South African Health Review - latest Issue

The Global Report on Urban Health: Equitable, healthier cities for sustainable development issued in March 2016 by the World Health Organization and the United Nations Human Settlements Programme (UN-Habitat) emphasises the need for enhanced governance and leadership to achieve universal health coverage and the Sustainable Development Goals (SDGs). Noting that a healthy population forms the foundation for "sustainable economic growth, social stability, and full realisation of human potential", the report presents "practical, proven solutions for working across sectors to tackle these ... health challenges", and includes examples of such successes in South Africa.

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 health policy and legislation arena has been dominated in 2015/2016 by the release, after much delay, of the White Paper on National Health Insurance (NHI). Although a White Paper is expected to provide finality on a policy in a manner which is ready for implementation, including the development of any necessary legislation, the NHI document leaves many questions unanswered. The 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 to changes to the National Health Act and the Medical Schemes Act, and perhaps 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 to create a new National Public Health Institute of South Africa, have been taken. However, neither Bill has yet been tabled in Parliament.

---

The Medicines and Related Substances Amendment Acts of 2008 and 2015 will need careful promulgation, once the necessary secondary (regulations) and tertiary (guidelines) legislation have been developed. The new South African Health Products 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 legacy of the Medicines Control Council, but also complete and entrench the effective regulation of complementary medicines and medical devices.

---

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.

South Africa has implemented a number of policies that focus explicitly on equity and that seek to provide redress to those most affected by previous apartheid policies. Examples include the adoption of a primary health care approach, which in itself is a social justice philosophy, and the use of a combination of legislative, policy and resource allocation levers to achieve transformation and to improve population health.

---

This chapter explores the disconnections between progressive and far-reaching health policies in South Africa and the fault lines in implementation. Notwithstanding the progress made since 1994, the chapter presents a critical analysis of and reasons for the relatively poor performance of the South African health system compared with other countries of similar income level, and in light of the country's quantum of health care spending.

---

Three fault lines are identified: tolerance of ineptitude as well as leadership, 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 failure to deal decisively with the health workforce crisis.

---

These fault lines have negative consequences for patients, health professionals 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.

Post-apartheid South Africa can lay claim to having substantially increased access to piped drinking water for all. Virtually all urban households and most rural households now have access to piped drinking water, with the remaining deprived communities located in more remote rural areas and in urban informal settlements. While drinking water may not necessarily be safe (or consistently available) in rural communities, there has been no recurrence of waterborne epidemics on the scale of the cholera epidemic of 2000-2001. However, child under-five diarrhoea case fatality rates indicate ongoing health issues in rural communities deprived of water services.

---

Water-related health issues are emerging due to conditions of water stress and climate 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 eutrophication is degrading water and habitat quality, and the results are difficult to treat. With climate change, existing microbial diseases could become more prevalent which is especially disturbing as water treatment plants are discharging insufficiently treated effluent into rivers. Contamination of groundwater and surface water from acid mine drainage requires specialised treatment. All of these factors indicate the need for improved water and health management, with greater surveillance of water quality and the delivery of universal water services to ensure health and prevent disease outbreaks.

---

The water-related Sustainable Development Goals extend the range of commitment beyond access to basic water services, and include improved water quality, enhanced water use and re-use and better water-related ecosystems. These commitments will demand a well-integrated approach and close public monitoring.

Non-communicable diseases (NCDs) are the leading cause of death globally and they are on the rise both in low- and middle-income countries, with South Africa being no exception. Implicated in this upward trend in the country is an observed change in diet - a transition from traditional foods, to what has come to be known as the 'western' diet, i.e. more energy-dense, processed foods, more foods of animal origin, and more added sugar, salt and fat. Increasingly, international research links rapidly changing food environment with escalating chronic disease, i.e. it implicates population-level dietary change over individual factors such as knowledge, attitudes and behaviours. Environmental and/or policy interventions can be some of the most effective strategies for creating healthier food environments.

---

This chapter explores the link between the rise in diet-related NCDs, their proximal determinants (specifically an observed change in diet patterns), contributing environmental factors, what is currently being done or recommended to address this internationally, and the most relevant national-level policies for South Africa.

---

The authors conclude that to improve dietary patterns and reduce chronic diseases in South Africa will require a sustained public health effort that addresses environmental 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 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.

A population perspective on health underpins the 17 newly adopted Sustainable Development Goals (SDGs) and South Africa's recently promulgated White Paper on National Health Insurance (NHI). Monitoring their progress, identifying health service priorities and implementing effective delivery strategies requires a skilled public health (PH) workforce. Yet several key policies intended to transform the country's health system radically make no mention of this workforce.

