South African Health Review - Volume 2010, Issue 1, 2010
Volume 2010, Issue 1, 2010
Source: South African Health Review 2010, pp xi –xii (2010)More Less
We are well aware that Africa has experienced significant poverty, disease and death over the years, with many disparities within and between countries. Seeking solutions to this trend is complicated by the attenuation of our human resource capital through death, disease, civil wars, brain drain and, what is more, inappropriate training.
Author Welile ShashaSource: South African Health Review 2010 (2010)More Less
It is my pleasure to introduce the 14th edition of the South African Health Review (SAHR). Published since 1995, the SAHR seeks to provide a South African perspective on prevailing international public health issues, to stimulate debate and critical discourse and to provide a platform for assessing progress and areas for further attention. It is in keeping with these objectives that we have chosen to focus on the topical issues of the Millennium Development Goals (MDGs) and perspectives on a National Health Insurance (NHI) for this year's Review.
Source: South African Health Review 2010, pp 3 –28 (2010)More Less
Millennium Development Goal (MDG) 5 focuses on maternal health and the target for 2015 is to decrease the Maternal Mortality Ratio (MMR) by 75% from the levels in 1990. This chapter reviews the current status of maternal mortality and maternal health in South Africa. The evidence is that South Africa is definitely not on track to achieve MDG 5 and that maternal mortality has actually doubled since 1990.
The top five causes of maternal mortality in the 2005-2007 triennium remained non-pregnancy-related infections (43.7%), mainly due to AIDS, hypertension (15.7%), obstetric haemorrhage (12.4%), pregnancy-related sepsis (9%) and preexisting maternal disease (6%). The mortality rate of HIV-positive women was nearly ten times the rate of HIV-negative women, but preventable direct obstetric causes made up a significant proportion of deaths in both groups.
The recent guideline changes prioritising antiretroviral treatment for HIV-positive pregnant women will make a significant contribution to addressing HIV-related deaths if they are realised in practice. The other main priority is to improve the availability and quality of emergency obstetric care which is being targeted through initiatives such as the new Essential Steps in Managing Obstetric Emergencies training programme.
The high rates of antenatal care coverage and delivery by a skilled attendant in South Africa have not had any impact on the MMR. New indicators that are better correlated with maternal mortality in South Africa are required for planning and monitoring. The National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) is an important source of information on maternal deaths, but vital registration requires strengthening and regular Demographic and Household Surveys are required to monitor population-level process indicators.
The NCCEMD recommendations identify what needs to be done to improve maternal mortality, but have had little impact on maternal mortality over the last decade. Health system constraints that hinder implementation of the recommendations need to be overcome urgently.
How health systems investments can improve reproductive health services : the case of Tamil Nadu : reflections on the Millennium Development Goals - profileAuthor Sundari RavindranSource: South African Health Review 2010, pp 29 –32 (2010)More Less
Tamil Nadu ranks amongst the high-performing states in India in human development, with high levels of literacy, low fertility and mortality rates and good coverage by health care services. According to the 2001 Census the state had a population of 62.1 million. The literacy rate for the population aged seven years and above was 74 to 82% for males and 65% for females.
During 2005 and 2006, more than 60% of the women (or their partners) used contraception. From 2002 to 2005 almost all pregnant women (97%) were covered by antenatal services and 90% of women delivered in a health facility and received postnatal care within two days following delivery. Eighty-one per cent of all children between 12-23 months were fully immunised.
Source: South African Health Review 2010, pp 33 –48 (2010)More Less
Considerable progress has been made in expanding access to health services through strong political leadership and development of policies, guidelines and legislation. However, South Africans still face challenges and obstacles in accessing comprehensive treatment, prevention and care for sexually transmitted infections (STIs) including HIV, sexual and reproductive health (SRH), family planning and contraception, pregnancy, delivery, psychosocial support and counselling. Major challenges lie in ensuring that guidelines are implemented, that standard protocols are followed and that health-care worker performance is improved and monitored.
In order to fulfil the rights of all South Africans to equal access to health care and life-saving prevention and treatment programmes, evidence-based interventions, the provision of comprehensive and holistic care, optimal therapeutic care and SRH services need to be strengthened. The strengthening of SRH services also entails integrating reproductive health with other services and providing guidelines for implementation.
Source: South African Health Review 2010, pp 49 –58 (2010)More Less
This chapter provides an overview of the magnitude of sexual and gender-based violence (SGBV) in South Africa. The definition of SGBV is broad and encompasses a range of issues including intimate partner violence, human trafficking, early marriage and female genital mutilation, amongst others.
