South African Health Review - latest Issue

I am delighted to introduce the 20th edition of the South African Health Review. In commemoration of this achievement, this edition considers the healthcare developments of the past 20 years, explores the current challenges faced by our healthcare system, and reflects on possible issues for South Africa in the years ahead.

This 2017 edition of the South African Health Review (SAHR) comprises 21 chapters. In acknowledgement of the 20-year anniversary of the publication and the significant improvements to our health system over time, most of the chapters provide an overview of developments in their respective subject areas over the past two decades.

The year 2017 marks the 25th anniversary of Health Systems Trust and the 20th edition of the Trust’s flagship publication, the South African Health Review (SAHR). First published in 1995, the original intention of the SAHR (as it has commonly become known) was to systematically pull together information on health from as many sources as possible; to describe and critique policy initiatives to serve as a basis for gauging whether there has been successful implementation; and to help define a policy research agenda by highlighting policy thrusts.

Over the past 20 years, the SAHR has assiduously chronicled developments in the South African health system. It has curated knowledge from a wide spectrum of sources in order to provide the necessary information to assess progress in transformation of the health system since 1994 and has reflected on successes, failures and missed opportunities. During this time, the focus of the SAHR has shifted from the need for policy development, to analysis of policy implementation and the health system’s state of readiness to respond to policy reforms.

Although the introduction of National Health Insurance still dominates the health policy space in South Africa, there is little evidence of legislative action in this regard since the comment period on the White Paper ended in 2016.

No proposed amendments to the Medical Schemes Act have yet been revealed. Neither the National Health Laboratory Service Amendment Bill nor the National Public Health Institute of South Africa Bill have yet been tabled in Parliament. 

A draft Dental Technology Professions Bill has been published for comment. However, important regulations have been published in terms of the National Health Act, which should enable the operationalisation of the Office of Health Standards Compliance. 

The South African Health Products Regulatory Authority is expected to replace the Medicines Control Council in 2017, and will also have to tackle the long-neglected issue of medical device regulation. 

No radical redesign of the Health Professions Council of South Africa seems likely. 

Two important court judgments were delivered in 2017 – in the Dermalex case, and in respect of the appeal against the Stransham-Ford decision by the High Court. The National Ministerial Advisory Committee on Antimicrobial Resistance met for the first time, but implementation of the Antimicrobial Resistance National Strategy Framework 2014-2024 still demands urgent attention.

This chapter reviews public-health spending in South Africa over a 20-year period starting shortly after the dawn of democracy in 1994. Particular emphasis is placed on spending changes following the global economic recession in 2008, which has slowed the upward spending trajectory re-established since 2000. In South Africa, the slowdown in health spending following the global recession was delayed as government followed a counter-cyclical fiscal stance, protecting social-sector spending levels. However, by 2012/13, economic growth and tax revenue collected again slowed and the national deficit had risen to a troubling extent (5% of GDP on the main budget) contributing to growth in health budgets slowing considerably from 2012/13 to 2019/20. 

This chapter describes health-expenditure trends in the context of a decade of low national economic growth and rising input costs. Government-expenditure data are used. The chapter reviews some of the ways the health sector has responded to a funding slowdown, both planned and unplanned, and it argues that a better-planned approach to efficiencies and budget constraints might lead to better outcomes. Managing limited budgets under cost pressures while achieving efficiencies and service restructuring is a significant challenge for health service managers. This is contextualised within wider debates on the effects of austerity on health systems and outcomes from experience in other countries. 

Strategies adopted by the health sector include limiting personnel numbers, centralised tendering for medicines, prioritising ’non-negotiable’ core budget items over nonessential items, prioritising primary health care, and temporarily reducing capital infrastructure spending. The chapter emphasises both the need to seek efficiency solutions and the role that National Health Insurance can potentially play in turning around a seven-year period (from 2012/13 to 2019/20) of reduced public-health spending.