---

This chapter investigates the potential contribution of the Public Health Medicine (PHM) specialty to a public health workforce in South Africa. We describe the nature of PH, the competencies anticipated of a PH workforce and the training programmes for PHM specialists and the Master of Public Health (MPH). The discordance between 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.

---

PH is an inter-disciplinary field that aims to understand health problems, and to develop and evaluate programmes to improve the health status of populations. The evolution of PH in South Africa reflects two trends: one focused on compliance with measures protecting human health, and the other focused on the development of innovative participatory models and policy emphasising comprehensive care.

---

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.

---

Understanding the history of PH in South Africa, the broadening of its inclusive professional identity and the multi-disciplinarity of the PH workforce should facilitate use of these skills to deliver on national and international development goals.

Sickness absence and long-term incapacity leave contribute substantially to the national service delivery challenges that are particularly evident in the public health sector. The Auditor-General's reports, and the Department of Public Service and Administration, have highlighted these challenges.

---

Recognising this as an area requiring intervention, the Department of Public Service Administration developed the 'Policy and Procedure on Incapacity leave and Ill-health Retirement' and outsourced the management of sickness absence to private agencies. Management of ill-health among health-care workers is not addressed at the workplace; this has resulted in poor decision-making about fitness to work, and to work incapacity contributing to levels of absenteeism that exceed international benchmarks for the healthcare sector.

---

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 was done of the literature on current benchmarks and approaches to managing sickness absence; secondary data from national and provincial Department of Health reports were also reviewed. A description is given of a small sample of short-term sickness-absence cases (n=151) at a hospital in KwaZulu-Natal. Two of the cases are highlighted.

---

Healthcare workers experience a significant burden of disease caused by a range of workplace hazards. This, together with inadequate institutional management of sickness absence, results in a high number of lost work-days. In 2004-2006 and 2007-2009, the national cost of sickness absence was R7.3m and R8.8m respectively, while the provincial costs were R208m and R303m respectively. In 2014, sickness absence resulted in an average of seven days (senior management), eight days (skilled supervisors) and eight days (lower categories), among all those workers taking sick leave.

---

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.

There has been a longstanding call to employ trained interpreters to address language barriers in health care in South Africa. The international literature shows that while trained interpreters can be effective, the existing sophisticated models of upper-income countries are expensive and contextually inappropriate for low-resource settings like South Africa. In community interpreter models, members of 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 the literature.

---

In this chapter, we describe the findings of a pilot project in which community interpreters were introduced to hospitals in the Western Cape to address the language barrier experienced by isiXhosa-speaking healthcare users. Using participatory action research methods, we discuss emerging themes identified by the interpreters, from mentor sessions conducted with them over a three-year period. The emerging 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 the health system.

---

The experiences of the interpreters raise crucial questions about current language issues in our hospitals, while offering important insights into the potential to develop 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.

Traditional health practitioners (THPs) in South Africa are increasingly acknowledged as essential providers of health care and the National Department of Health is taking firm steps towards the formal regulation of THPs. However, tensions continue to dominate the landscape of research and policy debates on the role and practices of THPs, particularly with respect to historical injustices, gaps in scientific evidence, mistrust on the part of biomedical practitioners and toxicity of medicines.

---

In this chapter, we report on the findings of a study of peer reviewed and grey literature related to THPs up to 2015 and argue that the world view of the biomedical paradigm is very different from that of the healing paradigm as the former uses a scientific knowledge lens while the latter uses an indigenous knowledge lens.

---

We argue that in subscribing to indigenous knowledge systems, the merging of biomedical and traditional healing paradigms provides for a complementary system of plural health care, which could offer patients a truly holistic and comprehensive form of care.

---

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 Practitioners Act (22 of 2007).

Universal access to sexual and reproductive health services was included in the Millennium Development Goals and has been carried forward in the new Sustainable Development Goals (SDGs). Access to contraception is highlighted in the Family Planning 2020 (FP2020) initiative. Given South Africa's ongoing commitment to the SDGs and FP2020, this chapter explores the potential for achieving universal access to contraceptive services in South Africa against the backdrop of the country's domestic policies, current implementation efforts and HIV epidemic.

---

South Africa's laws, policies and guidelines on contraceptive service provision in the public sector are progressive and comprehensive, and promote integrated, rights-based service delivery.

---

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 specifically. Service delivery norms and approaches for budgeting and expenditure tracking are described, and national and provincial contraceptive statistics are presented.

