD) section of this chapter. Data on the relative mortality residence between 2011 and 2014. However, it also pointed out
burden from injuries per district and by age groups were included in that some property-related crimes (such as housebreaking/burglary,
the District Health Barometer 2014/15.67
O
for adolescents and children.36 The Sustainable Development Goals partly because of a lack of confidence in the abilities or commitment
(SDGs) include a target of a 50% reduction in road traffic deaths of the police. In terms of homicide, the highest rates are reported
R
and injuries by 2020. In 2015, the World Health Organization in the Western Cape. Data from state mortuaries and the Provincial
released the Global Status Report on Road Safety, which noted that Injury Mortality Surveillance System were used to calculate crude
BA
most of the 1.2 million annual deaths from road traffic accidents homicide rates and compare these with the figures reported by
the South African Police Service.169 The calculated figure for the
O
traffic injuries”.166 It also noted that only 95 countries have any to that reported by SAPS (42.4/100 000).
data on the proportion of road traffic deaths attributable to alcohol,
contrasting the low rates (less than 1%) in Costa Rica and Oman
with the high rate (58%) in South Africa. It pointed out that 39% of
road traffic deaths in Africa are among pedestrians. With a road
accident fatality rate substantially higher than the global average of
17.4 deaths per 100 000 population and estimated GDP lost due to
road traffic crashes of 7.8%, analysis of country statistics ought to be
a priority. However, the Annual Report 2014/15 of the Road Traffic
Management Corporation (RTMC) admits that five out of six planned
road safety reports have not been issued.167 The reason given is
that the outstanding reports were “still subject to quality assurance
processes”. The promised remedial action is long on words, but
will need to be backed by action: “A long-term strategy is being
undertaken to ensure alignment, integration and co-ordination in
the management of road traffic information which, going forward,
will result in a refined operating model in the management of
information”.
S A H R 20 1 6 295
Table 31: Injury indicators by province
EC FS GP KZN LP MP NC NW WC SA Ref
Always wear a seat belt when driven by someone else (%)
2011 NYRBS 14.6 25.2 29.1 16.6 24.6 22.4 25.4 24.9 19.2 21.5 a
Drove after drinking alcohol (%)
2011 NYRBS 10.9 19.4 19.2 10.6 8.1 10.8 12.0 13.6 11.7 12.8 a
Road accident fatalities per 100 000 population
2009 female - - - - - - - - - 16.8 b
2009 male - - - - - - - - - 57.2 b
2009 total - - - - - - - - - 36.1 b
2010 26.5 41.4 19.5 26.2 28.1 44.0 40.1 36.2 25.3 27.9 c
2011 - - - - - - - - - 27.6 d
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a NYRBS 2011.135 Learners in grades 8–11.
PM
b Matzopoulos et al. 2015.170
c Road Accidents 2010.171
d Arrive Alive.172 Number of fatalities: 13 954. No provincial values available in source found. No updated stats on RTMC website.
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA
N
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EM
2 96 S A H R 20 1 6
Health and Related Indicators
PM
convey, in particular measures of the performance of particular parts of the health system, such as maternity
and obstetrics units, emergency services and the provision of essential medicines (other than ARVs, TB
medicines and a limited list of tracer items).
16 6
Civil society pressure on public and private sector health facilities provision of the needed resources, and the means to monitor and
can be a powerful driver of change. An example is provided by the react to measures of quality of care. Without that support, initiatives
20 IL
Treatment Action Campaign (TAC) march on 27 September 2015 like the Ideal Clinic programme will remain paper exercises,
to the Western Cape Provincial Department of Health, specifically applied only in ‘pilot’ sites at best. What is needed is not merely
Y T
to raise concerns about the quality of care provided to pregnant
women at maternity and obstetrics units.173 As the NSP Review put it:
‘strengthening’, but the long-term development of ‘resilience’.178 By
August 2015, compliance with the Ideal Clinics standards had been
A N
“Long queues, medicines shortages, rude staff, undignified facilities, assessed in 962 of 1 139 facilities (85% of the total selected for
M U
many users of the public healthcare system simply just accept it as assessment in this period, but excluding the Western Cape).179 The
the way things are”. The NSP Review also drew attention to the national performance figures may appear to be reassuring for some
South African Human Rights Commission’s report into emergency components (Figure 9), but it is the remedial action that is important,
4 ED
medical services in the Eastern Cape,174 a service described as “a and how sustainable any change will prove to be. Achieving
complete shambles”. Noting that positive policy statements do not the required standard is elusive, with one facility obtaining gold
always translate into improved services, the NSP Review concluded status and three facilities obtained silver status. The remaining 958
O
that “even as the Minister makes the ‘test and treat’ announcement facilities that conducted status determinations did not obtain any
and as the world applauds, there will be many clinics in this country Ideal Clinic category status.
G
for Quality Health-Care Services for Adolescents, issued by WHO in national information systems. Where available, data have been
and UNAIDS,175,176 nor is there a dearth of local experience.177 included in Table 32 and Table 33.
O
EC FS GP KZN LP MP NC NW WC SA Ref
Percentage of users of private health services highly satisfied with the service received
2012 GHS 96.0 93.5 94.7 81.0 94.1 93.0 87.0 91.8 94.1 92.2 a
2012 inpatient care - - - - - - - - - 69.5 b
2012 outpatient care - - - - - - - - - 57.1 b
2013 GHS 97.0 92.5 94.2 93.1 94.3 95.1 91.3 93.5 93.4 94.0 c
2014 GHS 95.1 91.2 91.6 89.8 95.1 95.9 92.0 91.4 92.4 91.5 d
Percentage of users of public health services highly satisfied with the service received
2012 GHS 64.6 61.4 52.3 51.6 67.5 59.2 61.7 50.7 57.8 57.3 a
2012 inpatient care - - - - - - - - - 32.7 b
2012 outpatient care - - - - - - - - - 24.5 b
2013 GHS 67.3 62.1 54.4 56.8 73.3 65.0 58.8 54.2 60.3 60.5 c
2014 GHS 62.1 59.0 51.8 56.7 68.0 64.1 64.8 50.1 52.8 57.1 d
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2012.46
b SANHANES-1.47 All participants aged 15 years and older very satisfied with care.
c Stats SA GHS 2013.23
d Stats SA GHS 2014.21
S A H R 20 1 6 2 97
Figure 9: Health facility performance on the Ideal Clinic components nationally, April to August 2015
Administrator
Communication
Infrastructure
PM
Support Services
0 10 20 30 40 50 60 70 80 90 100
Percent
16 6
Yes No Partial
20 IL
Source: The Ideal Clinic Programme 2015/16179
EC
Y T FS GP KZN LP MP NC NW WC SA Ref
A N
Average length of stay (ALOS)
2012 DHIS 6.9 4.9 4.8 6.5 5.7 4.5 3.2 5.8 5.9 5.6 a
M U
2013 DHIS 7.4 6.6 6.3 7.3 5.9 5.0 4.1 6.8 6.4 6.5 a
2014 DHIS 7.3 5.8 6.5 7.1 5.5 4.9 4.7 7.2 6.4 6.5 a
Inpatient bed utilisation rate - total (BUR)
4 ED
2013 DHIS 6.7 6.4 5.4 5.3 5.7 5.8 5.5 6.4 3.1 5.4 a
2014 DHIS 6.3 6.1 5.4 5.1 5.6 5.6 5.0 6.6 3.1 5.2 a
R
Number of beds
2014 District Hospitals 6 120 1 598 2 538 8 637 4 153 2 796 583 1 494 2 784 30 703 b
BA
2014 National Central Hospitals 527 636 6 053 846 - - - - 2 359 10 421 b
2014 Provincial Tertiary 1 615 609 2 172 995 1 003 725 657 471 272 8 518 b
O
2014 Regional Hospitals 2 122 1 195 4 425 7 091 1 533 840 141 1 953 1 384 20 682 b
EM
2014 Specialised Psychiatric 1 316 760 1 468 2 456 994 - 106 1 214 1 692 10 007 b
2014 Specialised TB 1 500 - - 2 023 62 384 36 - 1 026 5 031 b
2014 Public sector 13 200 4 798 16 656 22 048 7 745 4 745 1 523 5 132 12 421 85 362 b
Number of health facilities
2014 CHC/CDC 41 10 38 20 25 53 33 45 66 331 b
2014 District Hospitals 65 25 12 40 31 23 11 14 34 255 b
2014 National Central Hospitals 1 1 4 1 - - - - 2 9 b
2014 Private Hospitals 17 13 83 12 10 13 2 14 39 203 b
2014 Provincial Tertiary Hospitals 3 1 3 2 2 2 1 1 1 16 b
2014 Public clinics 731 212 333 592 456 242 131 273 212 3 182 b
2014 Regional Hospitals 5 4 10 13 5 3 1 5 5 51 b
2014 Specialised Hospitals 17 3 10 21 4 5 3 2 11 76 b
Tracer items stock-out rate (fixed clinic/CHC/CDC)
2012 DHIS 15.5 13.5 22.6 4.9 33.3 17.7 10.4 30.3 - 16.4 b
2013 DHIS 18.9 31.9 14.8 6.5 34.6 18.3 17.3 26.3 2.4 18.2 b
2013 Any ART/TB drug out 19.9 53.9 20.4 13.6 40.8 25.9 17.7 4.4 4.9 21.5 c
2014 DHIS 24.8 30.5 16.4 9.0 45.4 27.2 16.3 42.2 4.5 23.6 b
2014 Any ART/TB drug out 28.0 28.0 25.0 19.0 29.0 40.0 21.0 39.0 4.0 25.0 c
2 98 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Usable beds per 1 000 population
2014 District Hospitals 1.0 0.7 0.3 0.9 0.8 0.8 0.6 0.5 0.6 0.7 d
2014 National Central Hospitals 0.1 0.3 0.7 0.1 - - - - 0.5 0.2 d
2014 Provincial Tertiary 0.3 0.3 0.2 0.1 0.2 0.2 0.7 0.2 0.1 0.2 d
2014 Regional Hospitals 0.4 0.5 0.5 0.8 0.3 0.2 0.2 0.6 0.3 0.5 d
2014 Specialised Psychiatric 0.2 0.3 0.2 0.3 0.2 - 0.1 0.4 0.4 0.2 d
2014 Specialised TB 0.3 - - 0.2 0.0 0.1 0.0 - 0.2 0.1 d
2014 Public sector 2.2 2.1 1.8 2.4 1.5 1.3 1.6 1.6 2.1 1.9 d
Utilisation rate PHC
2012 DHIS 2.7 2.5 2.0 2.9 2.7 2.5 2.9 2.3 2.6 2.5 b
2013 DHIS 2.6 2.5 1.8 3.0 2.6 2.2 2.9 2.2 2.4 2.4 b
2014 DHIS 2.7 2.5 1.8 2.9 2.6 2.3 2.8 2.3 2.3 2.4 b
Utilisation rate PHC <5 years
2012 DHIS 4.4 3.8 4.2 4.7 6.0 4.8 4.9 4.4 4.3 4.6 b
PM
2013 DHIS 4.0 4.3 4.0 4.4 5.2 4.2 4.6 4.1 4.0 4.3 b
2014 DHIS 4.1 4.2 4.1 4.4 5.0 4.3 4.5 4.1 4.0 4.3 b
16 6
a DHIS.45 All facility types. Data for financial year from April of the year to
March of the following year (not calendar year).
20 IL
b DHIS.45 Data on stock-outs were not available for the WC in the national
DHIS datamart in 2012/13.
c Stock outs survey 2014.180
Y T
d DHIS.45 Calculated from DHIS usable beds for district hospitals, per
1 000 uninsured population (calculated from Stats SA GHS medical
A N
schemes coverage and mid-year population estimates).
M U
4 ED
O
G
R
BA
N
O
EM
S A H R 20 1 6 299
Health personnel
Context Sufficient skilled human resources are an absolute requirement for an effective health system. In South Africa, in
addition to an absolute shortage of human resources for health, there is also a persistent maldistribution of such
resources.
New data sources Nationally, new data have been reported in the:
• Health Professions Council of South Africa
• South African Nursing Council
• South African Pharmacy Council
Key issues and trends One of the key policy interventions in the post-apartheid era has been the introduction of community service for
newly qualified health professionals, starting with medical practitioners and eventually including all professions.
No data could be obtained from the NDoH since 2013 to show the number of community service personnel and
their distribution. It is also unclear whether, as is alleged, increased numbers of health science graduates are
placing this system under strain.
PM
Although, in comparison with other African countries, South
Africa has met the WHO targets for human resources for primary
health care, the country still faces significant challenges in this
regard.181 It appears that changes to public sector remuneration
16 6
(such as the Occupation-specific Dispensation) have succeeded
20 IL
in stemming emigration and decreasing shortages in the public
sector.182 However, at times of fiscal austerity, the imposition of
hiring moratoria can have serious implications for service delivery.