The aim of National Health Insurance (NHI) is to achieve universal health coverage by delivering a Health Service Package (HSP) of quality healthcare services to all South Africans. Health technology assessment (HTA) is an explicit, transparent and evidence-informed approach to healthcare prioritisation and HSP formulation. In this chapter, definitions of HTA are discussed, a legal and policy analysis of HTA development since 1994 is presented, and adoption of an HTA framework is recommended to guide future healthcare prioritisation, including HSP formulation. 

The 2015 NHI White Paper includes a strong policy intent for the comprehensive adoption of HTA systems. However, limited attention has been given to financing these prioritisation mechanisms and structures. A comprehensive secondary datagap analysis of relevant international and national resolutions and legislation revealed no specific provision in the National Health Act for HTA, which is narrowly and incompletely defined, and no legislative provision for evaluation of the broad range of interventions for which HTA could be used. 

Much prior work has been done and much consideration has been given to HTA in South Africa, but implementation efforts have been fragmented. Further development and amendment of the relevant HTA policy and legislative frameworks are needed in order to inform appropriate universal health coverage, and to align with the 2015 NHI White Paper. With no national HTA mechanism or entity yet in place, South Africa is well positioned to learn from the experiences of other countries and to establish an HTA framework that delivers the components of HTA in a way that meets the needs of NHI and the National Development Plan. 

A five-step implementation process is recommended to: define HTA through broad stakeholder engagement; align policies with NHI; harmonise legislation and policy; legislate amendments in Parliament; and implement a unified vision for HTA.

It has now been 20 years since the National Drug Policy (NDP) was published in 1996. This was one of the earliest comprehensive policy documents issued by the first post-apartheid Department of Health, and was subsequently included as an appendix to the 1997 White Paper on the Transformation of the Health System in South Africa. The NDP was developed in response to seven policy questions/ challenges posed by the Department, and set out three sets of objectives: health objectives, economic objectives, and national development objectives. Although elements of the implementation of the NDP have been addressed in previous editions of the South African Health Review and in various academic publications, no comprehensive evaluation has yet been attempted. 

The process of implementing the NDP has varied from being straightforward to highly contested, with litigation by a variety of stakeholders and an important Constitutional Court judgment in relation to medicines pricing. A number of high-profile issues, in particular considerations of intellectual property law, have not been pursued as aggressively as expected. Other issues, such as the appropriate regulation of traditional medicines, remain unaddressed or inadequately addressed. This chapter critically examines the process of developing and implementing the NDP from 1994 to date, and for the first time, covers all the key elements of the policy and its stated objectives. Emphasis is on the impact of the policy, but also on looking ahead to identify which elements of the NDP need reconsideration in the light of plans for National Health Insurance. This analysis follows the Walt and Gilson model, focusing not only on content, but also the actors, context and process.

Provincial governments in South Africa have a critical responsibility in terms of population health, yet few provincial-level analyses of health-system development have been undertaken. This chapter reports on research being conducted in the Western Cape to understand the province’s particular experience of health-system transformation since 1994, set against wider national experience. The research is being undertaken collaboratively by the authors of this chapter, a team of Western Cape provincial health managers and researchers. 

The chapter is structured to reflect the Western Cape’s 22-year experience. The situation that faced the province in 1994 is outlined briefly, followed by a description of key features of the three health strategies that have driven provincial health-system development over time. An assessment is then presented of the overall nature and patterns of Western Cape health-system change, and the achievements and limitations of this transformation are considered. The chapter concludes with some early lessons from this experience, and relevant, international experience is considered.

Training health professionals in rural areas increases their preparedness for rural practice and their subsequent likelihood of working in a rural area. In 2011, Stellenbosch University (SU) instituted a year-long training of final-year medical students at a rural training site. This longitudinal training model was subsequently adopted by other health professions in 2013. The nature of the training and the context within which it occurs facilitate a unique learning experience for the students, and has positive spin-offs for other role-players. 