This chapter focuses more narrowly on issues regarding the prevention and management of sexual assault, although the authors acknowledge that many forms of SGBV often co-exist. It begins by highlighting the magnitude of SGBV in South Africa as a development issue, the complexity of addressing prevention and comprehensive management of SGBV and the importance of a multi-sectoral response within the current policy and legal context. The latter sections of the chapter explore SGBV as a public health issue, highlighting the health sector response, comprehensive clinical care and links to the justice system. Many examples and data have been drawn from the important contributions that civil society and non-governmental players have made to the research and response to SGBV in South Africa.
Child mortality in South Africa : using existing data : reflections on the Millennium Development GoalsSource: South African Health Review 2010, pp 59 –72 (2010)More Less
Child mortality is generally credited as a surrogate marker for the quality of care within a health service. However, if mortality rates are to be used as an indicator of quality of care, or to monitor and evaluate the effectiveness of programmes aimed at improving child health and the quality of health care, it is critical that this data is accurate. The quality of data routinely collected in the South African health system is extremely variable. While data from primary health care clinics are generally good, that from hospitals is poor and data from the vital registration process is often incomplete.
This chapter describes five data sources currently in use in South Africa that assist in the monitoring of child mortality rates. In order to facilitate an improvement in the quality of these datasets, the available data has been used to present a profile of child mortality in 2007.
The year 2007 has been selected as this is the most recent year for which data from the death registration programme are available and is therefore the only year for which data are available from all five data sources. It is accepted that these data are incomplete and that some datasets have improved in subsequent years. However, by using these data the authors hope to stimulate reflection on the data as well as to precipitate improved data collection.
Maternal, newborn and child survival : data challenges : reflections on the Millennium Development Goals - profileSource: South African Health Review 2010, pp 73 –78 (2010)More Less
The Countdown to 2015 Initiative identified South Africa as one of 68 priority countries with a high burden of maternal and child mortality and one of the 10 countries with least progress towards achieving Target 4 of the Millennium Development Goals. As part of a mid-term review of progress towards meeting the goal, the initiative selected indicators to track programmes considered to be effective in improving the survival of mothers, newborns and children. The programmes were identified using evidence presented in the 2003 and 2005 Lancet series on Child and Neonatal survival.
Education : meeting the MDGs is not enough : reflections on the Millennium Development Goals - profileAuthor Graeme BlochSource: South African Health Review 2010, pp 79 –82 (2010)More Less
The Millennium Development Goal (MDG) 2 target aspires to ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling. South Africa's education system experiences a range of problems extending beyond the simple issues of meeting the MDG targets. Poor quality education reinforces major racial inequalities in society and inadequate systems make it difficult for South Africa to deliver on internal infrastructural promises or to achieve competitive levels in a globalised economy. These factors impact negatively on long-term development and internal stability in the country.
Building citizenry : the Soul Buddyz Club : reflections on the Millennium Development Goals - profileAuthor Sue GoldsteinSource: South African Health Review 2010, pp 83 –86 (2010)More Less
Soul City is a national non-governmental organisation established in 1992 to promote health and improve the quality of life of South Africans. In 2003, following the success of the Soul Buddyz mass media initiative, Soul City started the Soul Buddyz Club intervention. This is a joint initiative of Soul City Institute for Health and Development Communication and SABC Education, in collaboration with the Department of Education. The project was established in 2002 in response to an influx of requests from ordinary children in diverse South African communities.
A review of progress on HIV, AIDS and tuberculosis : reflections on the Millennium Development GoalsSource: South African Health Review 2010, pp 87 –100 (2010)More Less
As a United Nations member state, South Africa is signatory to the Millennium Declaration and is committed to achieve the Millennium Development Goals (MDGs) and targets for 2015. This chapter provides an overview of the status of South Africa's response to MDG 6 with a specific focus on the progress made to date with respect to HIV and tuberculosis (TB) - two intertwined epidemics contributing disproportionately to morbidity and premature mortality in South Africa. These epidemics are also closely linked to MDG 4 and 5 outcomes. Any progress made by South Africa to reverse current trends will have substantial implications for the global MDG targets as well as country level outcomes. This chapter will use available evidence to document the status of HIV and TB in South Africa relative to the South African Ministry of Health's strategy to address these diseases.