Y T
Such events are expected to be more common in future, as public
A N
expenditure limits are imposed.183 In particular, the Rural Health
Advocacy Project (RHAP) has called for “guidance for Treasuries on
M U
300 S A H R 20 1 6
Health and Related Indicators
Figure 10: Number of health professionals registered with their respective professional councils by population group, 2007–2015
Group
400 African
Number of clinical C oloured
HP C S A as s ociates Indian
regis tered 200
White
0
4 000
Number of dental
practitioners
regis tered 2 000
PM
400
Number of dental
therapis ts regis tered
200
16 6
0
20 IL
3 000
Number of 2 000
environmental
health practitioners
Y T
A N
regis tered 1 000
M U
practitioners
(including 20 000
s pecialis ts )
regis tered 10 000
O
0
6 000
G
Number of 4 000
R
phys iotherapis ts
regis tered 2 000
BA
0
O
6 000
EM
Number of
ps ychologis ts 4 000
regis tered
2 000
0
6 000
Number of 4 000
radiographers
regis tered
2 000
10 000
Number of
S AP C pharmacis ts
regis tered 5 000
0
2007 2008 2009 2010 2011 2012 2013 2014 2015
Source: HPCSA and SAPC.186,187 This figure does not show those with missing information for population group.
S A H R 20 1 6 301
Table 34: Number of health personnel practising by sector, and registered with applicable professional council, by province
EC FS GP KZN LP MP NC NW WC SA Ref
Number of clinical associates
2014 Public sector 71 5 39 28 9 26 4 39 0 221 a
2015 Public sector 58 20 39 40 7 54 4 48 0 270 a
Number of clinical associates registered
2014 Registered with HPCSA 65 19 112 50 19 38 13 47 6 369 b
2015 Registered with HPCSA 75 20 146 64 25 72 16 59 7 484 b
Number of dental practitioners
2014 Public sector 122 74 247 128 156 108 33 61 126 1 056 a
2015 Public sector 134 74 244 154 180 114 43 58 135 1 137 a
Number of dental practitioners registered
2014 Registered with HPCSA 317 195 2 274 829 228 282 94 191 1 317 5 856 b
2015 Registered with HPCSA 323 195 2 349 839 247 294 97 196 1 371 6 035 b
Number of dental specialists
PM
2014 Public sector - 1 116 1 4 - 1 - 32 155 a
2015 Public sector - 1 118 - 3 1 1 - 30 154 a
Number of dental therapists
2014 Public sector 9 2 41 117 87 23 9 16 2 306 a
16 6
2015 Public sector 10 1 38 116 101 16 9 16 2 309 a
Number of dental therapists registered
20 IL
2014 Registered with HPCSA 13 22 179 237 62 44 9 41 3 611 b
2015 Registered with HPCSA 15 20 186 249 67 48 10 38 4 638 b
Number of enrolled nurses
2014 Public sector 3 124
Y T 839 6 262 10 784 4 189 1 769 220 909 2 474 30 571 a
A N
2015 Public sector 3 293 882 6 485 10 603 4 240 1 739 232 927 2 468 30 870 a
Number of enrolled nurses registered
M U
2014 Registered with SANC 5 184 2 244 16 543 24 172 5 735 3 038 431 3 171 6 373 66 891 c
2015 Registered with SANC 5 733 2 382 17 469 24 962 6 158 3 262 453 3 265 6 616 70 300 c
4 ED
2014 Registered with HPCSA 373 228 848 702 287 219 105 154 471 3 391 b
G
2015 Registered with HPCSA 388 261 887 726 305 225 111 164 464 3 535 b
Number of medical practitioners
R
2014 Public sector 1 489 716 3 184 3 537 1 185 875 419 627 1 541 13 593 a
2015 Public sector 1 616 539 3 280 3 418 1 279 836 433 674 1 563 13 656 a
BA
2014 Specialist MPs 721 657 5 484 2 346 212 279 132 300 3 784 14 547 b
2014 General MPs + Specialists 2 801 1 894 14 192 7 165 1 404 1 475 580 1 316 8 894 41 132 b
EM
2015 General MPs 2 131 1 233 8 898 4 947 1 256 1 224 463 1 050 5 308 27 315 b
2015 Specialist MPs 750 645 5 666 2 448 228 292 135 306 3 916 15 008 b
2015 General MPs + Specialists 2 881 1 878 14 564 7 395 1 484 1 516 598 1 356 9 224 42 323 b
Number of medical researchers
2014 Public sector - 8 20 9 3 - 1 - 34 103 a
2015 Public sector - 6 21 6 3 - 1 - 40 100 a
Number of medical specialists
2014 Public sector 170 328 1 868 791 92 70 29 117 1 423 4 893 a
2015 Public sector 161 300 1 964 736 80 81 26 115 1 512 4 986 a
Number of nursing assistants
2014 Public sector 5 399 2 098 6 664 6 251 5 125 1 752 916 2 853 4 089 35 147 a
2015 Public sector 5 577 2 114 6 454 6 353 5 049 1 602 887 2 750 4 091 34 877 a
Number of nursing assistants registered
2014 Registered with SANC 7 325 3 319 18 634 12 789 9 600 4 048 1 163 4 974 8 567 70 419 c
2015 Registered with SANC 7 535 3 331 19 178 13 208 9 852 3 892 1 083 4 862 8 522 71 463 c
Number of occupational therapists
2014 Public sector 120 76 306 210 197 95 56 49 141 1 250 a
2015 Public sector 139 67 306 229 205 95 68 59 144 1 313 a
3 02 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Number of occupational therapists registered
2014 Registered with HPCSA 198 292 1 509 507 179 213 90 134 1 143 4 305 b
2015 Registered with HPCSA 220 310 1 618 537 197 223 92 133 1 208 4 575 b
Number of pharmacists
2014 Public sector 408 297 1 052 722 436 268 135 233 880 4 516 a
2015 Public sector 547 343 1 102 788 511 276 151 238 915 4 970 a
Number of pharmacists registered
2014 Registered with SAPC 939 429 4 463 1 717 436 530 171 601 2 028 13 364 d
2014 Registered with SAPC - female - - - - - - - - - 7 795 d
2014 Registered with SAPC - male - - - - - - - - - 5 576 d
2015 Registered with SAPC 1 570 431 4 655 1 888 516 568 181 639 2 166 13 479 d
2015 Registered with SAPC - female - - - - - - - - - 8 134 d
2015 Registered with SAPC - male - - - - - - - - - 5 345 d
Number of physiotherapists
PM
2014 Public sector 145 68 200 299 160 88 59 73 147 1 239 a
2015 Public sector 160 67 205 326 188 75 63 75 155 1 315 a
Number of physiotherapists registered
2014 Registered with HPCSA 339 358 2 355 939 258 269 111 194 1 743 6 673 b
16 6
2015 Registered with HPCSA 355 375 2 436 987 276 275 114 197 1 824 6 942 b
Number of professional nurses
20 IL
2014 Public sector 10 008 2 435 12 171 16 126 9 093 5 049 1 332 4 494 5 130 66 711 a
2015 Public sector 10 273 2 353 12 672 16 431 9 356 5 194 1 365 4 337 5 268 68 105 a
Number of professional nurses registered Y T
2014 Registered with SANC 15 190 8 004 34 847 29 174 10 987 6 964 2 237 9 236 16 488 133 127 c
A N
2015 Registered with SANC 15 392 8 075 35 770 30 475 11 464 7 106 2 250 9 621 16 701 136 854 c
Number of psychologists
M U
2014 Registered with HPCSA 460 273 3 794 870 149 174 56 247 1 714 7 883 b
2015 Registered with HPCSA 482 275 3 944 905 158 186 61 266 1 838 8 255 b
Number of pupil auxiliary nurses registered
O
2014 Registered with SANC 1 061 200 3 837 1 727 344 113 113 362 792 8 549 c
2015 Registered with SANC 1 132 199 3 817 1 864 375 428 149 572 776 9 312 c
G
2015 Registered with SANC 2 074 461 6 765 6 501 434 527 0 614 1 470 18 846 c
Number of radiographers
BA
2014 Public sector 344 186 676 568 167 116 100 120 456 2 735 a
2015 Public sector 352 163 694 595 175 95 106 115 468 2 765 a
O
2014 Registered with HPCSA 614 511 2 512 1 328 243 303 163 267 1 433 7 430 b
2015 Registered with HPCSA 635 528 2 610 1 384 267 321 167 287 1 524 7 787 b
Number of student nurses
2014 Public sector 258 - 4 233 1 815 443 765 - 234 - 7 748 a
2015 Public sector 73 - 3 734 1 694 461 865 - 70 - 6 897 a
Number of student nurses registered
2014 Registered with SANC 3 821 1 394 4 870 3 264 1 951 991 238 1 925 2 849 21 303 c
2015 Registered with SANC 3 611 1 294 4 498 3 387 1 922 958 243 2 003 2 633 20 549 c
Total number of health professional posts
2014 Public sector (filled) 21 779 7 254 37 464 41 675 21 598 11 192 3 363 9 916 16 565 172 307 a
2015 Public sector (filled) 22 504 7 036 37 679 41 691 22 048 11 168 3 431 9 571 16 879 173 761 a
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a PERSAL.188 Note that this total includes only the posts that are filled at time of data extraction. The South African total includes the sum of the provinces
plus posts within the National Department of Health. Data for Environmental Health Practitioners only include those employed by provincial government.
Note that for provinces such as GP and WC a substantial number of EHPs may be employed by local government.
b HPCSA.187 Total for South Africa includes those with REGION indicated as Foreign or Unknown. The number on the register includes those professionals
who are retired, overseas, working part-time, working in other sectors or not working at all (a substantial proportion of the total for some professions).
c SANC.189 The number on the register includes those professionals who are retired, overseas, working part-time, working in other sectors or not working at
all.
d SAPC.186 The total for South Africa includes large numbers of pharmacists for whom province was unknown and thus the provincial breakdown should be
interpreted with caution. The number on the register also includes those professionals who are retired, overseas, working part-time, working in other sectors
or not working at all.
S A H R 20 1 6 3 03
Table 35: Public sector health personnel per 100 000 uninsured population by province
EC FS GP KZN LP MP NC NW WC SA Ref
Dental practitioners per 100 000 population
2014 Public sector 2.01 3.20 2.71 1.38 3.04 3.03 3.54 1.97 2.77 2.40 a
2015 Public sector 2.16 3.20 2.57 1.62 3.44 3.13 4.52 1.84 2.95 2.53 a
Dental specialists per 100 000 population
2014 Public sector - 0.04 1.27 0.01 0.08 - 0.11 - 0.70 0.35 a
2015 Public sector - 0.04 1.25 - 0.06 0.03 0.11 - 0.66 0.34 a
Dental therapists per 100 000 population
2014 Public sector 0.15 0.09 0.45 1.26 1.70 0.64 0.97 0.52 0.04 0.69 a
2015 Public sector 0.16 0.04 0.40 1.22 1.93 0.44 0.95 0.51 0.04 0.69 a
Enrolled nurses per 100 000 population
2014 Public sector 51.4 36.3 68.6 116.3 81.8 49.6 23.6 29.3 54.4 69.4 a
2015 Public sector 53.2 38.1 68.4 111.4 81.0 47.7 24.4 29.4 54.0 68.6 a
Environmental health practitioners per 100 000 population
PM
2014 Public sector 0.82 3.68 1.68 1.88 2.95 4.29 3.44 1.39 0.09 1.93 a
2015 Public sector 0.63 3.16 0.97 0.98 1.74 2.44 2.42 1.17 - 1.78 a
Medical practitioners per 100 000 population
2014 Public sector 24.5 31.0 34.9 38.1 23.1 24.5 45.0 20.2 33.9 30.8 a
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2015 Public sector 26.1 23.3 34.6 35.9 24.4 22.9 45.5 21.3 34.2 30.3 a
Medical researchers per 100 000 population
20 IL
2014 Public sector - 0.35 0.22 0.10 0.06 - 0.11 - 0.75 0.23 a
2015 Public sector - 0.26 0.22 0.06 0.06 - 0.11 - 0.88 0.22 a
Medical specialists per 100 000 population
2014 Public sector 2.8
Y T 14.2 20.5 8.5 1.8 2.0 3.1 3.8 31.3 11.1 a
A N
2015 Public sector 2.6 13.0 20.7 7.7 1.5 2.2 2.7 3.6 33.1 11.1 a
Nursing assistants per 100 000 population
M U
2014 Public sector 88.9 90.8 73.0 67.4 100.0 49.1 98.4 91.9 90.0 79.8 a
2015 Public sector 90.1 91.4 68.1 66.7 96.5 43.9 93.3 87.1 89.5 77.5 a
4 ED
2014 Public sector 6.7 12.9 11.5 7.8 8.5 7.5 14.5 7.5 19.4 10.2 a
G
2015 Public sector 8.8 14.8 11.6 8.3 9.8 7.6 15.9 7.5 20.0 11.0 a
Physiotherapists per 100 000 population
R
2014 Public sector 2.39 2.94 2.19 3.22 3.12 2.47 6.34 2.35 3.23 2.81 a
2015 Public sector 2.59 2.90 2.16 3.42 3.59 2.06 6.63 2.38 3.39 2.92 a
BA
2015 Public sector 166.0 101.7 133.7 172.6 178.7 142.5 143.6 137.3 115.3 151.3 a
Psychologists per 100 000 population
EM
2014 Public sector 1.02 1.56 2.54 1.24 1.97 0.98 1.83 1.55 1.89 2.75 a
2015 Public sector 1.16 1.43 2.44 1.15 2.27 0.99 2.00 1.65 1.93 2.75 a
Radiographers per 100 000 population
2014 Public sector 5.7 8.1 7.4 6.1 3.3 3.2 10.7 3.9 10.0 6.2 a
2015 Public sector 5.7 7.0 7.3 6.2 3.3 2.6 11.1 3.6 10.2 6.1 a
Student nurses per 100 000 population
2014 Public sector 4.2 - 46.4 19.6 8.6 21.4 - 7.5 - 17.6 a
2015 Public sector 1.2 - 39.4 17.8 8.8 23.7 - 2.2 - 15.3 a
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a PERSAL.188 Note that this value was calculated using only the posts that are filled at time of data extraction. Population estimates for the applicable year
and medical scheme coverage from Stats SA GHS were used to estimate the public sector dependent population denominator.