This case study presents the training model followed at SU’s Rural Clinical School (RCS). Drawing on five years of research, we describe some of the ways in which the RCS training model has influenced the role-players. Key lessons learnt are outlined from both educational and health system perspectives. It is recommended that all health professions students be exposed to training in rural areas, including continuous longitudinal rotations.

With the recent change from the Millennium Development Goals to the 17 new Sustainable Development Goals, the focus of the global development agenda is expanding: there is attention on a broader set of social determinants and, importantly, a specific sensitivity to equity, which could have a substantial effect on health. Addressing social determinants is a cornerstone in the National Department of Health’s Primary Health Care Re-engineering Strategy, and an approach that is embedded in the country’s National Development Plan. However, the translation of this policy commitment to programmatic action at different levels in the health system and in partnership with other sectors remains elusive. 

This chapter draws on evidence collated by the World Health Organization Commission on the Social Determinants of Health, complemented with empirical evidence from South Africa to strengthen the contextual sensitivity of the analysis, in order to identify the social determinants impacting on the major components of the burden of disease in South Africa. Obesity is used as a case study to illustrate how action to address these determinants is required at different levels in the health system, and in partnership with other sectors. 

The evidence is then used to interrogate the National Development Plan and the PHC Re-engineering Strategy as two major policy instruments that have the potential to address social determinants. The particular limitations of both policy initiatives are identified, and the chapter proposes how the health sector can take on a stronger advocacy role both within government and beyond to support the broader international health and development agenda.

Similar to the rest of the region, South Africa has a high prevalence of communicable diseases, an increasing non-communicable disease burden, and diverse internal and cross-border population movements. Healthy migration should be good for social and economic development, but in South Africa, current health responses fail to address migration adequately. A review was done of the available data in order to provide recommendations for improved health-systems responses to migration and health in the country, and we drew on our experience in relevant policy processes.

 The findings show that addressing migration and health is a priority globally and locally. The number of people moving internally within South Africa far exceeds the number of cross-border migrants. Contrary to popular assumptions, internal migration presents greater governance, health-system, and health-equity challenges than crossborder migration, but current responses do not recognise this. Our findings show why recognising migration as a determinant of health assists in addressing associated health inequities. Data suggest that a healthy migrant effect, and a subsequent health penalty prevail in South Africa. Evidence shows that both non-nationals and South African nationals who move within the country face challenges in accessing health care; of particular concern is the lack of a co-ordinated strategy to ensure continuous access to treatment, care and support for chronic conditions. 

Migration impacts the South African public healthcare system but not in the ways often assumed, and sectors responsible for improving responses have a poor understanding of migration. The need for better data is emphasised, existing policy responses are outlined, and strategic opportunities for intervention are suggested. Recommendations are made for migration-aware health systems that embed population movement as central to the design of health interventions, policy and research. Such responses offer strategic opportunities to address health inequity, both nationally and regionally, with resulting health and developmental benefits for all.

The hospital sector in South Africa mirrors deep inequalities in the country as a whole. The private, for-profit hospital sector is well resourced and caters to a population that tends to be wealthier, urban and more likely to be formally employed. The public-hospital sector, catering to the majority of South Africans, faces lower human-resourcing ratios, financial constraints and ageing infrastructure.

This chapter contextualises the development of the two sectors, describes the current divide, and considers the implications in terms of equity, access and quality of care. 

A unique dataset of quality-accreditation-survey scores was used, which allowed for analysis of the two sectors according to a common yardstick. These data reflect a wide array of structure- and process-related quality indicators; in addition, the patient perspective reflected in data from the General Household Survey was used to illustrate the quality differential. The research provides evidence of the polarisation between public and private facilities: private facilities consistently scored above public facilities across a range of accreditation categories, and there was far greater variability in the scores achieved by public facilities. The same polarised relationship was found to hold across key sub-components of the scores, such as management and leadership of hospitals in the two sectors. 

