Health In South Africa: 20 Years After Apartheid

Health in South Africa since 1994:
achievements and challenges.
Will current policy initiatives resolve the
crisis?
SaSa
A WHO Collaborating Centre for Research and Training in Human Resources for Health
David Sanders
Emeritus Professor
School of Public Health
University of the Western Cape
Member of Global Steering Council
Peoples Health Movement
Member of Steering Committee PHM South Africa

 South Africa’s comparative performance in health
 Disease pattern and premature mortality – levels and
causes
 Health policy and the health sector: advances and
continuing challenges
 NHI and ‘Re-engineering PHC’: rationale and
challenges to implementation
 Proposed priority initiatives to address health
challenges, including the role of social movements

Democracy: so much promise …
• Legislation
– Constitution
– UNCRC
– Children's act
• Policies & programmes
–  basic services
–  in social grants &c
–  clinic building
– Tobacco control
– Food fortification
– PSNP
• Global
– Adoption of MDGs

Life expectancy vs wealth
SA
Banglades
h
Cuba

National Health Indicators
• Life expectancy 49.41 (60)
• Infant mortality 33.4
– EC 45 vs WC 18
• Under five mortality 47.7
- KZN 61 vs WC 25
• Maternal mortality 300
• No. living with HIV 5.58 million
South African Health Review 2011

Quadruple burden of disease
 pre-transitional diseases and poverty related
conditions eg childhood undernutrition and infections,
maternal mortality
 emerging chronic diseases eg obesity, heart disease,
diabetes, mental ill-health
 injuries - including interpersonal violence
 HIV/AIDS and TB epidemics (TB cases increased
from 109,000 in 1996 to 341,165 in 2006. 55% cases
also have HIV)
MRC Burden of Disease Unit, 2004

Millennium development goal 4
Goal 4: Reduce child mortality
Reduce by two-thirds, between 1990 and 2015, the
under-five mortality rate
Photo:LReynolds

MDG4: SA progress
http://www.thepresidency.gov.za/learning/me/indicators/2009/indicators.pdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR: 20 by 2015
Department of Health (2012)

Health Inequalities in South
Africa

0%
2%
4%
6%
8%
10%
12%
Athlone
Blaauwberg
Central
Helderberg
Khayelitsha
Mitchells
Plain
Nyanga
Oostenberg
South
Peninsular
Tygerberg
East
Tygerberg
West
HIV prevalence (estimated)
0%
10%
20%
30%
40%
50%
60%
Athlone
Blaauwberg
Central
Helderberg
Khayelitsha
Mitchells
Plain
Nyanga
Oostenberg
SPM
Tygerberg
East
Tygerberg
West
TOTAL
% unemployed
Cape Town Equity Gauge, UWC SOPH, 2002
0
10
20
30
40
50
Athlone
Blaauwberg
Central
Helderberg
Khayelitsha
Mitchells
Plain
Nyanga
Oostenberg
SPM
Tyg.East
Tyg.West
Region
Infant Mortality
0%
20%
40%
60%
Athlone
Blaauwberg
Central
Helderberg
Khayelitsha
Mitchells
Plain
Nyanga
Oostenberg
SPM
Tygerberg
East
Tygerberg
West
TOTAL
% households below poverty line

Causes of under-five deaths in South Africa
• Neonatal causes;
pneumonia,
diarrhoea and other
child illness; and
HIV/AIDS each
account for 30% of
U5 deaths
• According to Child PIP
60% of children were
underweight and a
third were severely
malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12, 2008, 1294-1304

Key Determinants of Disease and Death

Structural
Societal
Behavioural
Biological
Burden of Disease study, PGWC
DOWNSTREAM UPSTREAM

Diarrhoea and Environmental Factors
in South Africa

Trends in diarrhoea deaths
numbersofchilddeaths
Numbers increasing, but fewer die
Source: Tony Westwood

Diarrhoea in the city
Numbers increasing, but fewer dehydrated
Source: Tony Westwood

Good paediatrics & health system
performance is not enough
Selective PHC:
Access to good health care
Dealing with the causes?
✓
✗
These (& the causes of the causes)
lie outside the domain of the DoH …
and the dominant 'narrow' paediatric
vision of child health

Health In South Africa: 20 Years After Apartheid

Table XX: Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20%
of households
Children in
richest 20%
of households
Income poverty
*
100% 0%
Child hunger
*
28% 3%
Inadequate water
*
54% 9%
Inadequate sanitation
*
47% 9%
Overcrowding
*
28% 5%
Educational throughput
†
46% 17%
Clinic far from home
*
46% 25%
Source: Statistics South Africa (2011) General Household Survey 2010. Analysis by Katharine Hall, Children’s Institute, UCT.
* See Part 3: Children Count – The numbers for more information on these indicators.
†Proportion of children aged 16 – 17 who have completed compulsory schooling (grade 9).