304 S A H R 20 1 6
Health and Related Indicators
PM
2014 Public sector 49 11 31 64 - 155 a
2015 Public sector 48 9 34 63 - 154 a
Number of dental therapists
2014 Public sector 260 4 33 4 - 306 a
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2015 Public sector 269 6 33 1 - 309 a
Number of dental therapists registered
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2014 Registered with HPCSA 359 3 124 31 94 611 b
2015 Registered with HPCSA 394 4 126 29 85 638 b
Number of enrolled nurses
2014 Public sector
Y T
27 590 2 247 321 398 - 30 571 a
A N
2015 Public sector 28 106 2 069 299 360 36 30 870 a
Number of environmental health practitioners
M U
2014 General MPs 7 856 944 3 781 10 428 3 576 26 585 b
2014 Specialist MPs 2 023 247 2 017 7 428 2 832 14 547 b
BA
2014 General MPs + Specialists 9 879 1 191 5 798 17 856 6 408 41 132 b
2015 General MPs 8 449 1 039 3 817 10 592 3 418 27 315 b
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2015 Specialist MPs 2 092 285 2 132 7 753 2 746 15 008 b
2015 General MPs + Specialists 10 541 1 324 5 949 18 345 6 164 42 323 b
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S A H R 20 1 6 305
African Coloured Indian White Other All Ref
Number of pharmacists registered
2014 Registered with SAPC 2 260 463 2 595 7 978 74 13 364 c
2015 Registered with SAPC 2 595 487 2 736 7 608 53 13 479 c
Number of physiotherapists
2014 Public sector 552 194 161 326 - 1 239 a
2015 Public sector 596 204 183 329 3 1 315 a
Number of physiotherapists registered
2014 Registered with HPCSA 956 542 597 3 582 996 6 673 b
2015 Registered with HPCSA 1 059 598 638 3 717 930 6 942 b
Number of professional nurses
2014 Public sector 56 889 5 897 1 491 2 319 - 66 711 a
2015 Public sector 58 311 5 890 1 528 2 216 160 68 105 a
Number of psychologists
2014 Public sector 695 82 63 369 - 1 213 a
PM
2015 Public sector 723 86 69 353 7 1 238 a
Number of psychologists registered
2014 Registered with HPCSA 886 308 480 4 655 1 554 7 883 b
2015 Registered with HPCSA 1 004 349 515 4 930 1 457 8 255 b
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Number of radiographers
2014 Public sector 1 514 498 298 421 - 2 735 a
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2015 Public sector 1 554 497 305 402 7 2 765 a
Number of radiographers registered
2014 Registered with HPCSA 1 993
Y T 701 705 2 375 1 656 7 430 b
2015 Registered with HPCSA 2 243 764 756 2 477 1 547 7 787 b
A N
Number of student nurses
2014 Public sector 7 137 166 242 159 - 7 748 a
M U
2014 Public sector (filled) 138 252 14 535 6 853 12 343 - 172 307 a
2015 Public sector (filled) 140 333 14 200 6 821 12 039 368 173 761 a
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
O
a PERSAL.188 Total for South Africa includes those with unknown population group.
b HPCSA.187 Total for South Africa includes those with unknown population group. The number on the register includes those professionals who are retired,
overseas, working part-time, working in other sectors or not working at all.
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c SAPC.186 The total for South Africa includes pharmacists for whom population group was unknown. The number on the register also includes those
professionals who are retired, overseas, working part-time, working in other sectors or not working at all.
R
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3 06 S A H R 20 1 6
Health and Related Indicators
Health financing
Context Health financing remains the most contested element of the plans to implement National Health Insurance (NHI).
A Treasury input document on this subject is expected shortly.
New data sources Nationally, new data have been reported in the:
• National Treasury Budget Review 2016
Documents of interest:
• White Paper on National Health Insurance (Dec 2015)
Internationally, reports of interest include:
• WHO Health financing country diagnostic
• WHO Raising revenues for health in support of UHC policy brief
Key issues and trends Although updated budget figures for the public sector are presented here, no new private sector expenditure, as
reported by the Council for Medical Schemes, has been reported since the last issue of the Health Review. Of
particular note is the allocation of funds to implement a national electronic medicine stock management system.
PM
The extent to which this system will be able to deliver real-time, disaggregated (by district and facility) data
remains to be seen.
The WHO 100 Core Health Indicators propose a daunting list of Even before NHI is implemented, progress towards the goal of
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measures, some of which are not easily completed at present, from universal health coverage will depend on a sufficient public sector
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existing data sources: health budget.190 Doherty and McIntyre have argued cogently that “to
➢➢ total current expenditure on health (% of gross domestic preserve the impetus towards universal health coverage, the Minister
product); Y T of Health and others need to engage with debates within Cabinet
and Treasury on appropriate macroeconomic and fiscal policy
➢➢ current expenditure on health by general government and
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choices. The Department of Health will strengthen these arguments,
compulsory schemes (% of current expenditure on health); and win the trust of colleagues from Cabinet and Treasury, if it is
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➢➢ out-of-pocket payment for health (% of current expenditure on able to demonstrate achievements in service delivery and combat
health); corruption.”191 A ‘country diagnostic’ review of health financing has
4 ED
government expenditure was expected to grow by 7.1% over the over three years. Although the ‘cushion’ was intended only to apply
medium term, to reach R1.69 trillion in fiscal year 2018/19.122 until 2015/16, it was extended for an additional year. The largest
The Treasury pointed out that average growth in spending on share of this R2.1 billion ‘cushion’ in 2016/17 was allocated to
education, health and social protection had outpaced inflation by KwaZulu-Natal, followed by the Eastern Cape and Limpopo.
1.4%. The health budget will be R168.4 billion in 2016/17, of
which R31.9 billion will be for primary healthcare services, R88.2
billion for hospitals, and R15.9 billion for HIV and AIDS treatment
and prevention. Some of the key additional allocations are:
S A H R 20 1 6 3 07
Table 37: Medium term estimates for public sector health expenditure, 2015/16–2018/19h
PM
National Health Laboratory Service 5 466 5 672 6 193 6 542 3.3% 6.2%
National Department of Health 2 421 3 094 3 694 4 429 2.0% 22.3%
Total 159 377 168 393 183 629 198 556 100.0% 7.6%
of which:
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Compensation of employees 100 095 107 990 116 379 123 996 63.3% 7.4%
Goods and services 44 545 46 463 51 725 58 045 28.4% 9.2%
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Transfers and subsidies 5 640 4 687 4 950 5 252 2.7% -2.3%
Buildings and other fixed structures 6 019 5 994 7 230 7 838 3.8% 9.2%
Machinery and equipment 2 942 3 140 3 225 3 418 1.8% 5.1%
Y T
Source: National Treasury as cited in 2016 Budget Review.122
A N
M U
257. These changes will come into effect on the date of the 2016
local government elections. The Treasury describes this as “the most
wide-ranging re-demarcation since the current system of wall-to-wall
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308 S A H R 20 1 6
Health and Related Indicators
EC FS GP KZN LP MP NC NW WC SA Ref
Claims ratio (%)
2013 - - - - - - - - - 86.5 a
2014 - - - - - - - - - 88.2 a
Headcount ratio of catastrophic health expenditure (%)
2006 49.3 37.6 35.7 59.0 32.6 48.2 57.7 36.1 30.6 42.0 b
Headcount ratio of impoverishing health expenditure (%)
2006 78.3 98.8 53.4 96.5 109.9 51.1 29.4 60.4 19.3 72.0 b
Health as percentage of total expenditure
2013 Outcome - - - - - - - - - 15.5 c
2014 medium-term estimate - - - - - - - - - 15.1 c
2015 medium-term estimate - - - - - - - - - 15.0 c
Total current expenditure on health as percentage of gross domestic product
2013 Private sector - - - - - - - - - 4.6 c
PM
2013 Public sector - - - - - - - - - 4.4 c
2013 Total - - - - - - - - - 9.0 c
2014 Private sector - - - - - - - - - 4.4 c
2014 Public sector - - - - - - - - - 4.3 c
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2014 Total - - - - - - - - - 8.7 c
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2015 Private sector - - - - - - - - - 4.3 c
2015 Public sector - - - - - - - - - 4.2 c
2015 Total - - - - - - - - - 8.5 c
Medical scheme beneficiaries
2013 703 895
Y T
404 691 2 952 924 1 293 764 433 220 588 386 189 264 524 408 1 299 153 8 778 308 d
A N
2014 697 125 402 672 2 982 814 1 301 813 437 906 589 900 192 409 524 879 1 310 998 8 814 458 e
Medical scheme coverage (%)
M U
2013 GHS 10.5 17.1 29.3 13.3 9.0 15.6 20.2 15.6 25.7 18.4 f
2013 med schemes 10.9 14.9 24.1 13.2 8.4 14.8 17.4 15.4 22.6 16.6 g
4 ED
2014 GHS 10.5 17.9 28.2 12.8 8.6 14.9 19.8 14.8 26.3 18.1 h
2014 med schemes 10.2 14.4 23.0 12.1 7.8 14.0 16.4 14.4 21.5 16.3 i
Pensioner ratio (%)
O
2014 real 2014/15 prices 835 916 939 977 756 740 1 058 920 952 897 k
Per capita health expenditure
EM
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Medical Schemes 2014–15.22
b Ataguba et al. 2014.194 Based on analysis of the Stats SA Income and Expenditure Survey.
c Fiscal Review 2015.195 Financial year.
d Medical Schemes 2014–15.22 SA total includes 4 640 outside of the Republic and 383 963 unclassified. Provincial numbers are calculated primarily on
the basis of the location of principal members.
e Medical Schemes 2014–15.22 SA total includes 4 224 outside of the Republic and 369 718 unclassified. Provincial numbers are calculated primarily on
the basis of the location of principal members.
f Stats SA GHS 2013.23
g Medical Schemes 2013–14.196 Calculated from Medical Schemes beneficiaries per population from Stats SA mid-year estimates for 2013.
h Stats SA GHS 2014.21
i Medical Schemes 2014–15.22 Calculated from Medical Schemes beneficiaries per population from Stats SA mid-year estimates for 2014.
j Medical Schemes 2013–14.196
k DHB 2014/15.67 Data for financial year from April of the year to March of the following year (not calendar year).
l Medical Schemes 2014–15.22 Average benefits paid per beneficiary per annum.
S A H R 20 1 6 3 09
m National Treasury. Calculated from provincial expenditure (National Treasury) per uninsured population. For financial year in nominal prices.
n Calculated from Medical Schemes Council and National Treasury data.
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2013.23
b Stats SA GHS 2014.21
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310 S A H R 20 1 6
Health and Related Indicators
Conclusion Appendices
As South Africa embarks on the challenging task of achieving the
Maps
targets set by the Sustainable Development Goals (SDGs), access
to accurate indicators of progress will be needed to ensure focused The indicator maps show the provincial, district and sub-district
action. This is as true for the health sector as for any other. In boundaries according to the demarcation which came into effect
addition, the SDGs will demand greater attention to intersectoral with the local government elections in May 2011. The boundaries
issues, many of which are important determinants of health. As this of wards and districts are determined by the Municipal Demarcation
chapter has shown, the range of data sources continues to expand, Board (MDB). As at September 2010, the MDB demarcated
allowing greater opportunities for triangulation of data and attention 4 277 wards in 231 local municipalities within eight metropolitan
to issues of data quality, reliability and timeliness. However, there councils and 45 districts. Wards are voting areas, as used by the
are still significant lacunae, especially in regard to the delivery of Independent Electoral Commission and have been identified as the
health services in the private sector. All too often, data are sourced level of service delivery for PHC Ward-based Outreach Teams by
exclusively from the public sector, or from structures such as the the PHC Re-engineering Strategy. The MDB has announced several
National Health Laboratory Service. The implementation of National major boundary changes that will come into effect on the date of
PM
Health Insurance will both present new opportunities to bridge this the 2016 local government elections, reducing the total number of
gap and demand data that reflect the health status of all South municipalities in the country from 278 to 257 (Map 1).