---

Public sector delivery of contraceptive services nationally faces both similar and unique challenges as compared to other health services. Issues relating to health systems constraints are identified, including scarce resources and the burden of HIV in the country, and their impact on delivery of contraceptive services is discussed. The recent introduction and roll-out of the subdermal contraceptive implant is highlighted as a case study illustrating both successes and challenges.

---

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.

Recent global evidence shows that breastfeeding benefits both mothers and babies in rich and poor nations. Furthermore, evidence suggests that concerted national efforts to scale up breastfeeding interventions, policies and programmes can bring about rapid change, and that creating an enabling environment to practise breastfeeding has huge potential as an investment in the future health of mothers and the healthy life course of their children.

---

In South Africa, available national data suggest that most mothers initiate breastfeeding after birth. However, it has been observed that very few babies are exclusively breastfed during the first six months of life. Many babies also receive complementary foods between two and three months of age, and in some cases, even 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 as in adulthood.

---

This chapter interrogates whether we are making progress in our country to improve breastfeeding practices. A review was done of breastfeeding progress globally, and South Africa's commitment to breastfeeding as a component of infant and young child feeding (IYCF) over the past few years. The chapter determines what has been done to promote breastfeeding, including which policy changes have imminently promoted breastfeeding. Thereafter, the key determinants of breastfeeding in South Africa are unpacked and detailed, together with a review of proven interventions at different levels of society. Finally, the chapter makes practical recommendations to restore breastfeeding as the 'new' norm for infant nutrition in all sectors of South African society.

In August 2014, the National Department of Health implemented MomConnect as a national digital maternal health program that implements the South African mobile health (mHealth) strategy and the National Health Normative Standards Framework for Interoperability in electronic health (eHealth). As the first digital health program communicating with people at scale, MomConnect enrolled more than 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.

---

MomConnect uses a mobile phone application to support a pregnancy registration system in antenatal care facilities, allowing pregnant women to receive stage-based messages to help them improve their health and that of their babies. Women can self-subscribe or be subscribed by community health workers to receive a limited set of health-promotion messages. Registered users interact with the system by rating the service received, asking questions, and submitting compliments or complaints. The mobile system connects to a central health-information exchange that facilitates interoperability between digital health applications and includes data validation, a national pregnancy registry and a monitoring and reporting system.

---

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 clients. As such, it is an exemplar implementation of the Health Normative Standards Framework enabling national-level innovation as a model for future health system strengthening, enabling interoperability between digital health applications, and achieving universal health coverage.

---

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.

Reduction in child mortality has been a priority issue in South Africa leading up to the Millennium Development Goals. However, the contribution of congenital disorders (CDs) to child mortality is yet to be recognised and acted upon.

---

Rapid reductions in child mortality have resulted largely from comprehensive HIV and AIDS programmes and interventions such as the childhood Expanded Programme of Immunisation. However, the Rapid Mortality Surveillance System reports that since 2011, reductions in child mortality rates "stopped abruptly". This indicates that health issues other than those currently being addressed may require long-term prioritisation. In 2013, congenital anomalies (excluding many CDs) overtook infection as the third leading cause of early neonatal deaths, which account for one-third of all under-five deaths.

---

As South Africa transitions epidemiologically, the proportion of deaths caused by CDs is increasing, as mortality from communicable diseases drops, revealing the 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 inaccurate data result in an underestimation of the true disease burden of CDs in the country.

---

As up to 70% of CDs can be prevented or ameliorated, it is essential that they be prioritised and that relevant, accessible services for prevention and care be implemented. A good legislative and regulatory framework exists in South Africa for the provision of services, but implementation has been poor and fragmented. Current services are available at a lower base than in 2001.

---

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.

As implied by the World Health Organization's statement, "There is no health without mental health", it is essential to think of mental health as an integral part of health. As such, it should be integrated into health policy and practice in order to improve global health and address the significant treatment gap for mental, neurological and substance use (MNS) disorders.

---

Efforts to address this in South Africa have included policy responses as well as research and service innovations integrating mental health into general health care. This chapter provides an overview of the current policies and services in place for mental health care in South Africa; it also describes current research on effective strategies for providing such services, and identifies key barriers and facilitators in implementing these policies and scaling up mental health services.

---

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 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 required to evaluate both the outcomes of scaled-up mental health care and the best practices to achieve this.

---

Integration of mental health requires a vision, high-level commitment, allocation of resources, as well as oversight and support of the provinces in the implementation of mental health services. The vision is apparent in the South African Mental Health Policy and Strategy Plan - the implementation of this policy is the challenge that now lies ahead.