Non-communicable Diseases,
overweight and obesity in South Africa

Figure 2. Diabetes prevalence based on 1985 WHO criteria presented by age categories for men
and women in 1990 and 2008/09.
Peer N, Steyn K, Lombard C, Lambert EV, et al. (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans.
PLoS ONE 7(9): e43336. doi:10.1371/journal.pone.0043336
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043336

South Africa’s Double Burden of Malnutrition
NFCS, 1999; NFCS, 2005; SANHANES, 2012

Determinants of ‘Overnutrition’
in South Africa

Consumption of sweet beverages and confectionery
 Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola
products per person per year, an increase from
around 130 in 1992 and 175 in 1997.
 In 2010, up to half of young people were reported to
consume fast foods, cakes and biscuits, cold drinks,
and sweets at least four days a week.
 Carbonated drinks are now the third most commonly
consumed food/drink item among very young urban
South African children (aged 12–24 months)—less
than maize meal and brewed tea, but more than
milk . Hawkes C. (2002), Coca-Cola Company (2010)
Theron et al (2007), Reddy et al. (2010)

• There is a shortage of healthy
low-fat food and little fresh fruit
and vegetables in the
townships.
• ‘Low-fat milk is not available in
our shops’, stated one of the
CHWs after she had tried to
cut down on the fat in her diet.
• ‘I am scared of exercising
because I will lose weight and
people may think that I have
HIV/AIDS.’
Chopra M, Puoane T. Diabetes Voice 2003; 48: 24–6.
Societal Factors in Obesity

Bread, Pastry, Cakes, Biscuits and Other Baker's
Wares

Bread, Pastry, Cakes, Biscuits and Other Baker's Wares

Rapid growth of supermarkets in
South Africa
• Supermarkets now share at
least 50-60% of food sales50-60% of food sales in
South Africa, with the
majority of this growth
occurring after 1994
• In a recent study, nearly
two-thirdstwo-thirds of households in a
rural area in South Africa
were now buying their food
at supermarkets
Number of households in two rural areas in
Transkei, Eastern Cape going to supermarkets
Xume Luzie Total
Percent of
total
78.4% 50.0% 64.8%
Source: D'Haese, Marijke, and Guido Van Huylenbroeck. "The rise of
supermarkets and changing expenditure patterns of poor rural households
case study in the Transkei area, South Africa." Food Policy 30 (2005): 97-113.

Expansion of Supermarkets in Cape Town
Battersby, AFSUN

Total imports of soft drinks and processed snack
foods into South Africa and other SADC countries
Source: FAOSTAT detailed trade data

Regional trade and investment policies in SADC since 1990
• early 1990s: ongoing liberalization associated with multilateral trade
negotiations
• 1996: SADC trade agreement signed
• 1997-2003: South Africa strengthens investment policy and signs 22
Bilateral Investment Agreements
• 1999: South Africa signs bilateral agreement with European Union (EU)
• 2000: SADC trade protocol comes into effect; Government of South
Africa strengthens support for regional export and investment
• 2002: new Southern Africa Customs Union Agreement completed
• 2007: Interim Economic Partnership Agreement concluded between EU
and Botswana, Lesotho, Namibia, Swaziland and Mozambique
• 2008: SADC Free Trade Area completed (except for Angola,
Democratic Republic of the Congo, Seychelles)

“… trade policy that
actively encourages the
unfettered production,
trade, and consumption of
foods high in fats and
sugars to the detriment of
fruit and vegetable
production is contradictory
to health policy …” (p 10)

From a Nestlé press release:
Vevey, February 21, 2008
“Popularly positioned products (PPPs). Products
aimed at lower income consumers in the developing
world, will continue to grow strongly in 2008 and
beyond. Nestlé PPPs, which mostly consist of dairy
products, Nescafé and Maggi culinary products,
grew by over 25% to reach around CHF 6 billion in
sales in 2007. The overall market for such products in
Asia, Africa and Latin America is estimated at over CHF
80 billion.”

Olivier de Schutter
UN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence, The Guardian, 9 March 2012

SA: Income share by decile
Leibbrandt, Finn & Woolard (2012).
http://dx.doi.org/10.1080/0376835X.2012.645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
% share
of income

HEALTH SECTOR DETERMINANTS
Health sector policy, funding and
performance since 1994

“…the underlying philosophy for restructuring the
health system is the primary health care
approach, with emphasis on appropriate,
comprehensive, promotive, preventive, rehabilitative
and curative care provided by appropriate PHC
facilities, with priority for PHC service in rural areas
and poor urban areas…based on full community
participation…”
National Health Plan 1994
Policy endorsement of PHC

Comment
The concept of PHC had strong sociopolitical
implications. It explicitly outlined a strategy
which would respond more equitably,
appropriately and effectively to basic health care
needs and ALSO address the underlying social,
economic and political causes (determinants) of
poor health.