Africans.
The remaining maps show the spatial variation in a selection of
16 6
indicators relating to non-communicable diseases and their risk
factors or determinants. Since many NCDs increase in prevalence
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in the elderly, the Ageing Index indicates where disease prevalence
may be concentrated (Map 4). Maps 5 to 12 are based on the
Y T analysis of premature mortality or Years of Life Lost (YLLs) presented
in the District Health Barometer 2014/15. These percentages do
A N
not give any indication of the absolute level of mortality due to this
Acknowledgements cause as would be provided by age-standardised mortality rates,
M U
As in previous years, this chapter is very much the product of but only the relative proportion of all premature mortality (years of
collective efforts at all levels of the health system over many years. In life lost). Therefore the percentage of YLLs due to all causes would
4 ED
particular we acknowledge the national and provincial Departments total 100%. Map 5 gives the relative proportion of YLLs for the
of Health for the use of data from the District Health Information broad cause group non-communicable diseases. The next set of
System and various other databases and publications. Other people maps provides the same information by the main NCD single causes
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and institutions have also contributed significantly. Thanks are due to of premature mortality.
Muchiri Wandai, Noluthando Ndlovu and Algernon Africa for data
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of the team of reviewers (Peter Barron, Robin Dyers, Ega Janse van
Rensburg-Bonthuyzen).
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S A H R 20 1 6 3 11
Map 1: Changes in demarcation of municipalities to come into effect in 2016
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3 12 S A H R 20 1 6
Health and Related Indicators
Map 2: Hypertension prevalence (%) in adults age 15 years and older by district, 2012
PM
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Source: Analysis of National Income Dynamics Study as reported in the District Health Barometer 2014/15.67
S A H R 20 1 6 313
Map 3: Air pollution level in cities (annual mean concentration of particulate matter less than 10 microns in diameter in μg/m3), 2012
PM
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A N
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314 S A H R 20 1 6
Health and Related Indicators
PM
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Source: Calculated from DHIS population estimates for 2015 as the ratio of the number of people 65+ to the number under 15 years.
S A H R 20 1 6 315
Map 5: Percentage of years of life lost (YLLs) due to non-communicable diseases by district, 2013
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Source: Stats SA Causes of death 2013 as analysed and reported in the District Health Barometer 2014/15.67
Note: These percentages do not give any indication of the level of mortality due to this cause as would be provided by age-standardised mortality rates, but
only the relative proportion of all premature mortality (years of life lost).
316 S A H R 20 1 6
Health and Related Indicators
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Map 8: Percentage of YLLs due to cerebrovascular disease by district, 2013
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Map 9: Percentage of YLLs due to chronic obstructive pulmonary disease (COPD) by district, 2013
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318 S A H R 20 1 6
Health and Related Indicators
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Map 11: Percentage of YLLs due to hypertensive heart disease by district, 2013
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Map 12: Percentage of YLLs due to ischaemic heart disease by district, 2013
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indicators
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The WHO Global Reference List of 100 Core Health Indicators7 HIV/AIDS; Global TB = Global Tuberculosis Reports / Database;
provides a useful starting point for national indicator choices that GYTS = Global Youth Tobacco Survey; HDR = Human Development
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will be useful to monitor the SDGs as well as progress in realising Report; HEAIDS = Higher Education HIV/AIDS Programme;
universal health coverage. Figure 11 gives a sense of the range Hospitals Direct = Wilbury & Claymore database of private
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of sources available for these indicators at national level for South hospitals; HSRC = Human Sciences Research Council; IES = Stats SA
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Africa. It is not intended to be exhaustive, but the density of blocks Income and Expenditure Survey; IHME = Institute for Health Metrics
gives an indication of the wealth (or dearth) of data sources, and and Evaluation; MDG = Millennium Development Goals reports /
the time periods for which they are available. Some sources may database; med schemes = Council for Medical Schemes; mid-year
be disaggregated geographically and by some dimensions such as = Stats SA mid-year estimates; NCCEMD = National Committee
age group, gender or population group, and selected results are on Confidential Enquiries into Maternal Deaths; NCR = National
included in Table 40. Cancer Registry; NICD = National Institute for Communicable
Diseases; NiDS = National Income Dynamics Study; NYRBS =
Figure 11 indicates the number of main data series available from
National Youth Risk Behaviour Survey; PMTCT survey = Prevention
country sources (star symbol) and global agency estimates (circle).
of mother-to-child transmission survey; Postmortem = mortuary
It is not intended to identify every source but to show the variety
and post-mortem records; PPIP = Perinatal Problem Identification
of sources and the number of years for which data are readily
Program; RMS = Rapid Mortality Surveillance; RTMC = Road Traffic
available.
Management Corporation; SABSSM = South African HIV/AIDS
Abbreviations for data sources include: Behavioural Risks, Sero-Status and Mass Media Impact Survey;
AHS = Annual Health Statistics; ASSA = Actuarial Society of South SAGE = Study on global AGEing and adult health; SANHANES =
Africa; BoD = National Burden of Disease Study; Countdown = South African National Health and Nutrition Examination Survey;
Countdown to 2015: Maternal, Newborn and Child Survival; CS THEMBISA = integrated demographic and epidemiological model
= Community Survey; DHIS = District Health Information System; of the South African population; Treasury = South African National
GBD = Global Burden of Disease study; GHS = Stats SA General Treasury; UNICEF/WHO = United Nations Children’s Emergency
Household Survey; Global Report = various UNAIDS reports on Fund/WHO; WHO = World Health Organization.
320 S A H R 20 1 6
Health and Related Indicators
Figure 11: Snapshot of data available for South Africa in relation to the WHO 100 Core Health Indicators
Domain Sub-domain Indicator 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 data_series
Null
Input
PM
systems availability
HEAIDS
Utilisation rate PHC Hospitals Direct
HSRC
Quality and Inpatient crude death rate IES
safety
IHME
Maternal mortality ratio in facility /
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institutional (iMMR) Inter-agency group
MDG
Outcome
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mid-year
Percentage of households using
electricity for cooking (%) Nanoo et al.
NCCEMD
Percentage of households with
access to piped water NCR
RMS
Diabetes prevalence (%) RTMC
SABSSM
Exclusive breastfeeding rate (%) SAGE
SANHANES
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TB register
Percentage participating in
insufficient physical activity THEMBISA
R
Treasury
Prevalence of raised blood
pressure (%) UNICEF/WHO
vital registration
BA
Null
C ountry data s eries
Total alcohol per capita (age 15+
years) consumption (litres per year) G lobal data s eries
EM
Wasting (%)
S A H R 20 1 6 32 1
Births attended by skilled health
Domain Sub-domain Indicator (%)
personnel 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 data_series
Service Repro, Null
Outcome
PM
HSRC
Adult mortality (45q15 - probability
General IES
of dying between 15-60 years of a..
IHME
Life expectancy at birth Inter-agency group
MDG
Child under 5 years diarrhoea with
Infectious med schemes
dehydration incidence (per 1 000)
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disease
mid-year
Child under 5 years pneumonia
incidence (per 1 000) Nanoo et al.
NCCEMD
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HIV incidence (%) NCR
NICD
HIV prevalence (%) (age 15-49) NiDS
Treasury
Reported cases of TB (all types)
(per 100 000) UNICEF/WHO
vital registration
R
000
N
Null
Source: Compiled from WHO 100 Core Health Indicators list and multiple data sources reviewed for this chapter.
322 S A H R 20 1 6
Table 40: Selected national trends for WHO 100 Core Health Indicators
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total current expenditure on health as percentage of Fiscal Review 2015 private sector 4.6 4.5 4.6 4.6 4.4 4.3
Input Level
gross domestic product public sector 4.1 4.4 4.4 4.4 4.3 4.2
EM
Financing Subdomain
Total 8.7 8.9 9.0 9.0 8.7 8.5
Infrastructure
BA
Hospitals
Provincial Tertiary 0.2
R public sector 2.2 2.2 2.2 2.1 1.9
Regional Hospitals 0.6 0.6 0.5
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Dental practitioners PERSAL public sector 1.7 1.8 1.9 1.9 1.9 2.2 2.3 2.4 2.4 2.5
Dental specialists per 100 000 population PERSAL public sector 0.1 0.1 0.1 0.1 0.3 0.3 0.3 0.3 0.4 0.3
N O
Workforce
Dental therapists per 100 000 population PERSAL public sector 0.4 0.4 0.4 0.4 0.4 0.4 0.6 0.6 0.7 0.7
Enrolled nurses PERSAL public sector 50.6 51.8 55.4 56.2 58.8 65.8 69.3 69.9 69.4 68.6
Environmental health practitioners per 100 000 PERSAL public sector 2.1 2.1 2.0 1.8 1.9 1.9 2.1 2.2 1.9 1.8
population
4 ED
Medical practitioners per 100 000 population PERSAL public sector 23.2 24.1 26.0 26.5 27.3 29.0 29.0 31.3 30.8 30.3
Medical researchers per 100 000 population PERSAL public sector 0.3 0.2 0.2 0.3 0.3 0.3 0.2 0.2 0.2 0.2
S A H R 20 1 6
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Medical specialists per 100 000 population PERSAL public sector 9.0 9.7 9.8 10.5 10.7 11.2 11.1 11.4 11.1 11.1
Nursing assistants per 100 000 population PERSAL public sector 77.4 80.4 83.1 82.8 84.2 87.7 85.7 83.9 79.8 77.5
A N
Occupational therapists PERSAL public sector 1.6 1.8 1.9 2.0 2.0 2.3 2.4 2.6 2.8 2.9
Pharmacists PERSAL public sector 4.2 4.4 4.5 4.5 7.2 8.6 9.1 9.8 10.2 11.0
Y T
Physiotherapists per 100 000 population PERSAL public sector 1.9 2.1 2.2 2.3 2.4 2.6 2.6 2.8 2.8 2.9
Professional nurses PERSAL public sector 107.2 109.2 116.7 120.4 125.6 135.4 139.5 147.6 151.4 151.3
Psychologists PERSAL public sector 1.0 1.0 1.1 1.1 1.2 1.3 1.4 2.6 2.8 2.8
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Radiographers PERSAL public sector 5.1 5.1 5.2 5.4 5.6 5.9 6.1 6.1 6.2 6.1
Student nurses PERSAL public sector 21.8 23.4 23.8 26.1 26.4 26.5 25.0 17.6 15.3
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Tracer items stock-out rate (fixed clinic/CHC/CDC) DHIS NDoH 10.5 16.4 18.2 23.6
Output
Stock outs survey Any ART/TB drug out 21.5 25.0
Utilisation rate PHC DHIS DHIS 2.2 2.2 2.3 2.4 2.4 2.5 2.5 2.4 2.4
PM
Health systems
Inpatient crude death rate DHIS NDoH 5.6 5.5 5.1 5.8 5.4 5.2
Maternal mortality ratio in facility / institutional (iMMR) DHIS DHIS 138.5 144.9 132.9 133.3 132.5
