South African Health Review - Volume 2006, Issue 1, 2006
Volume 2006, Issue 1, 2006
Source: South African Health Review 2006, pp 3 –18 (2006)More Less
In accordance with the State's duty to realise the right of access to health care services, it has adopted a wide range of legislative and other measures. Though the pace at which these measures have been adopted has been challenged and criticised by some, there is no doubt that the range of legislative measures presently in place, if properly implemented, are likely to go a long way in ensuring access to health care services, in developing a rights framework in respect thereof and ultimately inholding institutions and individuals accountable for the delivery of efficient and quality health care services for all South Africans.
This chapter discusses some of the key legislative developments over the past year, provides an overview of current pending legislation and discusses some of the key court challenges and legal debates relating to health legislation and policy in the South African context.
Author Scott SinclairSource: South African Health Review 2006, pp 19 –30 (2006)More Less
Important aspects of South Africa's flagship health legislation, the National Health Act, conflict with legally binding commitments the former apartheid regime negotiated under the World Trade Organization's General Agreement on Trade in Services. This trade treaty conflict threatens to undermine the legislation and, if left unresolved, would make meeting the health needs of the majority of the population more difficult. South Africa has several options for resolving this conflict in favour of its health policy imperatives, but each entails risk. South Africa's dilemma should serve as a worldwide warning that health policy-makers, governments and citizens need to be far more attentive to international treaties governing services and ongoing negotiations to expand them. Hopefully, this increased awareness will spur action to ensure that South African health policy initiatives can proceed without World Trade Organization's General Agreement on Trade in Services interference.
Source: South African Health Review 2006, pp 31 –64 (2006)More Less
Public sector health care funding continues to stabilise, with provincial expenditure growing by 5.6% annually above inflation (i.e. real terms) from 2002/03 to 2008/09. The main areas which have benefited from funding growth are primary health care (8.5% annually), HIV and related illnesses (30.1%), infrastructure (14.3%) and emergency medical services (14.3% annually). With the exception of capital expenditure, hospital funding, particularly for central hospitals, has been constrained for a decade. Spending in under-resourced provinces such as Limpopo and Mpumalanga is growing strongly.
Improved funding has supported an increase in primary care visits by 20 million since 2000 and public sector health personnel numbers have recovered by almost 20 000over the past two years to reach 235 000. However despite various funding, service and public health improvements, mortality is increasing largely driven by the HIV epidemic and resultant TB. Greater attention to improving effectiveness and outcomes is required.
Private medical scheme beneficiary numbers increased marginally, by 2.7% in 2005. This is associated with lower than usual contribution increases, given the high solvency margins that have now been achieved by schemes.
Author Faith KumaloSource: South African Health Review 2006, pp 65 –76 (2006)More Less
This chapter looks at national and international trends in health information systems. The organisation and development of the South African national health information system over the past five years is discussed within this context. A health management information system fundamentally requires the use of health information at policy, health system and health service levels to support management decisions.
The chapter explores the importance of locating a health management information strategy within a conceptual framework that captures the fundamental essence and purpose of HMIS. This framework should guide the identification and implementation of the most appropriate programmes and activities. To obtain such a conceptual framework requires further development work with relevant stakeholders.
South Africa has seen many achievements in the strengthening of its health management information system. However, one of the key challenges remains to get managers at the various levels of the health system to use the available information optimally inorder to inform decision making. These decisions are required around all aspects of the health system including identification of health needs and priorities, health systems and service planning, monitoring progress in implementation and evaluation of the impact of interventions, health policy, programme design and resource allocation.
Monitoring and evaluation is a vital component of any health system but it cannot take place without good quality data. The national Department of Health and National Treasury have been instrumental in leading the institutionalisation of the use of routine health information for planning and monitoring. The Provincial Strategic Plans and the District Health Planning Guidelines are two examples that are briefly discussed.
Finally some recommendations are made to strengthen the health management information system in South Africa.