SELECTED KEY POLICY ADVANCES
AND IMPLEMENTATION SUCCESSES
• Unification of separate health services
• Establishment of districts
• Anti-smoking legislation
• Free health care for mothers and children
• Choice on Termination of Pregnancy Bill
• Notification of and enquiry into maternal deaths
• Clinic building programme (1800 built)
• Essential drugs list
• Primary School Nutrition Programme
• HIV/AIDS programmes expanded (PMTCT & ART)

ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC
POLICIES AND BIOMEDICAL DOMINATION
• Failure to address inequities between public
and private sectors
• Voluntary severance packages and downsizing
of health workforce
• Ringfenced funding of tertiary and academic
care but not primary
• Grossly inadequate funding (until recently) of
priority programmes e.g. HIV/TB
• Failure to implement intersectoral approaches
• Slow transformation of training programmes
• Increasing dominance of managerialism
• Abandonment for 10 years of community health
worker programmes

Size of private insurance
WHO National Health Accounts database

Health workforce
Drs per 10 000 population
Source: WHO country profile [http://apps.who.int/nutrition/landscape/report.aspx?iso=rwa]

SA paediatricians: distribution
SA
0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA & Statistics SA. Mid-year population estimates 2006

Currently, both the coverage and quality of these priority
interventions are inadequate, especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings. Only 35% of young children (12 – 59
months) received vitamin A supplements, 38% of
pregnant women received antenatal care in the first 20
weeks of pregnancy, and only 26% of babies were
exclusively breastfed for the first six months.
Department of Health (2012) Strategic Plan for Maternal, Newborn, Child and
Women’s Health (MNCWH) and Nutrition in South Africa 2012 – 2016. Pretoria: DoH.
Shisana O et al (2010) South African National HIV Prevalence, Incidence, Behaviour
and Communication Survey, 2008: The Health of Our Children. Cape Town: HSRC
Press.

Immunisation
DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country

What are the key challenges to improving
access to quality health care?

Key actions to strengthen the health system
 Dedicated, adequate and skilled health workforce
 Sustainable and equitable access to health
services
 Competence and accountability from managers
and leaders
Lancet 374, 2009: 760

• National Health Insurance (NHI)
• Re-Engineering Primary Health
Care

Health care financing and rationale for NHI
Mechanism for addressing:
• Existing health system challenges
Ensuring whole population is:
• Able to get care when needed - 16.6% experience difficulty in
accessing health care (Shisana et al 2007)
• Financially protected from the costs of care (currently 13% of
health care spending is out-of-pocket)

National Health Insurance Proposal
Recognition of the crisis
Principles:
– Universal coverage
– Social solidarity
– Equity
– Access
– Efficiency
– Primary health care

Increase funding of health services through:
•Increased allocations from general tax revenue
•Mandatory health care contributions by employees
and employers
•Removal of tax subsidies to medical aids
•Pool these funds

Purchase from accredited providers (public and private):
Medical schemes will remain:
Likely that membership will decline
Fewer schemes

Additional aspects of NHI
• NHI fund administered separate from DOH
• Office of Standards Compliance
• Accreditation of facilities
• 11 Pilot districts – PHC model (current)

The three key recommendations are essentially:
1.Strengthen the district health system (DHS).
2.Place much greater emphasis on population based
health and outcomes, which includes a new strategy for
community-based services through a PHC outreach
team based on community health workers (CHWs) and
mobilising communities.
3.Pay greater attention to those factors outside of the
health sector that impact on health, the social
determinants of health (“upstream factors”)
63

Three streams for Re-engineering PHC
(a) a ward based PHC outreach team
for each electoral ward;
(b) strengthening school health
services; and
(c) district based clinical specialist
teams with an initial focus on
improving maternal and child
health.
64

PHC outreach team
– Professional nurse,
– staff nurse and
– community health care workers
The PHC outreach team will provide
comprehensive PHC health care services to a
defined number of families. Each PHC
outreach team will operate out of a PHC clinic
which is based within the community that it
serves. A PHC clinic may accommodate more than
one PHC outreach team with a recommended
maximum of three PHC teams per clinic
66

Global examples of CHW ratios
Brazil:
•248,000 CHWs
•Population of 121 million
•1 CHW for a population of approx 500 people
Thailand:
•750 000 village health volunteers
•Population of 70 million
•1 VHV to 93 people / 5 per 15 households
Rwanda:
•60 000 CHWs
•11 million population
•1/5th
population of South Africa with the same number of
CHWs