323
324
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Air pollution level in cities (particulate matter [PM]) Global Health Observatory PM10 56.0
Percentage of households using electricity for cooking Census Census 73.9
Outcome Level
(%) Community Survey CS 66.4
disease
Infectious
Anaemia prevalence in children (%) SANHANES-1
O G
under 5 years 10.7
Anaemia prevalence in women of reproductive age (%) SANHANES-1 16-35 years 23.1
Diabetes prevalence (%) Diabetes Atlas
N O age 20-79 8.3 8.4 7.0
age 20-79 (age- 9.3 9.4 7.6
standardised)
S A H R 20 1 6
HIV-exposed 4-8 weeks 20.4 35.5 54.1
M U
HIV-unexposed 4-8 31.3 43.6 59.2
weeks
A N
Obesity (%) NCD Trends 2015 NiDS female 15+ 35.0 38.9 36.0
Y T
NiDS male 15+ 12.7 16.2 12.2
NiDS total 15+ 25.2 28.5 25.1
Ng et al. 2014 boys <20 years 7.0
20 IL
female 20+ 42.0
girls <20 years 9.6
male 20+ 13.5
16 6
NYRBS NYRBS 5.3 6.9
NYRBS female 7.2 10.0
PM
NYRBS male 3.3 3.6
SANHANES-1 boys 2-14 years 4.7
female 15+ 39.2
girls 2-14 years 7.1
male 15+ 10.6
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Percentage participating in insufficient physical activity NYRBS NYRBS 41.5 42.8
NYRBS female 46.2 47.5
Outcome Level
NYRBS male 36.7 37.7
S A H R 20 1 6
M U
GYTS female 10.5 12.1
GYTS male 22.8 21.7
A N
Reddy et al. 2015 female 18+ 7.3
male 18+ 29.2
Y T
total 18+ 17.6
SANHANES-1 age 15+ 16.2
20 IL
Smoking 1980-2012 IHME female 8.5 9.1
IHME male 23.1 22.0
IHME total 15.5 15.3
16 6
Wu et al. 2015 SAGE Wave1: 50+ 19.4
Stunting (%) NiDS NiDS <15 years 17.4 22.2 21.2
PM
NiDS female <15 16.2 21.1 20.1
NiDS male <15 18.5 23.3 22.3
NYRBS 2011 NYRBS 13.1 12.9
NYRBS female 11.1 11.3
NYRBS male 15.2 14.7
SANHANES-1 female <15 years 13.7
male <15 years 16.7
Health and Related Indicators
32 5
326
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total alcohol per capita (age 15+ years) consumption Global Alcohol 2014 drinkers only 27.1
(litres)
Outcome Level
Wasting (%) NiDS Wave 3 v1.2 under 5 years 5.6 4.6 5.4
adolescent
DHIS DH 12.5 12.0 12.9 12.4
N O DHIS NC 26.2 26.6 25.9 30.1
DHIS PT 20.7 18.2 22.1 23.1
S A H R 20 1 6
M U
Antiretroviral coverage (%) Global Plan Progress children 0-14 (GP 2015) 11.0 32.0 43.0 47.0 49.0
Service coverage
Infectious disease
THEMBISA 1.0 THEMBISA children 44.7
A N
THEMBISA female 15+ 62.7
THEMBISA male 15+ 51.5
Y T
THEMBISA total 8.6 13.0 18.7 27.0 35.7 46.0 57.0
Antiretroviral treatment exposure (%) HIV Household Survey 2012 age 0-14 45.1
age 15-24 14.3
20 IL
age 15-49 28.9
age 25-49 32.2
16 6
age 50+ 42.7
all ages 31.2
Case detection rate (all forms) Global TB Report Global TB 64.0 65.0 71.0 73.0 73.0 75.0 69.0 68.0 68.0
PM
HIV-positive new and relapse TB patients on DHIS DHIS 29.9 32.8
antiretroviral therapy (ART) during TB treatment (%) DoH TB TB register 28.0 60.6 72.0 78.9
Mother postnatal visit within 6 days rate (%) DHIS NDoH 5.6 26.3 56.4 65.2 73.0 74.3
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Number of patients receiving ART AHS 2012 Adults (men) 550 492
Adults (women) 1 060 579
Outcome Level
Children 124 619
DHIS Adults (Mar) 2 161 170 2 519 870 2 940 541
EM
S A H R 20 1 6
M DU
Immunization UNICEF/WHO 78.0 84.0 72.0 77.0
Births attended by skilled health personnel (%) HIV Children 2008 doctor 27.6
A N
doctor or nurse/midwife 94.3
nurse/midwife 66.7
Y T
327
328
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Adolescent fertility rate (per 1000 girls aged 15–19 Fertility 2011 Census 70
years)
Impact Level
Millennium Development 54.0
Fertility Subdomain
Goals
General
O G
ASSA2008 male 56.4 56.1 54.1 51.4 50.0 49.2 48.8 48.6 48.4 48.2
Burden of Disease SA 2010 BoD 42.6
Global Burden of Disease GBD 2013 female 35.0 35.3
GBD 2013 male 44.1 45.2
N OE
NiDS Demography Wave 1 NiDS female 52.0
4
NiDS male 57.0
RMS 2014 RMS 2014 female 40.0 38.0 35.0 32.0 30.0 28.0
S A H R 20 1 6
RMS 2014 male 51.0 48.0 46.0 44.0 42.0 40.0
M DU
RMS 2014 total 46.0 43.0 40.0 38.0 36.0 34.0
Life expectancy at birth ASSA2008 ASSA2008 54.6 55.1 56.4 57.6 58.2 58.4 58.5 58.5 58.5 58.6
A N
ASSA2008 female 57.7 58.3 59.7 60.9 61.5 61.7 61.7 61.6 61.5 61.5
ASSA2008 male 51.6 51.9 53.1 54.3 54.9 55.2 55.4 55.5 55.6 55.7
Y T
Burden of Disease SA 2010 BoD 58.8
RMS 2014 RMS 2014 female 59.7 61.2 63.2 64.0 65.1 65.8
20 IL
RMS 2014 male 54.6 56.0 57.8 58.5 59.4 60.0
RMS 2014 total 57.1 58.5 60.5 61.3 62.2 62.9
Stats SA Mid-year mid-year 55.3 57.5 58.7 59.7 60.0 59.7 60.2 61.3 62.5 62.5
16 6
estimates mid-year female 56.6 58.8 60.3 61.3 61.5 61.1 61.6 62.8 64.5 64.3
mid-year male 53.9 56.2 57.1 58.0 58.3 58.3 58.8 59.7 60.5 60.6
PM
Child under 5 years diarrhoea with dehydration incidence DHIS DHIS 21.1 17.1 13.2 11.2 14.1 11.3
(per 1 000)
disease
Infectious
Child under 5 years pneumonia incidence (per 1 000) DHIS DHIS 87.0 90.1 94.9 97.4 83.6 80.3 66.8 53.2 49.3
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
HIV incidence (%) ASSA2008 ASSA2008 total 1.0 0.9 0.8 0.8 0.7 0.7 0.7 0.7 0.7 0.7
population
Impact Level
HIV Household Survey 2012 HSRC age 2+ 1.1
S A H R 20 1 6
M U
Stats SA Mid-year mid-year 9.1 9.2 9.3 9.5 9.6 9.8 9.9 10.0 11.1 11.2
Estimates
Incidence of TB (all types) (per 100 000) Global TB Report 2015 Global TB (2015) 963 977 977 967 948 922 892 860 834
A N
Malaria mortality rate (per 100 000 population) DoH Malaria Statistics DoH Surveillance 0.2 0.3
Y T
Stats SA Causes of death VR 0.5
2013
Percentage of deaths due to AIDS ASSA2008 ASSA2008 39.9 39.1 36.1 32.9 31.7 31.3 31.5 31.9 32.4 32.8
20 IL
Burden of Disease SA 2010 BoD 35.0
BoD female 36.9
BoD male 33.1
16 6
Murray et al. 2014 GBD 2013 51.6
Stats SA Mid-year mid-year 46.2 42.6 38.9 35.8 34.6 34.6 33.5 31.9 29.2 30.5
Estimates
PM
Reported cases of cholera DoH Notification System NDoH 4 343.0 7 554.0
NICD surveillance NICD lab confirmed 570.0 1.0 1.0 0.0 1.0 2.0 0.0
cases
Reported cases of malaria (per 100 000) DoH Malaria Statistics NDoH 25.7 11.1 14.0 11.4 15.8 19.1 13.1 16.7 25.8 19.9
Reported cases of measles DoH Notification System NDoH 1 243.0 2 188.0 4 867.0 8 683.0
NICD surveillance NICD lab confirmed 40.0 5 860.0 12 499.0 92.0 20.0 8.0 69.0 15.0
cases
Health and Related Indicators
32 9
33 0
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Reported cases of TB (all types) (per 100 000) DoH TB TB register 722.4 739.6 794.9 820.2 802.2 762.3 689.3 648.9 592.5
Impact Level
Nanoo et al. 2015 Nanoo et al. 774.0
STI treated new episode incidence (per 1 000) DHIS DHIS 48.3 43.1 45.4 42.6 39.4 38.7 35.0 32.5 31.0
S A H R 20 1 6
male colorectal 7.6
M DU
male kaposi sarcoma 5.9
male lung 8.5
A N
male primary unknown 8.8
male prostate 29.9
Y T
Mortality between 30-70 years from cardiovascular, Global NCD 2014 27.7 26.8
cancer, diabetes or chronic respiratory disease
Infant mortality rate (deaths under 1 year per 1 000 live ASSA2008 ASSA2008 44.6 42.0 37.8 35.2 34.5 33.8 33.2 32.5 31.9 31.3
20 IL
births) Burden of Disease SA 2010 BoD 34.2
Child Mortality 2015 IGME Inter-agency group 34.0
16 6
RMS 2014 RMS 2014 39.0 35.0 28.0 27.0 29.0 28.0
Stats SA Mid-year mid-year 55.6 53.6 50.8 49.1 47.1 45.1 43.5 36.4 35.3 34.4
Estimates
PM
Maternal mortality ratio (MMR) IHME publications IHME 237.0 91.3 174.1
Maternal Mortality WHO 410.0 300.0 140.0
Impact Level
DHIS DHIS 11.0 9.9 10.2 10.9 11.6 12.3 12.1 12.2 12.8
IHME publications IHME 17.0
S A H R 20 1 6
M U
Perinatal deaths 2011-13 registered 13.0 13.0 14.0 14.0 15.0 14.0 13.0 17.0
registered (updated) 14.4
A N
Under 5 mortality rate (deaths under 5 years per 1 000 ASSA2008 ASSA2008 65.4 61.9 55.7 50.9 49.9 48.8 47.7 46.7 45.7 44.8
live births) Burden of Disease SA 2010 BoD 51.8
Y T
Child Mortality 2015 IGME Inter-agency group 41.0
(2015)
Global Burden of Disease GBD 42.6 40.0 37.0
20 IL
GBD female 50.2 38.2 35.8 32.9
GBD male 50.2 46.8 44.1 40.9
16 6
IHME publications IHME 57.4 57.1 56.0 53.4 50.9 50.7
RMS 2014 RMS 2014 56.0 52.0 40.0 41.0 41.0 39.0
Stats SA Mid-year mid-year 80.9 76.7 72.3 68.5 65.2 62.1 59.5 48.8 46.5 45.1
PM
Estimates
Headcount ratio of catastrophic health expenditure (%) Ataguba et al. 2014 NDoH 42.0
Health
Headcount ratio of impoverishing health expenditure (%) Ataguba et al. 2014 NDoH 72.0
systems
Financing
Health and Related Indicators
33 1
Indicator definitions for data tables presented in this chapter
WHO Core7
Type Indicator Definition
classification
Adolescent fertility rate Impact: Health status: Annual number of births to women aged 15-19 years per 1 000 women in that age group.
Demographic
(per 1 000 girls aged 15–19 Fertility It is also referred to as the age-specific fertility rate for women aged 15–19 years.
years) The adolescent birth rate is generally computed as a ratio. The numerator is the number of live births to women
aged 15–19 years, and the denominator is an estimate of exposure to childbearing by women aged 15–19 years.
The numerator and the denominator are calculated differently for civil registration and survey and census data.
Census data: With census data, the adolescent birth rate is generally computed on the basis of the date of last
birth or the number of births in the 12 months preceding the enumeration. The census provides both the numerator
and the denominator for the rates. In some cases, the rates based on censuses are adjusted for under-registration
based on indirect methods of estimation.
Age dependency ratio The ratio of the combined child population (0-14 years) and the aged population (65 years and over) - persons in the
dependent ages - to every 100 people of the intermediate age population (15-65 years) - economically active ages.
Where more detailed data are lacking, the age-dependency ratio is often used as an indicator of the economic
burden the productive portion of a population must carry - even though some persons defined as dependent are
producers and some persons in the productive ages are economically dependent.
PM
Ageing index Ratio of the number of people 65+ to the number under 15 years.
i.e. a value of 16 means there are 16 people aged 65 and over for every 100 under 15 years of age.
Calculated as ([65+/0-14]*100)
Average household size Average number of people living in each household where household is defined as a person, or a group of persons,
who occupy a common dwelling (or part of it) for at least four days a week and who provide themselves jointly
16 6
with food and other essentials for living. In other words, they live together as a unit. People who occupy the same
dwelling, but who do not share food or other essentials, are enumerated as separate households.
20 IL
Crude death rate (deaths per Number of deaths in a year per 1 000 population.
1 000 population)
Total fertility rate Impact: Health status: The average number of children that a woman gives birth to in her lifetime, assuming that the prevailing rates
A N
rate population size. It takes into consideration all the components of population growth, namely births, deaths and
migration.
Population Total number of people.
M U
Projected population figures are based on various projection models attempting to quantify the expected effects of
HIV and AIDS on population growth.
4 ED
Population % by province Proportion of South African population in each province (calculated from population per province and population for
whole of South Africa).
Population % by population Proportion of South African population in each population (ethnic) group (calculated from number of people per
group population group and population for whole of South Africa).
O
Public sector dependent This is an adjustment of the total population to the number assumed to be dependent on services in the public
population health sector based on medical scheme (health insurance) coverage.