Source: South African Health Review 2006, pp 77 –94 (2006)More Less
The national Department of Health estimates that 5.54 million South Africans were living with HIV in 2005, an estimated prevalence of 10.8%. Partly as a result of HIV, South Africa is one of 22 high burden TB countries and has the fifth highest number of notified TB cases in the world. The number of TB cases reported annually has quadrupled from 61 486 in 1988 to 279 260 in 2004. TB is the most common opportunistic infection and is the most significant cause of mortality in people living with HIV in developing countries where access to ART is limited. Obtaining good TB treatment outcomes is critical to decreasing HIV-related morbidity and mortality. Likewise, access to appropriate treatment and care for HIV is essential to containing TB.
Collaborative care that engages the interconnectedness of these infections is critical to controlling these epidemics. In 1997, the National HIV / AIDS / STI review recommended improved collaboration between the TB and HIV / AIDS programmes. Whilst there has been progress in TB / HIV collaboration, it appears to have been slow (although assessing progress is made difficult by a lack of implemented standardised reporting systems). Progress is hampered by a range of factors including constraints in access to essential medicines and antiretroviral therapy as well as community adherence support and mobilisation around TB and antiretroviral treatments.
The promotion and strengthening of integrated care should be pursued and other models for scale-up explored. Integrated care should include HIV counselling and testing and routine TB case finding at every HIV clinical visit. Initiatives to increase treatment adherence such as dedicated community adherence workers and simplified drug regimens, especially for paediatrics are critical. The intransigent dilemmas of improving staffing levels and morale need to be addressed as well as task-shifting explored as components of integrated HIV and TB care.
Source: South African Health Review 2006, pp 95 –104 (2006)More Less
This chapter highlights some of the findings of a qualitative research study which was undertaken in four areas in the provinces of KwaZulu-Natal and Limpopo. The study collected information on some of the critical barriers to community participation in HIV and antiretroviral services. One urban and one rural community or municipality was chosen in each province for the study.
Respondents included health care workers at clinic and hospital level, community workers, people living with HIV, traditional healers, community leaders, non-governmental organisations and community based organisations in the geographic area, clinic committees and support groups.
Findings indicate that poverty and stigma operate as significant barriers to accessing HIV and AIDS care and treatment services in the public health sector. Women and youth face particular challenges in participating and accessing services and bear a disproportionate burden of the HIV epidemic. Socio-economic constraints (e.g. travel costs) coupled with perceptions that access to treatment is fraught with difficulties and delays were cited as compelling barriers at facility level which impact on uptake of treatment. Human resource shortages contribute to the poor acceptability and responsiveness of health services. Social security for people living with HIV is inequitable and the current eligibility criteria for disability grants can result in unintended outcomes. Nutritional support and food insecurity have a powerful impact on adherence and treatment stability. Sustained gains in broadening access to treatment and care are likely to remain elusive without the full support and participation of communities. NGOs have a key role to play in assisting communities to identify their strengths and available resources as well as areas of need. Transparent and credible mechanisms such as forums for dialogue and discussion between communities and other stakeholders must be created at local level. Finally, successful models of community involvement must be disseminated and popularised.
Source: South African Health Review 2006, pp 107 –126 (2006)More Less
Maternal and Child health is a global priority. Numerous treaties, initiatives and programmes have been formulated to try and improve the health and well-being of pregnant women and mothers and their children. The latest effort is the Millennium Development Goals that aim to inspire countries to drastically reduce maternal and child mortality and address specific disease and related challenges by 2015.
International figures currently show that despite the many commitments, the health status of mothers and children remain poor in most developing countries. The same is true for South Africa despite its middle income status. Local data show a steady increase in infant and under-5 mortality, and maternal health status is also not optimal.