The cycle of poverty, hunger and ill-health : reflections on the Millennium Development Goals - profileSource: South African Health Review 2010, pp 101 –106 (2010)More Less
The relationship between poverty and health, and their impact on important infectious diseases, such as HIV, AIDS, tuberculosis (TB) and malaria is well known. The World Health Organization has identified the people who live in absolute poverty as being most vulnerable to such infectious diseases.
The impact of global health initiatives on access to antiretroviral therapy in South Africa : reflections on the Millennium Development Goals - profileSource: South African Health Review 2010, pp 107 –110 (2010)More Less
South Africa's health funding does not rely on international donors - except in regard to HIV-related services. Donor aid was less than 1% of South Africa's overall health budget in 2007, but accounted for 26% of HIV and AIDS expenditure. Though donor funding has dramatically increased since 2000, the South African government remains the largest source of HIV-related funding in South Africa. The number of patients in need of antiretroviral therapy (ART) continues to grow, with South Africa's antenatal HIV prevalence standing at 29.3% in 2008.
Environmental sustainability, climate change and health : reflections on the Millennium Development GoalsSource: South African Health Review 2010, pp 111 –122 (2010)More Less
The Millennium Development Goals have highlighted the importance of ensuring environmental sustainability to mitigate and prevent climate change and to prevent any further deterioration of the health of the people of the world.
Progress to achieving these goals, however, has been limited and climate change may threaten gains in environmental protection and in health improvement. Climate change induced drought, land degradation and increasing food prices are resulting in food insecurity for millions of poor South Africans and increasing malnutrition among children and may lead to increased internal and external migration.
Although South Africa has policies that have embraced sustainable development, the natural environment is continually threatened. There is fierce competition for resources due to a declining economy and competing health threats such as the HIV, AIDS and tuberculosis epidemics.
Water is a threatened resource in South Africa. Poor people who are often subsistence farmers or urban slum dwellers are particularly vulnerable to drought and extremes of weather. Although access to potable water and appropriate sanitation has improved substantially, climate change can threaten these gains resulting in water- and food-borne disease.
Greenhouse gases can lead to global warming and locally to pollution-related respiratory disease. South Africa has a much larger carbon footprint relative to other African countries and needs to lead in addressing climate change.
Action needs to be taken at an individual, community and national level to increase awareness of the importance of environmental sustainability to health and well-being and to establish intersectoral collaboration necessary to address the health impacts of climate change.
Public health implications of greywater generation in South Africa : testing a greywater treatment model : reflections on the Millennium Development Goals - profileSource: South African Health Review 2010, pp 123 –126 (2010)More Less
Greywater is wastewater generated from domestic activities such as laundry, dishwashing and bathing that can be recycled on-site for re-use in landscape irrigation and constructed wetlands. Greywater differs from water from toilets, designated sewage or blackwater, which contains human waste.
Greywater is thus domestic wastewater, without any input from toilets, which carries finite concentrations of microorganisms such as faecal coliforms, E.coli and opportunistic pathogens. It also contains easily degradable organic matter that can result in microbial re-growth. Re-growth and biodegradation leads to a decrease in the concentration of dissolved oxygen and the evolution of odours and promotion of mosquito breeding. Greywater has been shown to contain heavy metals and up to 900 xenobiotic organic compounds.
Health legislation and policy : context, process and progress : reflections on the Millennium Development GoalsSource: South African Health Review 2010, pp 127 –142 (2010)More Less
The current health leadership in South Africa has committed to a substantial overhaul of the public health sector to address the complex burden of disease; meet the Millennium Development Goals (MDGs); improve health-care outcomes, access and affordability; and ensure responsiveness to population health needs.
Using a contemporary policy analysis framework, this chapter reviews health and health-related legislation, key health policy initiatives and progress with implementation for an 18-month period from December 2008 until May 2010. The methods include a literature review and interviews with ten key informants.
The review found that there is an enabling legal, policy and fiscal environment and context that facilitates the achievement of the MDGs in South Africa. However, there is potential overlap, fragmentation and lack of co-ordination of the various laws and policy initiatives. Progress with the implementation of the National Health Act remains slow and both the National Health Amendment and Medical Schemes Amendment Bills have lapsed. The review of three policy initiatives: the Health Sector Road-map; the Integrated Support Teams; and the Advisory Committee on National Health Insurance - all aimed at improving the functioning of the health system - illustrates that the process and timing of many policy initiatives appear to be flawed, often resulting in alienation of many stakeholders, particularly those responsible for implementation. Although the proposed National Health Insurance system is welcomed and supported by many, to date a transparent process and meaningful public participation have been largely absent.