G
It is calculated by subtracting the number of people with medical scheme cover (determined from medical scheme
membership reports, or surveys indicating percentage of population on medical schemes) from the total population.
Area (square km) Land area covered by geographic entity.
Socio-Economic Distribution
Area as a % of total area of Area of province divided by total area of country (South Africa).
South Africa
BA
Air pollution level in cities Outcome: Risk factors: Annual mean concentration of particulate matter of less than 2.5 microns of diameter (PM2.5) [mcg/m3] (or of less
(particulate matter [PM]) Environment than 10 microns [PM10] if PM2.5 is not available) in cities.
EM
332 S A H R 20 1 6
Health and Related Indicators
WHO Core7
Type Indicator Definition
classification
Drinking Water System (Blue Composite score measuring compliance of water suppliers with water quality management requirements. Includes
Household Facilities
PM
(%) households and where excreta are safely disposed in situ (e.g. in a sealed latrine pit until they are safe to handle
and re-use, such as an agricultural input ) or transported to a designated place for safe disposal or treatment (e.g.
treatment facility or hygienically collected from septic tanks or pit latrines by a suction truck or similar equipment
that limits human contact and thereafter transported to a designated location such as a treatment facility or solid
waste collection site).
16 6
The Stats SA General Household Survey defines ‘improved sanitation’ as households that had access to RDP
(Reconstruction and Development Programme) standard toilet facilities, i.e. flush toilets connected to a public
20 IL
sewerage system or a septic tank, and a pit toilet with a ventilation pipe.
Adult mortality (45q15 - Impact: Health status: The probability of dying between the ages of 15 and 60 years of age (percentage of 15-year-olds who die before
Mortality
million population)
M U
Prevalence of disability (%) Percentage of people reporting moderate to severe disability in a survey where disability is defined as a limitation
in one or more activities of daily living (seeing, hearing, communication, moving, getting around, daily life activities,
learning, intellectual and emotional).
4 ED
Since the 2009 GHS (revised in 2011), Stats SA have also excluded data on children under 5 years old, since it was
thought that these are often categorised as being unable to do the various activities, when this is in fact due to their
level of development rather than any innate disabilities.
Prevalence of hearing In the Census questionnaire, respondents were asked to indicate whether or not there were any people with serious
O
disability (%) visual, hearing, physical or mental disabilities in the household. The seriousness of the disability was not clearly
defined. Rather, the respondent’s perceptions of seriousness were relied on.
G
Reported cases of cholera/ Impact: Health status: The number of cases of cholera/ measles/ rabies reported to the Department of Health. Since case reporting of
Infectious
Disease
measles/ rabies Infectious disease notifiable diseases has been incomplete and delayed for several years, the number of laboratory-confirmed cases
R
from NHLS has been included where available, although these would be expected to include only a subset of the
total number of notified cases.
BA
Case detection rate (all Outcome: Service Proportion of incident cases of TB (all types) that were notified for a given country, it is calculated as the number
Tuberculosis (TB)
forms) coverage: Infectious of notified cases of TB in one year divided by the number of estimated incident cases of TB in the same year, and
O
incident cases
Incidence of TB (all types) Impact: Health status: Estimated number of cases of tuberculosis (all types) per 100 000 population (for the year).
(per 100 000) Infectious disease Adjusted for estimated under-reporting of TB cases and other factors.
Incidence of TB (PTB new Estimated number of cases of tuberculosis (pulmonary TB, new smear positive cases) per 100 000 population (for
Sm+) (per 100 000) the year). Adjusted for estimated under-reporting of TB cases and other factors.
Prevalence of multidrug Estimated percentage of new cases of TB which are multidrug resistant.
resistance among new TB
cases (%)
Tuberculosis death rate per Number of deaths due to TB in HIV-positive people per 100 000 population. Note that these deaths are officially
100 000 (in HIV-positive classified as being caused by HIV/AIDS according to the International classification of diseases.
people)
Tuberculosis mortality rate Impact: Health status: Number of deaths due to tuberculosis (all types) reported per 100 000 population (for the year).
Tuberculosis (TB)
per 100 000 Infectious disease Note that the estimates calculated from the Stats SA cause of death data are not corrected for under-reporting or
ill-defined coding, and are thus not an accurate of mortality due to TB. In addition many deaths in HIV-positive TB
cases are misattributed to TB rather than HIV (according to the ICD-10 rules).
Tuberculosis mortality rate Impact: Health status: Number of deaths due to tuberculosis (all types) reported per 100 000 population (for the year). The reported TB
per 100 000 (excluding HIV) Infectious disease mortality excludes deaths occurring in HIV-positive TB cases, in accordance with the definition used in ICD-10.
Tuberculosis prevalence rate Impact: Health status: Number of people with TB (all types) per 100 000 population.
per 100 000 population Infectious disease
S A H R 20 1 6 333
WHO Core7
Type Indicator Definition
classification
Bacteriological coverage The bacteriological coverage rate reflects the percentage of cases of PTB for which sputum microscopy results
Case finding
rate (%) were available. As such, it reflects both the availability of laboratory services and compliance with the national TB
guidelines which stress the use of sputum microscopy in the diagnosis of PTB.
Proportion of extra- Number of extra-pulmonary TB cases divided by total number of TB cases.
pulmonary TB HIV-infected individuals are more likely to suffer from extra-pulmonary TB. The rising proportion of extra-pulmonary
TB reflects the effect of the HIV epidemic on patterns of TB infection.
Reported cases of MDR-TB Number of laboratory-diagnosed cases of MDR-TB. MDR-TB is defined as resistance to rifampicin and isoniazid,
with or without resistance to other first-line anti-TB drugs.
Reported cases of TB (all Number of cases of tuberculosis (all types) reported to the DoH for the year.
types)
Reported cases of TB (all Impact: Health status: Number of cases of tuberculosis (all types) reported to the Department of Health per 100 000 population (for the
types) (per 100 000) Infectious disease year).
Note that reporting rates in some areas are far from complete and this may influence the values quite significantly.
Reported cases of TB (PTB Number of cases of tuberculosis (new smear positive) reported to the DoH for the year.
new Sm+)
PM
Reported cases of TB (PTB Number of cases of tuberculosis (pulmonary TB, new smear positive cases) reported to the Department of Health
new Sm+) (per 100 000) per 100 000 population (for the year).
Note that reporting rates in some areas are far from complete and this may influence the values quite significantly.
Reported cases of TB (PTB) Number of cases of tuberculosis (pulmonary TB) reported to the DoH for the year.
16 6
Reported cases of XDR-TB Number of laboratory-diagnosed cases of XDR-TB. XDR-TB is defined as resistance to rifampicin, isoniazid, any
fluoroquinolone and resistance to one or more of the following injectable anti-TB drugs: kanamycin, amikacin, and
capreomycin.
20 IL
Retreatment ratio Number of Sm+ retreatment cases divided by the number of Sm+ cases (new + retreatment) expressed as a
percentage.High defaulter rates contribute to high retreatment ratios.
Smear positivity (% of PTB Number of new smear positive PTB cases divided by number of PTB cases.
cases which are new Sm+)
Case fatality rate (MDR-TB)
Y T The percentage of registered MDR-TB patients who die while on treatment.
A N
(%)
Cure rate (new Sm+ cases) Percentage of patients who are proven to be cured.
M U
(%) Cured = a pulmonary TB patient with bacteriologically-confirmed TB at the beginning of treatment who was smear-
or culture-negative in the last month of treatment and on at least one previous occasion.
Defaulter rate (MDR-TB) (%) Percentage of patients who defaulted treatment.
4 ED
months or more.
MDR-TB started on Number of MDR-TB patients who started treatment
G
treatment
Smear conversion rate (new Percentage of new smear positive PTB cases who are smear negative after two months of anti-TB treatment and
R
(MDR-TB) (%)
BA
Successful treatment rate Percentage of patients who are cured plus those who complete treatment but without laboratory proof of cure (of
(new Sm+) (%) new smear positive patients).
O
TB client lost to follow up The percentage of TB clients (all types of TB) who were lost to follow up (defaulted) treatment.
rate (all TB) (%)
EM
TB death rate (all TB) (%) The percentage of TB clients (all types of TB) who died from any cause during treatment.
TB treatment failure (all The percentage of TB clients (all types of TB) who failed treatment.
TB) (%) Failed = a TB patient whose sputum smear or culture is positive at month five or later during treatment.
TB treatment success rate The percentage of TB clients (ALL types of TB) cured plus those who completed treatment
(all TB) (%)
XDR-TB started on Number of XDR-TB patients who started treatment
treatment
Case fatality rate: malaria Number of deaths divided by number of cases expressed as a percentage.
Malaria
33 4 S A H R 20 1 6
Health and Related Indicators
WHO Core7
Type Indicator Definition
classification
AIDS sick (number of Number of people estimated to be living with AIDS-defining conditions.
HIV Prevalence
PM
HIV prevalence (%) Impact: Health status: Percentage of population estimated to be HIV positive.
(total population) Infectious disease WHOCore indicator is given per 1 000 population rather than %.
People living with HIV The number of people who are HIV+.
AIDS orphans (maternal Number of children under 18 years who have lost either a mother (maternal orphan), a father (paternal orphan) or
HIV and AIDS
16 6
orphans <18 years) both parents (a double orphan) due to HIV/AIDS.
ANC clients tested for Proportion of women coming for their first antenatal visit who are tested for HIV.
HIV (%)
20 IL
Antenatal client initiated on Outcome: Service Antenatal clients on ART as a proportion of the total number of antenatal clients who are HIV positive and not
ART rate coverage: Infectious previously on ART.
disease Y T Not measuring the same thing as the WHO Core list indicator ‘Prevention of mother-to-child transmission’ which
is the % of all HIV-positive pregnant women who receive ART to reduce mother-to-child transmission during
pregnancy.
A N
Antiretroviral coverage (%) Outcome: Service The number of patients receiving ART, divided by the number needing treatment.
coverage: Infectious
M U
The denominator has changed over time, due to changes in treatment guidelines affecting the criteria for treatment
disease eligibility. The latest definition is that all HIV-infected patients should be on ART.
Antiretroviral treatment Outcome: Service Percentage of people living with HIV on ART.
4 ED
exposure (%) coverage: Infectious Measured by laboratory testing for antiretroviral drugs in HIV-positive samples.
disease
Early infant diagnosis The numerator is the number of PCR tests performed by the National Laboratory Service for infants 2 months old or
coverage younger, as a proxy for the first PCR test. The estimated number of HIV-exposed infants (denominator) is calculated
by multiplying antenatal maternal HIV prevalence rates by the number of live births.
O
HIV testing coverage (%) Percentage of target population who have been tested for HIV.
The DHIS indicator ‘HIV testing coverage (including ANC)’ is defined as Clients HIV tested (ANC and other) as
G
relapse TB patients on coverage: Infectious percentage of those registered in a specified time period.
antiretroviral therapy (ART) disease
during TB treatment (%)
BA
Infant 1st PCR test around 6 Indicator previously called ‘Baby PCR test around 6 weeks uptake rate’. Babies PCR tested 6 weeks after birth as
weeks uptake rate (%) the proportion of live births to HIV-positive women. (DHIS – National Indicator Data Set)
O
Infant 1st PCR test positive Indicator previously called ‘Baby PCR test positive around 6 weeks rate’. Babies tested PCR positive 6 weeks after
around 6 weeks rate (%) birth as the proportion of babies PCR tested at 6 weeks. (DHIS)
Male circumcision (% of men The percentage of men (15–59 years, unless otherwise specified) who have been circumcised.
who are circumcised)
Mother-to-child transmission This indicator measures the proportion of HIV-exposed infants who received a PCR test under two months of age
rate of HIV <2 months of age who tested positive.
Percentage of deaths due Impact: Health status: Percentage of total deaths attributed to AIDS related causes.
to AIDS Infectious disease WHOCore indicator is AIDS-related mortality rate (per 100 000 population)
Defined as: Estimated number of adults and children who have died due to AIDS-related causes in a specific year,
expressed as a rate per 100 000 population.
TB cases with known HIV Outcome: Service Percentage of TB cases (all TB) with known HIV status (positive or negative)
status (%) coverage: Infectious WHO Core list calls this: HIV test results for registered new and relapse TB patients
disease Defined as: Number of new and relapse TB patients who had an HIV test result recorded in the TB register,
expressed as a percentage of the number registered in
a specified time period.
Percentage men with painful Percentage of men 15 years and older with painful urination, penile discharge or genital sores in the last 3 months.
STIs
S A H R 20 1 6 335
WHO Core7
Type Indicator Definition
classification
Age of first sex under 15 Percentage of people surveyed (of various age groups) who report having first had sexual intercourse at age 14
Contraception and sexual behaviour
years (% having first had sex years or younger. The age cut-off varies slightly between surveys with the HSRC HIV Household survey including
at age 14 or younger) ‘under 15 years’ compared to the NYRBS which includes ‘under 14 years’.