South Africa has adopted almost all international treaties, initiatives and programmes. Concerted efforts must therefore be made to rectify and address the core contributing factors to poor maternal and child health. Whilst many of these lie outside of the health sector, the health services have a significant contribution to make and, at the very least, health interventions with known effectiveness must be implemented in the best possible way. In addition, all other sectors need to be held accountable for their role in improving maternal and child health. For children, in particular, all sectoral policies and plans need to be viewed through a child-rights lens, and child impact assessments must be done to ensure that children and their families are not harmed, but enjoy maximum benefit.
Source: South African Health Review 2006, pp 127 –150 (2006)More Less
Mortality and morbidity trends in South Africa have been dominated by the HIV epidemic. Despite imperfect health statistics, it has been possible to observe a substantial increase in mortality of young adults during the last decade that has severely affected women aged 20 to 44 years and men in a wider age band. HIV-related diseases are by far the leading cause of death among young women as well as non-HIV-related TB and pneumonia together with homicide and road traffic accidents. Women in the slightly older age group of 45-54 years are more affected by chronic diseases such as stroke, diabetes mellitus, hypertensive heart disease, ischemic heart disease and cervical cancer. In 1998 there were indications that the maternal mortality ratio for South Africa was relatively high. Indications are that this has been exacerbated by the HIV epidemic. Mortality rates do not reflect some important aspects of health such as mental health problems. A review of available data suggest that a sizable burden of mental health problems also affect women in this age range.
While it is estimated that HIV has increased child mortality rates in South Africa, reliable data for this essential indicator are completely lacking. Government is urged to improve the situation and collect good quality data that will provide accurate statistics on this critical indicator, a key indicator to monitor the Millennium Development Goals.
Provincial variations in the mortality of children and women allude to much larger inequalities in health status that are masked by the average mortality rates presented in this chapter. Health managers at all levels of health care are urged to consider the health status of the population in their planning of programmes and services. This will require extensive improvements to the current health information system.
The impact of male sexuality on women's and children's health : maternal, child and women's health : generalSource: South African Health Review 2006, pp 151 –164 (2006)More Less
There is a strong rationale to involve men in supportive roles in issues that impact on sexual and reproductive health. There is also an urgent need for men to use sexual and reproductive health services in a much more active manner than has traditionally been the case.
Current data on the impact of disease on morbidity and mortality points to the devastating effect that HIV is having, particularly on young women and children. Similarly sexual violence and coercion are having a profound impact. Men have an obvious responsibility to improve the situation, but it is noted that they are not escaping the impact of the epidemic. Men may suffer less from HIV than women in their corresponding age cohorts, but they inevitably pay for this in the long run. When other causes of death, particularly violence and traffic accidents are taken in account, men have a shorter life expectancy than women.
Current research has emphasised the value of several new areas of innovation, which include participatory forms of men's empowerment, health and gender education, the potential role of circumcision as well as structured engagement with high risk industries such as the transport sector and settings such as prisons. There are numerous international examples of successful men's involvement and also an increasing range of South African case studies of progressive initiatives, some national in scope and others more focused at a district level.
Author Prinslean MaherySource: South African Health Review 2006, pp 167 –180 (2006)More Less
Making health care services accessible to everyone is a duty imposed by the Constitution, yet it remains one of the greatest challenges to our transitional health care system. Legislation aimed at improving access to health care has increased over the last few years, testing health workers' ability to practically implement such laws. Children are a particularly vulnerable group within society and should have their health needs addressed at all levels of service provision. However, in most instances children are unable to access necessary health care services on their own and require the prior consent of a legally qualified third party in order to obtain health care. Health legislation further restricts children's ability to consent by setting age limitations resulting in the suspension or prevention of access to health care services for many children in South Africa. Once it is operational, the long awaited Children's Act will increase access to health care for children by lowering the age of consent but it is also likely to add to existing implementation challenges currently faced by health care workers.
Source: South African Health Review 2006, pp 181 –202 (2006)More Less
Child health promotion activities offer some of the most cost-effective interventions that any government can make. Many child disease prevention activities are affordable, can be delivered effectively and offer decades of good health for a modest investment.