We conclude that there is a need for the measurement of health outcomes across the system. Policy attention is required in terms of accountability and quality improvement. A focus on improving value in the system will, by necessity, have to engage with the discrepancies between the sectors.

The Ideal Clinic Realisation and Maintenance (ICRM) programme was designed in response to the current deficiencies in the quality of primary health care services and to lay a strong foundation for the implementation of National Health Insurance. 

An ‘Ideal Clinic’ is defined as a clinic with good infrastructure (i.e. physical condition and spaces, essential equipment, and information and communication tools), adequate staff, adequate medicines and supplies, good administrative processes, and adequate bulk supplies; such a clinic uses applicable clinical policies, protocols and guidelines, as well as partner and stakeholder support, to ensure the provision of quality health services to the community. 

The ‘Ideal Clinic’ initiative is structured in three phases: development of the concept (phase one), planning for implementation (phase two), and implementation (phase three). This chapter deals with the implementation phase. 

The ICRM scale-up process continued to use an implementation research model and 322 Ideal Clinics were accredited in one year. In addition, the number of clinics that scored over 70% increased from 139 to 445, while the number that scored less than 40% dropped from 213 to 90. This was achieved by focusing on processes to improve integrated clinical-service management, infrastructure, human resources for health, service-user waiting times, financial management, and supply-chain management. However, given that the country has 3 477 primary health care facilities, an achievement of only 322 Ideal Clinics leaves much to be desired. 

This chapter reports on implementation progress and challenges for government’s 2015/16 financial year, and includes a description of strategies to overcome these challenges, and progress in this regard.

South Africa has been engaged in pharmacovigilance (PV) activities to assess the impact of adverse drug reactions on public safety and health for 40 years. Activities have evolved from passive regulatory reporting to active surveillance systems. The HIV and AIDS and TB epidemics stimulated pharmaco-epidemiological research into the risks associated with medicines used in the standardised regimens of mass treatment programmes. Specific safety concerns, supported by robust local cohort data, have prompted major changes to national and international treatment policies.

This chapter describes the expanding body of local knowledge and the historical and emergent surveillance systems that address the burden of drug-related harms, noting the challenges to health system responsiveness. The South African context presents a unique opportunity to characterise the scale and nature of such harms in mass HIV and AIDS and TB treatment programmes. The use of complex regimens at scale poses new PV challenges. There is an urgent need to develop cohesive, sustainable systems to support evidence-based decisions on appropriate regimen choices, while minimising medicine-associated risks. The increasing use of computerised clinical, laboratory and dispensing records, with unique patient identifiers facilitating data linkage, will increase PV surveillance capacity. 

A coherent national PV framework is an essential part of medicines policy, encompassing regulatory, programmatic and individual needs. The key pillars of this framework are: (i) consolidation and expansion of active and passive PV surveillance, optimising existing programmes; (ii) prioritising post-marketing monitoring within the new health products regulatory authority; and (iii) instilling a culture of active risk management in clinical practice through the creation of effective channels of communication and feedback into policy and practice.

The South African programme for the prevention of mother-to-child transmission of HIV (PMTCT) began 15 years ago. Underpinned by strong political will and civil involvement, evidence-based national policy updates culminated in January 2015 with the introduction of lifelong triple antiretroviral therapy (ART) for all HIVpositive pregnant and lactating women (PMTCT Option B+), and three-monthly HIV testing of HIV-negative pregnant and lactating women. This chapter tracks the development and impact of the South African PMTCT programme from 2002 to 2016. 