Condom use at last sex (%) Percentage of those, who reported ever having had sex, who used a condom the last time they had sex. Note that
the precise definition of this indicator varies between surveys.
Couple year protection rate The rate at which couples (specifically women) are protected against pregnancy using modern contraceptive
methods INCLUDING sterilisations.
(previously Women year protection rate).
Numerator: Contraceptive years equivalent
Denominator: Target population 15–49 years (couples using females as proxy). Denominator was females 15–44
years in data up to 2010/11.
HIV knowledge: correct The percentage of people who correctly answer a composite measure of accurate knowledge of two questions
knowledge about prevention related to HIV prevention in combination with rejecting four myths and misconceptions about the disease. The two
and rejection of major questions on prevention of HIV transmission were ‘To prevent HIV infection, a condom must be used for every round
misconceptions of sex’ and ‘One can reduce the risk of HIV by having fewer sexual partners’ while the four questions about myths
and misconceptions were ‘There is a cure for AIDS’, ‘AIDS is caused by witchcraft’, ‘HIV causes AIDS’, and ‘AIDS is
cured by having sex with a virgin’.
PM
Male condom distribution The number of male condoms distributed (to patients at the facility or through other channels) per male 15 years
coverage (condoms per and older.
male 15 years and older)
Male condoms distributed Number of male condoms distributed.
16 6
(thousands) Data should be interpreted with caution depending on what distribution channel it is for – i.e. condoms distributed
by national to provinces, or number distributed through PHC facilities (since some condoms are distributed to
20 IL
provinces, that are then distributed through several channels including PHC facilities).
Teenage pregnancy (%) Percentage of women aged 15–19 who are mothers or who have ever been pregnant. The percentage of women
who are mothers at the time of the survey is a more restrictive definition.
Y T Note that some of the surveys report this indicator as the percentage who have ever been pregnant of those WHO
HAVE EVER HAD SEX. This is a different denominator to that used by the Demographic and Health Surveys, and
A N
the data can therefore not be directly compared.
ANC coverage (%) Outcome: Service Proportion of pregnant women receiving some antenatal care.
Maternal health
coverage: Repro,
M U
DHIS data source: Estimated from the number of first ANC visits divided by the population under 1 year x 1.15 (as a
maternal, child, proxy for the number of pregnant women).
adolescent
WHO core list of indicators defines this indicator as ‘Percentage of women aged 15?49 years with a live birth in a
4 ED
given time period who received antenatal care, four times or more.’.
Caesarean section rate (%) Percentage of births that are by Caesarean section.
Delivery rate in facility (%) The percentage of deliveries taking place in health facilities under supervision of trained personnel. (The number
of children under one year, factorised by 1.07 due to infant mortality, is used as an estimated proxy denominator for
O
expected deliveries.)
Maternal mortality ratio Impact: Health status: The number of women who die as a result of childbearing, during the pregnancy or within 42 days of delivery or
G
(MMR) Repro, maternal, child, termination of pregnancy in one year, per 100 000 live births during that year.
adolescent
Maternal mortality ratio in Output: Health The number of women who die as a result of childbearing, during the pregnancy or within 42 days of delivery or
R
facility / institutional (iMMR) systems: Quality and termination of pregnancy in one year, per 100 000 live births during that year. Refers only to institutional / facility-
safety based deaths, not representing the entire population. Note that WHO Core list definition is per 100 000 deliveries
BA
(not live births) – Number of maternal deaths among 100 000 deliveries in health facilities/institutions.
Mother postnatal visit within Outcome: Service Mothers who receive postnatal care within 6 days of delivery after discharge from place of delivery as proportion of
6 days rate (%) coverage: Infectious all deliveries in facility.
O
disease WHO Core list defines this for 2 days from childbirth – ‘Percentage of mothers and babies who received postpartum
EM
DHIS definition: Termination of pregnancies performed in a health facility as the proportion of all expected
pregnancies in the catchment population.
33 6 S A H R 20 1 6
Health and Related Indicators
WHO Core7
Type Indicator Definition
classification
Age-standardised mean Outcome: Risk factors: Age-standardised mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years.
Nutrition
PM
NCDs and nutrition Proportion of children with weight for height over 2 standard deviations from the norm (reference population
median).
Adults:
Percentage of people with body mass index (BMI) of 25–29.9 kg/m2. BMI is weight in kg divided by the square of
height in m.
16 6
WHOCore indicators for children under 5 years of age and adults (aged 18+ years). Rates in adults to be age-
standardised.
20 IL
Stunting (%) Outcome: Risk factors: Proportion of children with height for age under 2 standard deviations from the norm (reference population median).
NCDs and nutrition
Underweight (%) Y T Children: Proportion of children with weight for age under 2 standard deviations from the norm (reference
population median).Adults: Percentage of people with body mass index (BMI) <18.5 kg/m2. BMI is weight in kg
divided by the square of height in m.
A N
Vitamin A coverage children Outcome: Service Proportion of children 12–60 months receiving vitamin A 200 000 units twice a year. The denominator is thus the
12–59 months (%) coverage: Repro, target population 1–4 years multiplied by 2.
M U
maternal, child, For surveys this indicator is usually given as the percentage of children who received Vitamin A supplements in the
adolescent preceding 6 months.
Vitamin A deficiency (%) Proportion of children with serum retinol <20mcg/dl.
4 ED
Waist-hip ratio (WHR) above Proportion of people with the ratio of waist / hip circumference >= 1.0 (for men) or >=0.85 (for women).
cut-off (%) Body Mass Index does provide an index for obesity, but has limitations in predicting risk for cardiovascular events.
Research has indicated that measurement of WHR enables prediction of cardiovascular risk (Am Heart J 2005 Jan
149: 54–60.)
O
Wasting (%) Outcome: Risk factors: Proportion of children with weight for height under 2 standard deviations from the norm (reference population
NCDs and nutrition median).
G
Child under 5 years Impact: Health status: Children under 5 years newly diagnosed with diarrhoea with dehydration per 1 000 children under 5 years in the
Child Health
incidence (per 1 000) Although reported as a rate per population, this is one example of the general WHOCore indicator: New cases of
vaccine-preventable diseases
BA
Defined as: Number of confirmed new cases of vaccine-preventable diseases that are included in the WHO
N
Disease (diphtheria, hepatitis B, pertussis, neonatal tetanus, total tetanus, measles, rubella, congenital rubella
syndrome, mumps, diarrhoea, pneumonia, Japanese encephalitis, yellow fever)
EM
Child under 5 years Impact: Health status: The number of children under 5 years diagnosed with pneumonia, per 1 000 children in the catchment population.
pneumonia incidence (per Infectious disease
1 000)
Child under 5 years severe The number of children who weigh below 60% expected weight for age (new cases that month) per 1 000 children
acute malnutrition incidence in the target population.
(per 1 000) Previously called ‘Severe malnutrition under 5 years incidence’.
Children living far from their Input: Health systems: This indicator reflects the distance from a child’s household to the health facility they normally attend. Distance is
usual health facility (%) Infrastructure measured through a proxy indicator: length of time travelled to reach the nearest health facility, by whatever form of
transport is usually used. The health facility is regarded as ‘far’ if a child would have to travel more than 30 minutes
to reach it, irrespective of mode of transport.
Exclusive breastfeeding Outcome: Risk factors: Proportion of living children receiving only breast milk from birth to various ages.
Child Health
S A H R 20 1 6 337
WHO Core7
Type Indicator Definition
classification
BCG coverage (%) Outcome: Service The proportion of expected live born babies that received BCG under 1 year of age (note: usually given immediately
Immunisation
PM
OPV 1 coverage (%) Outcome: Service The proportion of children under 1 immunised with OPV dose 1.
coverage: Repro,
maternal, child,
adolescent
16 6
PCV7 3rd dose coverage Outcome: Service The proportion of children who received their third PCV7 dose (around 9 months) – annualised.
(%) coverage: Repro,
maternal, child,
20 IL
adolescent
RV 2nd dose coverage (%) Outcome: Service The proportion of children who received their second RV dose (around 14 weeks) – annualised.
coverage: Repro,
Y T
maternal, child,
adolescent
A N
Child mortality (deaths The number of children aged 12 months to 5 years (i.e. to the end of the 4th year) who die in a year, per 1 000 live
Child mortality and related
births) adolescent
Live birth under 2500g in Outcome: Risk factors: Percentage of live births under 2 500g. Was previously called ‘Low birth weight rate’ in DHIS.
facility rate (%) Repro, maternal, child,
adolescent
O
Neonatal mortality rate Impact: Health status: Number of deaths within the first 28 days of life, in a year, per 1 000 live births during that year.
(NNMR) (deaths <28 days Repro, maternal, child, Also called Neonatal Deathy Rate (NNDR).
old per 1 000 live births) adolescent
G
Number of under-5 deaths The estimated number of deaths in children younger than 5 years.
Perinatal care index Perinatal mortality rate divided by the Low birth weight rate.
R
(perinatal MR / LBWR) The Perinatal Care Index is a quality of care index that has been validated as a true measure of the quality of care;
the higher the index the poorer the care. The values should be below 1 for CHCs and below 2 for all hospitals.
BA
Perinatal mortality rate The number of perinatal deaths per 1 000 births. The perinatal period starts as the beginning of foetal viability
(stillbirths plus deaths <8 (28 weeks gestation or 1 000g) and ends at the end of the 7th day after delivery. Perinatal deaths are the sum of
O
days old per 1 000 total stillbirths plus early neonatal deaths. These are divided by total births (live births plus stillbirths).
births)
EM
Post-neonatal mortality rate Number of deaths occurring between 28 and 365 days after birth per 1 000 live births in the same period.
(deaths 28–365 days age
per 1 000 live births)
Stillbirth rate (per 1 000 total Impact: Health status: Number of stillbirths per 1 000 total births.
Child mortality and related
33 8 S A H R 20 1 6
Health and Related Indicators
WHO Core7
Type Indicator Definition
classification
Cervical cancer screening Outcome: Service Women 30 years and older with a cervical (Pap) smear done for screening purposes according to the national
Chronic Diseases
coverage (%) coverage: Repro, policy of screening all women in this age category every 10 years, as the proportion of all women 30 years and older
maternal, child, in the target population. The denominator is 10% of the female target population 30 years and older.
adolescent
Diabetes prevalence (%) Outcome: Risk factors: Percentage of people with diabetes.
NCDs and nutrition Defined in SANHANES as those with HbA1c > 6.5%
WHOCore indicator is: Age-standardised prevalence of raised blood glucose/diabetes among persons aged 18+
years or on medication for raised blood glucose
Defined as:
fasting plasma glucose value ≥7.0 mmol/L (126 mg/dL) or on medication for raised blood glucose among adults
aged 18+ years).
Diabetes prevalence (per Number of people with diabetes per 1 000 people in the target population.
1 000)
Hyperlipidaemia prevalence Number of people with hyperlipidaemia per 1 000 people in the target population.
(per 1 000) Data for the private sector are based on the number of people being TREATED for this condition.
Hypertension prevalence Percentage of people with hypertension, where hypertension is usually defined as individuals with systolic
PM
(%) blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mm Hg and/or who reported the current use of
antihypertensive medication.
Hypertension prevalence Number of people with hypertension per 1 000 people in the target population.
(per 1 000) Data for the private sector are based on the number of people being TREATED for this condition.
16 6
The measured prevalence of hypertension was defined as those with BP equal or above 140/90 mmHg and/or
taking anti-hypertensive medication.
20 IL
Hypertension treatment Outcome: Service Hypertension is defined as usual systolic blood pressure over 140 mm Hg and/or diastolic blood pressure over
coverage (%) coverage: NCDs and 90 mmHg, or ‘currently taking medication for hypertension’. Hypertension treatment coverage is defined as the
nutrition proportion of people with hypertension who are currently taking medication.
Mortality between 30–70 Impact: Health status:
Y T Unconditional probability of dying between exact ages 30 and 70 from any of cardiovascular disease, cancer,
years from cardiovascular, NCDs and nutrition diabetes, or chronic respiratory disease.
cancer, diabetes or chronic
A N
Deaths from these four causes will be based on the following ICD codes: I00–I99, COO–C97, E10–E14 and J30–
respiratory disease J98.
According to WHOCore indicators: Modelling, using multiple inputs, is often used if no complete and accurate data
M U
are available.
Age standardization is done for comparability over time and between populations.
Prevalence of abnormal lipid Percentage of people with raised cholesterol or other abnormal lipid profiles.
4 ED
profiles (%)
Prevalence of mental Percentage of the population suffering from any common mental disorders.
disorders
Prevalence of raised blood Outcome: Risk factors: Percentage of people with systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg.
O
Currently drink alcohol (%) Proportion of people who currently drink alcohol.
Ever drank alcohol (%) Proportion of people who ever drank alcohol.