This chapter focuses on some key health promotion activities in South Africa including: immunisation, the Integrated Management of Childhood Illness strategy, childhood infection prevention, neonatal health and developmental screening. It highlights accomplishments over the past five years, reviews evidence for intervention effectiveness, describes challenges in implementing and institutionalising the interventions and outlines actions needed to maximise the effectiveness of the interventions in the future.
There have been impressive improvements in the delivery of some interventions - such as meeting the 90 per cent under-1 immunisation coverage goal, extension of Integrated Management of Childhood Illness services to all districts in the country and continued decline in the rates of many notifiable diseases. Other interventions have shown modest gains such as the number of birthing centres certified as being 'baby-friendly' in the country and caregivers' use of oral rehydration therapy. Lack of adequate progress is noted for developmental screening and the prevention of mother-to-child transmission of HIV interventions.
Failure to achieve targets is most often due to multiple constraints and barriers within broader health care provision, systemic factors limiting the efficient delivery of services, such as staff constraints, inadequate skills and the organisation of service delivery, rather than problems with the individual interventions themselves.
There are sound arguments for providing a universal or core programme of preventive health care, accessible to every child in the country. The content of this core in a South African setting has yet to be defined, but many of the activities reviewed in this chapter would form the backbone of such a strategy.
Source: South African Health Review 2006, pp 203 –220 (2006)More Less
The National Food Consumption Survey of 1999, among children aged 1-9 years indicated a high prevalence of stunting (21.6%) and overweight and obesity (17.1%). One in two children had an intake less than half the recommended requirements for vitamins A, C, riboflavin, niacin, B6, folate, calcium, iron and zinc. Studies in children with HIV report multiple micronutrient deficiencies and levels of underweight and stunting as high as 50% before commencement of antiretroviral therapy. Nutritional problems in children are currently being addressed through the Integrated Nutrition Programme. Key focus areas with goals and targets have been set for 2007. This chapter discusses information and findings of studies relating to the evaluation of the different focus areas of the Integrated Nutrition Programme. Progress has been made and targets have or are likely to be met in areas including: the Baby-Friendly Hospital Initiative; legislation relating to the mandatory fortification of maize meal and wheat flour with multiple micronutrients; mandatory iodization of salt; the provision of Road-to-Health Charts; and aspects relating to the National School Nutrition Programme. Other focus areas of the Integrated Nutrition Programme such as coverage of vitamin A through supplementation; legislation relating to the protection of breastfeeding mothers in the workplace and reducing morbidity and mortality in children from under-nutrition, over-nutrition and HIV / TB, require more attention if set targets are to be achieved. Key constraints in achieving the set goals and targets include high rates of household food insecurity and lack of adequate service delivery. Recommendations on how to address these challenges and strengthen the components of the Integrated Nutrition Programme are made.
Source: South African Health Review 2006, pp 221 –234 (2006)More Less
Mother-to-child transmission of HIV can take place in utero, intrapartum and postnatally through breastfeeding. The success and availability of antiretroviral drug interventions that reduce in utero and intrapartum transmission of HIV have shifted the focus to identifying interventions that will reduce postnatal transmission of HIV through breast milk. This chapter reviews the main infant feeding options for HIV-positive women which include replacement feeding or exclusive breastfeeding with early weaning. It looks at the challenge in finding ways to make feeding safer for infants of HIV-positive women, and finding effective strategies for supporting women in their infant feeding choices. Lastly, it reiterates the need for community level interventions that can increase the acceptability of feeding practices that are different from existing norms.