Three key recommendations arise out of this review: the need for focus and prioritisation; careful attention to process and actors when developing or implementing legislation or policies; and improved monitoring and evaluation to enhance accountability to the public and to achieve health outcome goals.
National Health Insurance : providing a vocabulary for public engagement : perspectives on a national health insuranceAuthor Di McIntyreSource: South African Health Review 2010, pp 145 –156 (2010)More Less
There has been considerable confusion and media debate about the proposal to introduce a national health insurance (NHI) in South Africa. The purpose of this chapter is to demystify the proposed health system reform. It explains the objective of the proposed reform, evaluates how South Africa currently fares relative to this objective and explores the implications of lessons from international experience for the South African health system. It also considers what is required to ensure that a reformed health system is affordable and sustainable.
This chapter argues that the term 'NHI' has itself contributed to the confusion about the intended reform and that the focus should instead be placed on the core objective of the reform, which is to achieve a universal health system. A universal system is one that ensures that everyone is able to use health services when needed and that provides financial protection against the costs of health care for everyone. The reality is that many South Africans cannot access health care when needed.
Another misconception is that the proposed reform is simply about how to fund health services. Instead, it is very much about ensuring that South Africans have real access to appropriate, efficient, quality health services.
A key area of contention has been whether a universal system is affordable or not. Not only is it premature to declare the NHI unaffordable when there are no details of the proposed reforms in the public domain, but it is also important to recognise that it is not the universality of a health system that makes it unaffordable. It is, instead, inappropriate design of a health system that can make it unaffordable.
There is neither doubt that health system change is needed in South Africa, nor dispute that it is possible to achieve an affordable universal system. What is required is constructive and evidence-informed debate from all stakeholders on how best to achieve improved health for all South Africans through health system reform.
A financial feasibility review of NHI proposals for South Africa : perspectives on a national health insuranceAuthor Alex Van den HeeverSource: South African Health Review 2010, pp 157 –170 (2010)More Less
National Health Insurance (NHI) has been introduced as a reform proposal for the South African health system by the African National Congress (ANC) from 2007. Until now such proposals were not seriously considered as South Africa has pursued the path of developing a public health system capable of guaranteeing universal access to health care. Proposals tabled by the ANC in September of 2010, however, propose an alternative institutional path coupled with ambitious budget bids. This chapter seeks to unpack and evaluate these most recent proposals, concentrating on their financial feasibility. Overall the chapter finds little evidence to support the central objective of the reform which seeks to raise up to 5% of Gross Domestic Product (GDP) in additional taxes to achieve a total public spend equivalent to 8% of GDP. No international precedent can be found for such a proposal, with no other developing countries spending anywhere close to this level on public health. Were such a proposal to be implemented it would require that personal tax rates rise to implausible levels, with a general doubling of tax rates. Aside from the general financial considerations the institutional proposals, involving the implementation of what is termed a "SARS-like" organisation, raise serious financial concerns. Aside from a lack of clarity over why this organisation is necessary and what institutional weaknesses it seeks to address, the ambitious list of proposed functions suggest that it will be considerably more costly than indicated. This chapter largely concludes that the ANC proposals are not implementable as proposed and are unlikely to seriously address existing weaknesses in the health system.
Human resource requirements for National Health Insurance : perspectives on a national health insuranceSource: South African Health Review 2010, pp 171 –178 (2010)More Less
In 2007, at its 52nd Conference in Polokwane, the African National Congress called for the implementation of a National Health Insurance (NHI) scheme. The proposed NHI scheme will potentially significantly increase funds available for health and restructure health service delivery. However, the success or failure of a NHI scheme will rely on the availability, skills and motivation of health workers.
This chapter will summarise key human resource (HR) challenges in South Africa and sketch important requirements to support the implementation of a NHI-funded health system. Transformation of the health system has been hampered by inadequate numbers and inequitable distribution of health workers between private and public sectors and urban and rural areas, lack of appropriate skills throughout the system, and poor planning and management. Clinic based services are limited in their ability to reach community level and, being focused on curative aspects, are often inadequate with regard to prevention, health promotion and rehabilitation services. There are a large number of community health workers in the country, yet they remain disorganised and peripheral to the public health system and the mid-level worker category has not been fully explored. Finally, there are no clear strategies for recruitment and retention of health workers in rural and under-resourced areas.
Using available evidence and information from interviews conducted with a number of key informants, the authors make recommendations on HR requirements for implementation of an effective and equitable health system funded by a NHI, including skills mix and projected numbers of health workers, and propose ways to improve the deficient HR situation.