BA
Ever smoked cigarettes (%) Outcome: Risk factors: Proportion of people who have ever smoked a cigarette, even one or two puffs.
NCDs and nutrition
O
Ever used drugs (%) Proportion of people who have ever used drugs.
Frequent smokers (%) Outcome: Risk factors: Proportion of people who smoked (cigarettes) on 20 or more days of the past 30 days.
EM
S A H R 20 1 6 339
WHO Core7
Type Indicator Definition
classification
Number of admissions for Number of patients admitted for treatment by treatment centres who are part of the SACENDU Project sentinel
Behaviour & Awareness
PM
years (%)
Total alcohol per capita (age Outcome: Risk factors: Total alcohol per capita is the total amount (sum of recorded alcohol per capita three-year average and unrecorded
15+ years) consumption NCDs and nutrition alcohol per capita) of alcohol consumed per adult (15+ years) in a calendar year, in litres of pure alcohol. Recorded
(litres) alcohol consumption refers to official statistics (production, import, export, and sales or taxation data), while
16 6
unrecorded alcohol consumption refers to alcohol which is not taxed and is outside the usual system of government
control. In circumstances in which the number of tourists per year is at least the number of inhabitants, tourist
consumption is also taken into account and is deducted from a country’s recorded alcohol per capita.
20 IL
Watch TV more than 3 hours Proportion of those surveyed (who have access to a TV, video or computer games) who spent 3 hours or more
per day (%) watching TV or playing video/computer games during an average school day.
Always wear a seat belt Proportion of people who always wear a seat belt when driven in a car by someone else.
Injuries
Road accident fatalities per Impact: Health status: Number of fatalities due to road accidents per 100 000 population.
100 000 population Injury and violence
Percentage of users of Percentage of users of private health services highly satisfied with the service received.
Health Services
4 ED
Average length of stay Average duration of patient stay in health facility. Numerator: Inpatient days + 1/2 Day patients. Denominator:
Health Facilities
(ALOS) Inpatient separations (currently defined as: Discharges + Deaths + Transfers out).
R
Inpatient bed utilisation rate Measure of the occupancy of the beds available for use.
– total (BUR) Numerator: (Inpatient days + 1/2 Day patients) x 100
BA
systems: Quality and clients, Inpatient discharges, Inpatient deaths and Inpatient transfer outs.
safety
EM
Tracer items stock-out rate Output: Health The proportion of all fixed clinics, CHCs and CDCs that had stock out of ANY tracer item for any period.
(fixed clinic/CHC/CDC) systems: Access and
availability
Usable beds per 1 000 Input: Health systems: The number of usable beds divided by the population x 1 000. Where this is calculated for public health sector beds,
population Infrastructure the population used is the public sector dependent (uninsured) population.
Utilisation rate PHC Output: Health Number of visits per person to PHC health facilities per year. Calculated from PHC headcount divided by total
systems: Access and population.
availability
Utilisation rate PHC <5 Number of visits per person <5 years to PHC health facilities per year. Calculated from PHC headcount <5 years
years divided by population <5 years.
Number of (health Number of this category of health professional working in the specified sector.
Health
population Personnel
professionals)
Number of (health Number of this category of health professional registered with the relevant professional council. This number
professionals) registered includes those working in the public or private sector as well as those registered but not working or overseas.
(Health professionals) per Input: Health systems: Ratio of the number of personnel to the population (per 100 000).
Personnel per
100 000 population Workforce Note that the measure of the number of personnel may differ for the public and private sectors and also that the
population may be adjusted to be the population assumed to be dependent on that sector.
3 40 S A H R 20 1 6
Health and Related Indicators
WHO Core7
Type Indicator Definition
classification
Claims ratio (%) Proportion of member contributions that has been utilised for the payment of benefits claimed by members of
Health Financing
medical schemes, as opposed to allocation of contributions for non-health benefits and the building of reserves.
Headcount ratio of Impact: Health Proportion of the population (or sub-population) facing catastrophic health expenditures.
catastrophic health systems: Financing Headcount ratios are the estimated total number of households facing catastrophic health expenditures over the
expenditure (%) total number of households.
A household is identified as facing catastrophic health expenditures when its out-of-pocket health expenditures
represent 40% or more of its capacity-to-pay. Capacity-to-pay is estimated as total expenditure net of a subsistence
level of food expenditure. The latter is calculated as the average food expenditure per equivalent adults of
households in the 45th–55th food budget share distribution. When actual food spending falls below this amount,
capacity-to-pay is defined as total expenditures net of actual food spending.
Headcount ratio of Impact: Health Proportion of the population (or sub-population) facing impoverishing health expenditures.
impoverishing health systems: Financing Headcount ratios are the estimated total number of households facing impoverishing health expenditures over the
expenditure (%) total number of households.
A household is identified as facing impoverishing health expenditures when its out-of-pocket health expenditures
push it below a poverty line (i.e. a household is above the poverty line when taking its total expenditure gross of
out-of-pocket payments but below the poverty line when taking total expenditure net of out-of-pocket payments).
PM
The poverty line is defined as subsistence level food expenditure estimated as the average food expenditure per
equivalent adults of households in the 45th–55th food budget share distribution. When actual food spending falls
below this amount, then capacity-to-pay is defined as total expenditures net of actual food spending.
Health as percentage of total Proportion of total (government) expenditure on health.
expenditure
16 6
Provinces with central hospitals have a higher share.
Medical scheme Number of medical scheme beneficiaries, as reported by the Medical Schemes Council.
20 IL
beneficiaries
Medical scheme coverage Proportion of population covered by medical schemes.
(%)
Pensioner ratio (%)
Per capita expenditure (non-
Y T Proportion of members of medical schemes who are 65 years or older, in registered medical schemes.
Amount spent on non-hospital PHC services by the public sector per person without medical aid coverage
A N
hospital PHC) (in Rand).Includes provincial expenditure from sub-programmes 2.2–2.7 (clinics, community health centres,
community-based services and other community services, nutrition and HIV) under District Health Services, plus
net Local government expenditure on health services. Expenditure is divided by the population without medical
M U
scheme coverage. Expenditure may be given in nominal terms (prices for the year of expenditure) or real terms
(inflation adjusted prices to a particular base year).
Per capita health Amount spent on health per person (in Rand)
4 ED
expenditure For the public sector, this is often calculated for the population without medical aid coverage (public sector
dependent population). For the private sector this is usually calculated for the number of medical schemes
beneficiaries.
Note that attention should be given to the notes for each data item, since financial indicators are affected by
O
inflation, and expenditure may be reported according to currency value for a particular year to facilitate comparison
of real differences.
G
Ratio of private to public Total private per capita expenditure divided by total public sector per capita expenditure.
sector per capita health Public health sector expenditure is divided by the population covered (public sector dependent population)
expenditure Private sector is total medical scheme expenditure divided by number of beneficiaries.
R
Total current expenditure Input: Health systems: Proportion of national Gross Domestic Product that is spent on healthcare.
on health as percentage of Financing
BA
S A H R 20 1 6 341
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348
EM
BA
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O G
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4 ED
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PM
Abbreviations
A
AFFIRM The Africa Focus on Intervention research for Mental Health
AHPCSA Allied Health Professions Council of South Africa
AHS Annual Health Statistics
AIDS Aquired Immune Deficiency Syndrome
ALOS average length of stay
AMD acid mine drainage
AMRH African Medicines Regulatory Harmonization
AMS antimicrobial stewardship
ANC African National Congress
ANC antenatal care
application programming interface
PM
API
ART antiretroviral therapy/ treatment
ARVs antiretroviral drugs
B
16 6
BCEA Basic Conditions of Employment Act
BDCT Birth Defects Collection Tool
20 IL
BFHI Baby-Friendly Hospital Initiative
BMI body mass index
BPCP Breastfeeding Peer-Counselling Programme
BUR
C
bed utilisation rate
Y T
A N
CAIR Centre for Artificial Intelligence Research
M U
S A H R 20 1 6 3 49
DPME Department of Performance Monitoring and Evaluation
DSD Department of Social Development
DST Department of Science and Technology
DWS Department of Water and Sanitation
E
EBF exclusive breastfeeding
EEA Employment Equity Act
eHealth electronic health
EHOs Environmental health officers
EHS Employee Health Services
EIMC early infant male circumcision
EMERALD Emerging mental health systems in low- and middle-income countries
EML Essential Medicines List
EMS Emergency Medical Services
Ens enrolled nurses
PM
EPDS Edinburgh Postnatal Depression Scale
EPI Expanded Programme of Immunisation
EPWP Extended Public Works Programme
EU European Union
16 6
F
FAS fetal alcohol syndrome
20 IL
FFC Financial and Fiscal Commission
FHIR Fast Healthcare Interoperability Resources
Food-EPI Food Environment Policy IndexY T
FP2020 Family Planning 2020
A N
FPL food poverty line
G
M U
H
HAI Health Action International
R
35 0 S A H R 20 1 6
Abbreviations
PM
IPTp Intermittent preventive therapy for malaria during pregnancy
IRS indoor residual spraying
ISCOLE International Study of Childhood Obesity, Lifestyle and the Environment
ISS Injury severity score
16 6
IUCD intrauterine contraceptive device
IYCF infant and young child feeding
20 IL
IYCN infant and young child nutrition
J
JMP Joint Monitoring Project Y T
JSON JavaScript Object Notation
A N
K
KMC Kangaroo Mother Care
M U
KZN KwaZulu-Natal
L
LBPL lower-bound poverty line
4 ED
M
M&E monitoring and evaluation
G
MD mean difference
MDB Municipal Demarcation Board
O
S A H R 20 1 6 35 1
MPH Master of Public Health
MPI master patient index
MPI Multidimensional Poverty Index
MRC Medical Research Council
MSDs musculoskeletal disorders
MSP multiple sexual partners
MTCT mother-to-child transmission of HIV
MTEF Medium-term Expenditure Framework
N
NACOSA Networking HIV and AIDS Community of South Africa
NAMDA National Medical and Dental Association
NaPeMMCo National Perinatal Mortality and Morbidity Committee
NAPHISA National Public Health Institute of South Africa
NCCEMD National Committee on Confidential Enquiries into Maternal Deaths
NCD non-communicable disease
PM
NCS National Core Standards
NDoH National Department of Health
NDP National Development Plan
Net-EN norethisterone enanthate
16 6
NGO non-governmental organisation
NHA National Health Act
20 IL
NHI National Health Insurance
NHIS National Health Information Systems
NHLS National Health Laboratory Service
Y T
NHRC National Health Research Committee
A N
NHRD National Health Research Database
NHRO National Health Research Observatory
M U
O
OASSSA Organisation of Appropriate Social Services in South Africa
OECD Organisation for Economic Co-operation and Development
OHSC Office of Health Standards Compliance
ORS oral rehydration solution
OSD Occupation-specific Dispensation
OSS Operation Sukuma Sakhe
P
PC101 Primary Care 101
PCC Presidential Coordination Committee
PDD Principles for Digital Development
PEPFAR United States President’s Emergency Plan for AIDS Relief
PFIP Partnership Framework Implementation Plan
PGWC Provincial Government of the Western Cape
PH public health
PHC primary health care
PHCP Primary Health Care Providers
PHEIC Public Health Emergency of International Concern
PHM Public Health Medicine
PILIR Policy and procedure on Incapacity Leave and Ill-health Retirement
352 S A H R 20 1 6
Abbreviations
PM
RCT randomised controlled trial
RDP Reconstruction and Development Programme
RDT rapid diagnostic tests
RECs Regional Economic Communities
16 6
RHAP Rural Health Advocacy Project
RIMS Road Incident Management System
20 IL
RIMS Research Information Management System
RMS Rapid Mortality Surveillance
RTMC Road Traffic Management Corporation
Y T
S
A N
SA South Africa
SACENDU South African Community Epidemiology Network on Drug Use
M U
S A H R 20 1 6 353
ToPs terminations of pregnancy
TSSA Trauma Society of South Africa
TST Test test for latent TB
U
U5MR under-5 mortality rate
UBPL upper-bound poverty line
UCT University of Cape Town
UHC universal health coverage
UK United Kingdom
UKZN University of KwaZulu-Natal
UMIC upper middle-income countries
UN United Nations
UNAIDS United Nations Programme on HIV and AIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
PM
UN-Habitat United Nations Human Settlements Programme
UNICEF United Nations Children’s Fund
UPFS Uniform Patient Fee Schedule
US United States
16 6
USAID United States Agency for International Development
USSD Unstructured Supplementary Service Data
20 IL
UTT universal test-and-treat
V
VAT
VOCS
Value Added Tax
Victims of Crime Survey
Y T
A N
W
WBOTs Ward-based Outreach Teams
M U
WC Western Cape
WC DoH Western Cape Department of Health
4 ED
X
XDR-TB extensively drug-resistant tuberculosis
G
Y
YLD years lived with disability
R
35 4 S A H R 20 1 6
PM
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