Sex work remains illegal and highly stigmatised in South Africa, resulting in sex workers - the majority of whom are internal or cross-border migrants - experiencing ongoing human rights violations and a high HIV burden. High levels of unemployment, limited socio-economic opportunities and associated migration dynamics mean that sex work remains a key livelihood option for many cisgender and transgender women and men in sub-Saharan Africa.

---

This chapter reviews the health system's response to sex work in South Africa, with a focus on HIV-related programmes. The analysis is based on the World Health Organization's health system 'building blocks' framework and is informed by a policy scan, literature review, consultation with sex work experts, and reflection.

---

We provide an analysis of the politics of much-needed structural interventions such as 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.

---

The authors argue that South Africa will not reach the United Nations Joint Programme 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 worker health.

---

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.

Trauma is a major burden of disease in lower- and middle-income countries, and to address the causes and treatment requires specialist services and multidisciplinary care. Despite this, governments have given trauma low priority as they have focused largely on primary health care.

---

This chapter demonstrates the extensive burden of trauma in KwaZulu-Natal (KZN) and illustrates that the entire country experiences a similar disease burden. Recent data from numerous studies are used to provide insight into the options for establishing systems of quality trauma care and accreditation programmes for hospitals and systems. Current and optimal staffing of trauma-care facilities, compliance with minimum equipment standards, and the potential for patient harm are addressed.

---

The authors show that trauma constitutes approximately 25% of the emergency 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 and the existing resources at regional and tertiary public facilities are strained.

---

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 authors highlight the need for prevention programmes and draw attention to the 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.

There is growing recognition that access to healthcare facilities is unlikely to improve health outcomes if the quality of the care provided at these facilities is inadequate. The emerging consensus on the importance of quality of health care is reflected in proposed policy reforms in South Africa, as well as in increased measurement of quality at primary health care facilities.

---

Through focus on clinical quality and client satisfaction, we provide a critique of current approaches used to measure quality. We argue that the measurement of quality will be strengthened by complementing current approaches with alternatives such as standardised clients and vignettes. Other alternative approaches that are also considered include health worker knowledge tests, direct observation and asking clients about the clinical dimensions of client-provider interaction. The presented alternative measures can help to overcome biases inherent in current approaches and assist in establishing a better understanding of the state of clinical quality in primary health care facilities.

---

More public debate is needed on meaningful, affordable and robust approaches to quality measurement. We recommend that such debates should consider and discuss the affordability, feasibility, reliability, credibility and relevance of current and alternative approaches.

South Africa has the largest number of persons living with HIV and on antiretroviral treatment (ART) in the world. In December 2015, 3.26 million South Africans were on ART, with this figure scaling up by approximately 400 000 persons per annum. To sustain increasing ART roll-out an additional R1-1.5 billion above inflation has been allocated annually over recent years, while R8.9 billion of the Comprehensive HIV and AIDS Conditional Grant is budgeted for the ART programme in 2015/16.

---

The roll-out may need to expand more rapidly, as South Africa has amended the treatment threshold to a CD4 cell count of 500 cells/mm³ and aims to reach the Joint United Nations Programme on HIV/AIDS 90-90-90 targets, effectively a form of test-and-treat, and to expand various prevention interventions.

---

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 pressures will be aggravated by other competing demands such as the 2015 wage agreement. Simultaneously in terms of bilateral agreements, funding is declining from donors such as the United States President's Emergency Plan for AIDS Relief.

---

This chapter analyses these questions using the results of the recent HIV and tuberculosis investment case, which includes the most 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.

South Africa has instituted various mechanisms to render the pricing of pharmaceuticals more transparent, including the Single Exit Price (SEP) that clarifies the price at which a manufacturer may sell a medicine to logistics service providers or medicine dispensers. The SEP consists of an ex-manufacturer price, a logistics fee and Value Added Tax. However, as more countries look to South Africa for lessons from its pricing policies, an understanding of the manufacturer's price, logistics fees and their relationship has become increasingly necessary to support the principle that the SEP leads to more transparent prices.

---

This chapter provides a descriptive analysis of the pricing dynamics between the ex-manufacturer's price and the logistics fee; a determination of the logistics fee relationship to the number of manufacturers of a product; and an examination of logistics fees among different therapeutic classes as well as the relationship to the essential medicine status of a product within the therapeutic class.

---

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 of prices negotiated between manufacturers and distributors/wholesalers.

---

Initiatives to conduct larger, in-depth pharmaco-economics evaluations are required for a deeper understanding of market trends, particularly in terms of the ex-manufacturer's price and logistics fee: how they behave in different therapeutic medicine classes and in response to changes in the patent status of medicines. These findings should guide policy decisions and importantly, gauge market changes in response to the various policies.