Source: South African Health Review 2006, pp 235 –256 (2006)More Less
Paediatric HIV care has lagged behind that for adults in South Africa. It is estimated that almost 300 000 children are HIV-infected. HIV is responsible for an upswing of child mortality in the country, reversing improvements in child survival. Despite the implementation of a perinatal prevention programme in 2003 and the increasing availability of antiretroviral therapy for children since early 2004, facilities still admit significantly large numbers of HIV-infected children. Little data exist evaluating the outcomes of the prevention of mother-to-child transmission of HIV programme. Postnatal transmission of HIV is elevated despite the availability of replacement feeds as part of the national prevention of mother-to-child transmission of HIV programme. Infant diagnosis rates are low even though guidelines recommend diagnosing infants from 6 weeks of age. Cotrimoxazole prophylaxis is not widely available, this contributes to high morbidity and mortality in HIV-infected infants. The number of children receiving antiretroviral therapy has increased over the past year from roughly 3 000 to more than 14 000, however inequalities exist across the provinces. Challenges for paediatric antiretroviral therapy include lack of sufficiently trained health care personnel, inadequate facilities, complexity of treatment recommendations, as well as drug regimens and formulations. Children are made particularly vulnerable by their circumstances and by frequent change of caregivers. Lack of integration of services results in attrition of patients at each step from prior to delivery through to the initiation of ART. Still relatively few children are benefiting from the services which should be available through the Comprehensive HIV and AIDS, Care, Management and Treatment Plan.
Author Anne RobertsonSource: South African Health Review 2006, pp 257 –270 (2006)More Less
Many South African children suffer from a chronic condition that requires ongoing care. The most prevalent of these conditions are congenital heart disease, neurological problems and HIV. In urban areas asthma affects more than 10% of children. The sequelae of poor perinatal care, poverty and poorly managed infections cause disability and place a high toll on rural families. In addition, a wide range of congenital conditions that affect children globally affect South African children as well. Diseases of lifestyle, previously mainly affecting adults, are now more prevalent as almost 20% of South African urban children are overweight. SA has the challenge of improving perinatal care, paediatric and child health services, controlling over and under-nutrition and decreasing poverty in order to prevent chronic conditions. The establishment of a family based multidisciplinary service for children with long term illness is a priority. The nature and scope of the service is outlined in the 2002 Policy framework for non-Communicable Chronic Conditions in Children. Excellent specialised services exist in pockets in the country; however, these services are inequitably distributed. for many conditions, children from rural areas are much less likely than their urban counterparts to access specialised care, and thus will inevitably have a poorer outcome and quality of life. Ensuring equity in provision of service, and establishing good family based care for children throughout South Africa will require innovation and commitment. Centres of excellence that provide care should be maintained and provided with resources to service the region. NGOs, patient-provider organisations and specialist working groups are encouraged to continue and extend the role they play in advocacy and support for service development and best practices.
Vulnerability of children with disability- the impact of current policy and legislation : child healthAuthor Sue PhilpottSource: South African Health Review 2006, pp 271 –282 (2006)More Less
This chapter outlines the particular vulnerabilities of disabled children and explores various factors that create and perpetuate these. The determinants of disability - both impairment and exclusion - are described. The limited prevalence rates that are available for childhood disability and chronic illness are presented. Key policies and legislation that affect children with disabilities are cited, particularly in relation to the health sector. The impact of these policies at service provision and community level is described, as there are persisting barriers that exclude children with disability from effective preventative, curative and rehabilitation health services. Finally, recommendations are made as to how these should be addressed.
Source: South African Health Review 2006, pp 283 –294 (2006)More Less
This chapter reflects on the health of older children in the school setting as schools are a site that is frequented by about 11.5 million learners nationally per year. Several National Health Policies are outlined that guide the services provided to older children. The role of School Health Services in particular is outlined and the indicators related to its implementation strategy are described. The crucial need for the development of systematically planned and evaluated health promotion programmes that address the determinants of behaviours that place older children at risk is illustrated through the evaluation of the Department of Education's Life-skills programme focusing on HIV. While recommendations to improve this programme are made, the crucial conclusion regarding the health of older children in general is that there is an urgent need for the adoption of a planned and systematic approach to intervention development that aims at addressing the determinants of their health behaviours.