The contribution of non-communicable disease (NCDs) to the overall burden of disease in South Africa now starkly outstrips the contribution of communicable diseases, and high-level political support and more funding are vital to implement the National Strategic Plan for NCDs.
Additionally, the significant increase in the unmet need for mental health services requires huge additional funding. The mental health treatment gap is a notable 92% — meaning that just 8% of those who need treatment actually receive care.
Also requiring urgent attention is the skyrocketing teen pregnancy issue, needing a holistic all-of-society response and not merely health sector intervention.
On the upside, there are more people on anti-retroviral treatment for HIV, and infant and child mortality rates have declined.
Daily Maverick reports that these are just some of the observations in a new book unpacking both the achievements over the past five years and the work needed to strengthen South Africa’s health sector.
More than 70 authors contributed to the 20 chapters of the book, entitled South African Health Reform, 2015-202 – the Road Ahead, which reviews the period that includes the outbreak of the Covid-19 pandemic and is a follow-on to the previous publication that reviewed the period 2010-2014.
In its concluding chapter, the editors, Yogan Pillay, Robert Fryatt, Precious Matsoso, Usuf Chikte and Lindiwe Makubalo, make 34 recommendations, some of which are highlighted below.
While many commentators have lamented the poor quality of care provided by the public health system and the high cost of the private health system as well as the inequities in the health sector, there are many positives that the next administration can build on and many areas that need razor-sharp focus and reconstruction, they said.
Impact of Covid on health
Before the pandemic, there were significant improvements in maternal and child mortality and an increase in the number of people living with HIV and on life-saving antiretroviral therapy. Life expectancy for men increased from 60.2 years in 2015 to 62.5 years by 2020 and for the same period from 64.3 years to 68.5 years for women.
However, the pandemic has resulted in some declines — for males this was to 59.3 in 2021 and for females to 64.6. The in-facility maternal mortality ratio also declined from 105.7 deaths per 100,000 live births in 2017 to 88 by March 2020 — again increasing in 2020/21 due to Covid-associated deaths by as much as 30% compared with 2019.
The infant (IMR) and child (under five) mortality rates also declined between 2015 and 2020. The IMR declined from 28/1000 live births to 21/1000 and the under-five deaths declined from 39/1000 to 28/1000.
Many of the positive trends will have been affected by the impact of the Covid-19 pandemic, like disruptions in health service provision. Additionally, apart from the immediate affect on health, the longer-term impact will come through worsening determinants, such as poverty, inequality, unemployment, pandemics, natural disasters and education.
The Department of Health should develop guidelines for provinces and districts on creating consultative engagements for sub-national government stakeholders. These could build on structures and processes that were developed to deal with Covid-19, with documented best practices and many innovations by provincial health departments.
The governance weaknesses in PHC need to be tackled by the formulation of a more coherent sub-district system, meaningful community engagement and empowerment, accompanied by a commitment to establishing stable, skilled and public-interested leadership in PHC and district health systems.
Very concerning is the inadequate uptake of contraceptives and the increasing number of teenage pregnancies, the crisis needing a holistic all-of-society response and not just intervention from the health sector.
Capacity and quality
An overarching coordinated national commitment is required for quality improvement and continuous learning, both in the clinical and corporate management of hospital-level services. The urgent implementation of the quality improvement (QI) strategy should involve all stakeholders, including frontline health workers, civil society and the many quality-of-care role players within separate health programmes or sectors.
Capacity to deliver healthcare infrastructure must be strengthened either by improving the required staffing capacity in the various Departments of Public Works across the provinces or by moving the function to provincial health departments, along with the necessary capacity.
Similarly, the skills and competencies of managers at all levels but especially in public hospitals, district offices and primary health care facilities need urgent strengthening in line with their delegations.
The passage of the NHI Bill should be fast-tracked alongside strengthening the capacity for its implementation. The government should urgently implement the recommendations of the Health Market Inquiry and advocate for greater multi-sector engagement
A more seamless health service for all requires that the national/provincial and province/province interfaces have specific attention. This could be through co-creating a health governance charter that clarifies the values underpinning this interface, the roles of various actors, the spaces of engagement, and forms of reciprocal accountability. As the country implements NHI, a similar governance charter with the private health sector will also be required.
Provincial and district health councils should be opened beyond current mandates as spaces for engagement with civil society, in addition to strengthening the functionality of clinic committees and hospital boards. Presently, these committees are merely advisory, with no power to intervene. Lessons from the functioning of school governing bodies may be useful guidance on how to strengthen these structures.
The national department should strengthen data governance, including norms and standards for the public release of data to achieve greater transparency and better use of existing data. It should also invest in systems making it possible to track patients and access more timely feedback across the health system.
As seen during the Covid pandemic the use of data to inform the public and help them seek solutions to health challenges is powerful.
The health information system needs to be urgently strengthened with both electronic patient medical records and an improved surveillance system. The former will strengthen clinical governance and the latter epidemic and pandemic preparedness and response.
The national health department should coordinate efforts from all stakeholders across national government to support the implementation of human resources for health plans effectively.
This would be helped by the urgent implementation of the Human Resources for Health Strategy and the establishment of a functional National Health Workforce Analysis and Planning Unit drawing on expert workforce planning expertise, and utilising data science opportunities for more predictive and intelligent analytics and decisions.
The government should continue to expand intersectoral collaboration to address the social and commercial determinants of health and improve the effectiveness of services. Everyone should be cognisant of actions needed to unblock bottlenecks
While government stewardship is critical, not only the state but also an active citizenry is required to keep the government accountable in all spheres.
The editors and authors of the South African Health Reforms, 2015-2020, believe that if these recommendations are implemented by government, in partnership with its stakeholders, the health system can be rapidly strengthened. If this effort also addresses the social and commercial determinants of health (including the impact of inequity), health outcomes too will significantly improve for all those living in South Africa.
* Yogan Pillay (Department of Global Health, Stellenbosch University); Robert (Bob) Fryatt (Lead, International Health, Mott MacDonald), Precious Matsoso (Wits Health Consortium, University of the Witwatersrand); Usuf Chikte (Department of Global Health, Stellenbosch University), Lindiwe Makubalo (World Health Organisation, Africa Region)
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