Glimpses into the South African Health Review 2012/13

The 16th edition of the South African Health Review (SAHR) broadly focuses on some of the key building blocks of the health system, namely, financing, governance and leadership, medical products and service delivery while issues pertaining to human resources and information run as a thread through most of the chapters. The Review also focuses on social determinants of health, non-communicable diseases, climate change as well as occupational health and South Africa’s quest on addressing these. In this edition, we also introduce the newly launched Emerging Public Health Practitioner award that provides a voice to young and upcoming under-35 year old public professionals. We hope that in years to come this award will inspire these practitioners to add to new and on-going public health debates and to present novel and innovative solutions to problems that plague our health system. The 2012/13 SAHR consists of 17 chapters written by a diverse set of public health experts on their areas of expertise.

Health Policy and Legislation

In the chapter on Health Policy and Legislation, Andy Gray and colleagues report that no new health-related legislation was passed during the 2012/13 period but two health-related Bills are being reviewed in Parliament, namely the National Health Amendment Bill (Bill 2 of 2011), which will introduce the Office of Health Standards Compliance, and the Mental Health Care Amendment Bill (Bill 39 of 2012). Gray and colleagues pay attention to the legislative barriers with regards to telemedicine and the newly released intellectual property policy released for comment by the Department of Trade and Industry. The authors conclude that despite progress being made to the provisions of the National Health Act, some critical elements remain unresolved. They propose that the costs of developing health-related legislation be calculated to increase accountability and awareness on the exact expenditure associated with legislation development.

National Health Insurance

Malebona Precious Matsoso and Robert Fryatt summarise progress against a plan of action and future plans for introducing the National Health Insurance (NHI) policy since the launch of the Green Paper in August 2011. They present a discussion on the NHI White Paper and legislative process including management reforms and designation of hospitals; hospital reimbursement reforms; and public health facility audit, quality improvement and certification. The Primary health care re-engineering progress is outlined in terms of human resources for health, information management and systems support and work to enable provinces to plan, manage, modernise, rationalise and transform infrastructure for public hospital infrastructure and equipment is presented. They also provide an overview of progress towards strengthening district health authorities, financing, establishment of the NHI Fund and considerations pertaining to accreditation and contracting private providers. A list of five key challenges accompanied by their risks and proposed mitigation is also presented under the headings of ‘consultation and communication’, “harnessing cost-effective health technology’, ‘making change happen’, ‘building up knowledge on what works’ and‘ retaining the focus on equity’. A number of case studies are presented and they conclude by stating that universal coverage is no longer simply a dream for South Africa but within reach.

HIV treatment

South Africa has the largest number of people with HIV in the world and now has the largest and possibly the most ambitious antiretroviral treatment (ART) programme globally. Francois Venter examines the political, policy, programmatic and other issues pertaining to the initiation and expansion of the South African ART programme and frames most of his discussion within three politically-related eras spanning the period 2004 to 2012. The role of non-profit organisations and civil society is also discussed with mention of the role of activism, litigation and negotiations at all levels. He highlights successes such as statistics showing that 2 million people are accessing ART at the end of 2012, a shift to improved treatment regimens; good viral suppression, retention in care and clinical outcomes; an increase in life expectancy attributed to increased access to ART; and a reduction in the national mother-to-child transmission of HIV rate from 30% to below 3%. Despite the undoubted gains, mostly made during the post-2008 era when a new political dispensation and subsequent reorientation and scale up of the programme occurred, the South African government still faces a number of challenges. The cost and scale of the programme, evolving HIV treatment guidelines, the failure of past and current prevention programmes, the need to continuously integrate HIV with tuberculosis (TB) and antenatal services, and the implications of adopting a ‘treatment as prevention’ programme in South Africa are also discussed. Venter states that good governance is required and also highlights that provincially, with the exception of one province, poor financial and programme planning have proven to be major obstacles to seamless implementation and scale up. The chapter concludes by emphasising the need for strong medicines supply and service delivery systems which if weak can threaten the expansion of the treatment programme. Furthermore, Venter challenges the government to consider thinking creatively about how to best manage HIV as a chronic disease through developing systems that will facilitate on-going disease monitoring and reducing the number of health facility visits.