District and facility-based quality improvement, mentorship, strong national leadership and civil action has led to rising antenatal HIV testing uptake (≥95% by 2015/16) and triple ART coverage (≥93% by 2015/16). Consequently the national risk of early (six weeks postpartum) mother-to-child transmission of HIV (MTCT), plummeted from approximately 25-30% prior to 2001 to an estimated 1.4% in 2016. There are no routine data sources monitoring long-term PMTCT effectiveness. However, data from the South African Medical Research Council measured the risk of MTCT at 18 months as 4.3% (3.7–5.0%). Possible game-changers to increase PMTCT effectiveness include strengthening safe-sex and family-planning services, pre-pregnancy through breastfeeding and beyond; repeat maternal and infant HIV testing at every contact with the health system; viral-load monitoring with immediate action for high-risk mothers; strengthening postnatal care; implementing a unique identifier to facilitate routine monitoring; real-time tracking of HIV-exposed infants and their mothers; early ART initiation for HIV-positive pregnant women and their HIV-positive family members in accordance with revised guidelines; mentorship and supervision of healthcare providers; and increasing accountability of communities and health care personnel at all levels. 

South Africa is well poised to achieve further MTCT reductions; however, reducing maternal HIV prevalence, strengthening postnatal care and increasing accountability need significantly more attention.

The female condom (FC) was introduced in South Africa in 1998, marking a parallel anniversary to this 20th edition of the South African Health Review. The FC programme has grown rapidly from a pilot phase to a national programme that is one of the largest government-funded FC programmes worldwide. Twenty-seven million FCs were distributed in South Africa in 2015/2016, exceeding the country’s National Strategic Plan (NSP) target of 25 million annually by 2016. 

The primary objective of this evaluation, conducted in 2014–2016, was to evaluate the national FC programme and identify determinants of FC uptake and continued use among couples. The study aimed to provide an evidence base for the future direction of South Africa’s FC programme, and to identify health system, provider and client barriers and facilitators to FC uptake and continued use. 

The evaluation included four components: a national survey in the public and private sectors consisting of interviews with providers and clients and an anonymous client survey; a cohort of new FC acceptors and their male partners; key informant interviews with policy and programme managers; and a unit-cost analysis of total programme costs. 

Results indicated that nearly 90% of men and women interviewed had heard of the FC, and approximately 20% had used it. Although FCs were available at almost all sites surveyed, only two-thirds of clients knew that FCs were available at their healthcare facility. Female condom distribution has doubled since 2008, but there are marked differences across provinces. Provider interviews indicated that three-quarters of providers had been trained in FC provision, but most sites lacked information, education and communication (IEC) materials and demonstration models. Findings underscore the need to promote awareness of FC availability in South Africa for HIV, sexually transmitted infection (STI) and pregnancy prevention and also to demonstrate the pivotal role of the provider in delivering FCs to potential users.

Drug-resistant tuberculosis (DR-TB) is a significant threat to efforts to end TB in South Africa. Responding to this epidemic requires access to drug-sensitivity testing among all TB patients and effective second-line anti-tuberculosis treatment for all diagnosed patients. South Africa currently treats the third-highest number of DR-TB patients globally, after India and Russia. The 12 527 cases (10% of the global cohort) reported to be enrolled on treatment in 2015 is close to four times the figure reported for 2007, yet represents only 64% of the diagnosed cases in 2015. Treatment outcomes are poor, with a success rate of approximately 50% nationally and globally. 

In this chapter we review the emergence of DR-TB in South Africa and progress towards universal access to diagnosis and effective treatment; we also discuss key policy initiatives that have contributed to treatment access and patient outcomes, and highlight opportunities and challenges moving forward. 

While DR-TB was first identified in the 1980s, systematic, standardised treatment was only rolled out across South Africa in 2001. Prior to this time, DR-TB treatment was only available in a small number of specialised TB hospitals. Following the publication of the 2008 updated World Health Organization guidelines, the standardised treatment used in South Africa was strengthened with the inclusion of more drugs. Implementation of new diagnostic tests, including the Xpert test from 2011 have significantly increased the number of diagnosed DR-TB cases. A policy supporting decentralised and deinstitutionalised DR-TB treatment provision at lower levels of the health system was introduced in 2011 but to date, implementation has varied. More recently, South Africa has expanded access to the newly available TB drugs. 