Maternal, newborn and child health

In the chapter on Maternal, newborn and child health, Lesley Bamford reports that although South Africa continues to experience unacceptably high rates of maternal, newborn and child mortality, a decline in the under-five and maternal mortality ratio has been observed. She gives an overview of global mortality rates and trends, at the same time presenting reviewing the primary causes of maternal, child and infant mortality and highlights the role of under nutrition in mortality in children. Evidence shows that increased coverage of proven interventions should specifically be aimed at the poorest and most disadvantaged children to overcome the increasingly observed disparity in mortality between the wealthiest and most deprived quintiles. The chapter concludes with a caution that without addressing the weaknesses and inefficiencies in the health system, namely ‘increasing the availability of adequate numbers of well-trained healthcare workers at facility and community levels’, “strengthening monitoring and evaluation systems’, ‘addressing equity’, ‘increasing accountability’, and ‘ensuring that all the components of the Maternal, Neonatal, Child and Women’s Health and Nutrition Strategic Plan are implemented’, South Africa will not attain the goals it has set for itself.

Occupational health

The chapter on occupational health takes a look at two occupational populations for which the National Department of Health has legal responsibility, namely healthcare workers at risk of contracting TB, including multidrug-resistant TB and former mineworkers with occupational lung disease due to exposure to hazardous dust. For former mineworkers, Shahieda Adams and colleagues specifically discuss the problem of the failure of statutory examination and compensation system for occupational lung disease. They question what the appropriate health system response is to the combined silica/silicosis and TB epidemic should be, given that in the case of mineworkers these conditions have their roots in the private mining sector yet become the problem of the public sector. In response a review of key legislation that touches on the management of lung diseases in mineworkers, access to benefit medical examinations by former mineworkers, and claims management are presented. The chapter concludes with a range of recommendations including an argument for instituting measures to hold the mining industry accountable for reducing the root causes of the epidemic, namely the risk of exposure to silica dust at source and for legal, financial and managerial reforms of compensation systems and intensified case finding, the provision of better prophylaxis and implementation of better infection control measures among health care workers.

Social accountability

A key component of the district health system is the community and in South Africa, as has been reflected in many chapters in this Review, civil society has played and continues to play a pivotal role in shaping health policy, particularly in the era of HIV and AIDS. Kerry Cullinan describes an innovative pilot project conducted in half of the NHI pilot districts aimed at reporting on health conditions at the district level in order to improve service provision. The underlying premise is that where political structures fail in the area of service delivery, collective citizen action (“social accountability”) by or on behalf of the poor will spur policy makers and service providers into action. Numerous national examples of media-driven social accountability through the use of citizen journalists are presented and a description of the initiative is provided.

Social determinants of health

Laetitia Rispel and Sara Nieuwoudt present an analytical perspective on the social determinants of health in South Africa and conclude that rhetoric on the social determinants of health in South Africa exists in policy and at national and provincial levels with structural mechanisms ranging from narrow bilateral departmental arrangements to integrated planning approaches. They suggest that the lack of prioritisation of intersectoral initiatives however casts doubt on government’s capacity and ability to make substantial and measurable progress in this regard. They characterise key barriers to intersectoral action and addressing the social determinants of health into five key areas relating to legislative and policy design, governance and leadership, gaps between policy and implementation, lack of or insufficient resources and resourcing, and lack of monitoring and evaluation.

Violence, alcohol misuse and mental health

Joanne Corrigall and Richard Matzopolous discuss gaps in the health system response to the interrelationship between violence, alcohol misuse and mental health. They cite a lack of governmental recognition and prioritisation of the multi-directional links between the triad as a key problem which results in knock-on effects of poor data availability, policies and interventions that can address these problems in an integrated manner. Other gaps relate to under-resourcing of the health system, the under-detection and inadequate management of these conditions within healthcare settings, and decreased access due to a range of logistic, cultural and knowledge-related barriers. Surveillance is identified as a key component in supporting the identification and management of these public health problems, in particular the institutionalisation of an injury mortality surveillance system.

Non-communicable diseases

In South Africa, non-communicable diseases (NCDs) account for 37% of all-cause mortality and 16% of disability-adjusted life years. Thandi Puoane and colleagues in their chapter on Chronic NCDs in South Africa describe the current status of chronic NCDs and key drivers thereof and provide a five-year overview on local policies and practices. The chapter focuses on the ‘big four’ NCDs – heart disease, cancer, type II diabetes and chronic obstructive pulmonary disease – with a focus on their risk factors as presented within a framework ranging from biological, behavioural (e.g. tobacco use, obesity, physical inactivity, alcohol misuse), societal (e.g. employment, poverty, education, accommodation, socio-economic status and behavioural risk factors) and structural and environmental (e.g. food environment, marketing of unhealthy products and behaviours) determinants. A range of policy responses are discussed, examples of initiatives and programmes targeting chronic NCDs in South Africa are presented.