Defining and piloting models of DR-TB care across different settings and supporting patients throughout treatment are important challenges moving forward. Incorporating new drugs into shorter, more effective treatments that can be delivered through primary care provides an opportunity to improve treatment outcomes and reduce mortality.

South Africa is experiencing an increase in the prevalence of non-communicable diseases (NCDs), which imposes a heavy burden on healthcare services. The South African government has made great strides towards management and control of NCDs, including the development of management guidelines, healthpromotion and prevention policies intended to assist healthcare workers, facilities and communities in NCD care. However, it appears that the facility-based component of NCD management and control efforts has received more attention than the community-level components. 

The national strategic plan for NCDs highlights the importance of community-level interventions in chronic NCD care. Thus there is a need for community-based strategies for NCD prevention, control and management to complement facility-based health services. 

This chapter explores the advancement of the NCD agenda in South Africa through an emphasis on community-level prevention and management. It describes interventions that used community actors such as community health workers in NCD care. The chapter discusses some of the challenges of these interventions, and ends with possible suggestions for South Africa.

It is projected that by 2030, more than 70% of the world’s cancer burden will be in low- and middle-income countries (LMICs), such as South Africa, where breast cancer is the most commonly diagnosed cancer among women. South Africa is committed to the Sustainable Development Goals, which call for universal access to reproductive health services and a one-third reduction in premature deaths due to non-communicable diseases, including cancer, by 2030. 

The South African National Department of Health is currently drafting the country’s first national policy on breast cancer diagnosis and management. This chapter explores the pathways available in South Africa for achieving universal access to breast cancer-related services under the new policy. 

The chapter also discusses barriers to the implementation of equitable access, and highlights health-delivery models that could help achieve South Africa’s goals. The chapter begins with a description of successes in breast-cancer treatment, both globally and within South Africa, over the last 20 years as access to better diagnostic and treatment options has improved and awareness regarding the importance of early screening and treatment has grown. This description includes a summary of South Africa’s current environment regarding breast cancer-related care. 

Significant challenges remain in terms of access and quality of care. Yet, there are few data from or guidance for LMICs regarding the most cost-effective approaches for breast-cancer management. The benefits of mammographic screening are well documented, although the cost-effectiveness of routine mammographic screening is contested. An argument is presented for South Africa to approach universal access to breast care in a step-wise fashion, first reducing widespread late presentation and late-stage disease through provider-based population-level screening, and later moving (if possible) to more costly, technologically dependent approaches. 

Finally, recommendations are made regarding optimal service-delivery approaches, recognising South Africa’s integrated primary health care model.

The objectives of this chapter are to review the history of cervical cancer prevention and to discuss and evaluate new and novel approaches from a South African perspective. Methods for prevention and early detection of cervical cancer have been well established since the 1960s, yet implementation of appropriate policies and healthcare interventions have not occurred in the majority of low- and middleincome countries (LMICs). In these countries, cervical cancer remains a significant cause of premature death and is the second most-common cancer in women after breast cancer. Further, good-quality data on the true incidence and mortality of cervical cancer are lacking in many LMICs due to lack of cancer registries and national cancer-control programmes.

Alternatives to cytology-based cervical cancer prevention have been studied in the past 20 years. Testing for high-risk types of human papillomavirus (HPV) and linking positive tests to immediate treatment is a promising approach. This approach, known as screen-and-treat, provides treatment during the same visit as the screening visit, and overcomes many of the obstacles to widespread screening. Point-of-care tests for HPV are also now available in South Africa. Primary prevention of cervical cancer using HPV vaccination in young girls aged 9–15 years is predicted to reduce the cumulative incidence of cervical cancer by 70–80% over the long term and is likely to be effective in HIV-positive women. South Africa introduced a HPV vaccination programme in 2014 for girls aged nine years or older or in grade 4. however, screening will need to continue for older women.