Climate change

Jonathan Myers and Hanna-Andrea Rother discuss the Public health impact of and response to climate change in South Africa. They pay attention to South African public sector responses and review the action taken national and provincial level. The authors focus on the barriers and enablers in the implementation of climate change interventions and recommend that enhancing knowledge of and an understanding of the potential impacts of climate change on health in South Africa, particularly on the existing burden of disease. This requires the modelling of local climatological data to understand the health-equity implications of these changes. Myers & Rother call for Research, development and collaborative work between academic health institutions and the health system which focuses on the link between climate change and its potential impact on South Africa’s burden of disease.

National health research system

Given the inclusion of research and development strengthening in the 2009 to 2014 South African 10 Point Plan, Flavia Senkubuge and Bongani Mayosi, discuss the state of the national health research system in South Africa and present an assessment of the performance of the national health research system as envisaged by the Health Research Policy of 2001 as well as the recommendations of the National Health Research Summit of 2011 on strengthening research and development in South Africa. The authors state that evidence shows that large economic return on investments can be observed when medical research is invested in at country-level, but also state that global commissions have shown that health research is not given its rightful place in improving health, equity and development in low and middle-income countries. A framework for assessing national health research systems is used to determine the state of the national health research system and focuses on stewardship, financing, creating and sustaining resources, and producing, synthesising and utilising research. It is noted that due to declining investigator-initiated original clinical research over the past few years, there is a need to revitalise clinical research.

Health policy and systems research

The chapter on health policy and systems research provides a South African higher education perspective on the growth of the field of Health Policy and Systems Research. Marsha Orgill and colleagues list the key milestones in the development of the field and provide basic definitions and seek to frame health policy and systems research within the broader terrain on health research in general. They present findings of a PHASA pre-conference health policy and systems research workshop and discuss challenges facing future local development of this field.

Decentralisation

An exploration of the complexities and challenges of managing a sub-district and framing a debate on the role of districts and sub-districts using systems thinking and management theory with regards to strategic policy direction setting and operational service implementation is presented by Soraya Elloker and colleagues. They focus on the intangible software of the health system such as relationships, communication practices, values and norms and its role in determining the behaviours of those working in the health system and the location of organisational practices and routines within this software dimension. The authors conclude that numerous competing demands, actors, existing organisational cultures and legacies undermine progress towards decentralisation and innovation and highlight the influence that organisational software has in this sphere. Ultimately, managers are expected, and should be willing and able, to manage in “calculated chaos”, hence management and leadership development programmes should focus on developing the software elements as well as technical skills and capacities.

Medicines selection and procurement

Bada Pharasi and Jacqui Miot shed light on medicine selection and procurement in South Africa with a focus on the components in the 1996 National Drug Policy. The authors note the numerous changes in both the public and private sectors over the past 16 years and emphasise the importance of applying evidence-based medicine, pharmacoeconomics and budget impact analysis when selecting medicines and that a coherent approach is required especially in preparation for NHI, along with engagement with academic sector. They highlight however that more attention to medicine supply chain management at lower levels in the health system particularly the district is imperative, and call for a monitoring and evaluation plan to measure the impact of the National Drug Policy’s implementation and for a national review of implementation thus far.

Emerging Public Health Practitioner award

The recipients of our inaugural Emerging Public Health Practitioner award are Nadia Hussey and Oluwatoyin Adeleke.  Nadia, a medical student at the University of Cape Town takes a closer look at the effects of language barriers on the access of patients and communities to quality health care. Her chapter provides an insightful glimpse into the challenges language barriers pose on work efficiency and holistic treatment. Oluwatoyin provides an overview of health system factors that influence health worker performance in implementing TB infection control in primary care clinics at district level.

SAHR

Editors of the South African Health Review, René English and Ashnie Padarath with the winners of the inaugural Emerging Public Health Practitioner Award. From left to right:  Dr René English, Nadia Hussey, Oluwatoyin Adeleke and Ashnie Padarath

As is customary, the Review concludes with the Health and Related Indicators chapter which is one of the most anticipated chapters of the Review each year. A comprehensive range of routine and non-routine data are presented and for each section that authors discuss some key developments. The content includes demographic, socio-economic, health services and health financing indicators. Provincial maps, colour graphs and indicator definitions are also included.

Note that the views expressed in this article are those of the author(s) and do not necessarily represent the views of PHASA.

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