Evidence for impact of community health workers
delivering curative interventions
Diarrhoea
Pneumonia

Implementation of CCM in Africa
pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries

Evidence for impact and cost-effectiveness
of community health workers
• Recent systematic review including studies
from Sub Saharan Africa on impact of CHWs
delivering curative interventions for children
• CHWs in national programmes achieved large
mortality reductions of 63% and 36%
respectively, with curative interventions.
Christopher et al. Human Resources for Health, 2011

• Selection
• Training
• Health system factors – esp support & supervision
• Community factors
• Political, macroeconomic and international factors
• Financial and non-financial incentives
Factors influencing success of CHW
programmes
Lehmann and Sanders, WHO, 2007,
http://www.who.int/hrh/documents/community_health_workers.pdf
Haines, Sanders et al, Lancet, 2007, Vol. 369, pages 2121-2131

RWANDARWANDA
Total health personnel in publicly funded facilities has
almost doubled in 3 years …

Nearly 60% of the existing Human Resources are
either nurses or paramedical workers while
doctors contributed to less than 7%
Rwanda now has 60,000 CHWs

Trends in Vaccination Coverage
Percentage of children 12-23
months fully vaccinated

Trend in Early Childhood Mortality
Deaths per 1,000
live births
28 ?
MDG
50 ?
MDG

U-5 MR: Rwanda & SA
U-5 deaths / 1000 live births
Rwanda
SA
MDG goals

Current CHW training and scope of practice
in South Africa
• Focusses on assessment and referral
• No curative functions
• Advising families where CHWs could be
delivering the interventions themselves:
“Inform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and
other necessary micronutrient supplements.”
Monitoring of pilot NHI site in NW province shows
that most frequent reasons for referral to health
facility are to collect Vit A and anthelminthics

Summary
• The current CHW programme will not
result in desired reductions in child
mortality without extending their scope
to include some curative functions and
improving the ratio of CHWs to
househods

NHI Pilot Districts
12 months progress report
Presentation to the Portfolio Committee on Health
Committee Room 514, Marks Building
24 July 2013

Background
• August 2011: NHI Green Paper – action plan
• April 2012: NHI pilot districts to prepare for:
– Purchasing of services;
– Engaging the private sector;
– Introducing a district health authority;
• April 2013: Rapid appraisal to:
– Assess progress in preparing for NHI
– Provide a framework for monitoring

NHI domains appraised
1. NHI management
2. Hospitals
3. Quality
4. Primary Health Care
re-engineering
5. Infrastructure &
Equipment
6. Human Resources
7. Health information
8. District Management
Teams
9. Conditional Grant
10.Referral
11.Contracting Private

Key
Nearly or completely achieved (where numerical data available >75%)
Partially achieved (where numerical data available 25 - 74%)
Minimally, or not achieved (where numerical data available <25%)
No data available
Tabular summary per District

NHI COULD be a mechanism to redistribute health care
resources BUT some key challenges need to be
addressed
 Definition of an acceptable ‘package’ of services
 Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of
NHI fund
 Regulation of private sector – to ensure that
inequities are not aggravated

Some key challenges need to be addressed
 Reconsider ratio of CHWs to households. Several
countries have two tiers of CBWs – full-time CHWs and
part-time CBWs in a ratio of 1:10. This could generate
>400 000 jobs
 Definition of an acceptable ‘package’ of services
including CHWs being allowed to undertake treatment
 Development of sufficient CAPACITY and ENSURING
ACCOUNTABILITY

 Rapidly increase investment in training: re-open
nursing colleges, increase output and appropriate
training by medical schools and other HEIs
 Brazil has more than 2.5 million workers formally employed in the
health sector, which represents about 1.3% of the country’s
population. South Africa has only 150,509 health professionals in a
population of 51 million (constituting 0.3% of the population) in
2010.
 Rapidly increase output of MLWs
 Reorientate health professionals to be able to
address local social determinants
 Reorientate specialists in District Specialist Teams

 Reduce power of conservative professional bodies;
enlarge ‘scope of practice’ of non-doctors
 Improve incentives and support in rural areas
 Upgrade infrastructure in rural/peri-urban areas
 REBUILD AND STRENGTHEN CIVIL SOCIETY

PEOPLE´S HEALTH
MOVEMENT
The Peoples Health Movement (PHM) is a
large global civil society network of health
activists supportive of the WHO policy of
Health for All and organised to combat the
economic and political causes of deepening
inequalities in health worldwide and revitalise
the implementation of WHO’s strategy of
Primary Health Care.
www.phmovement.org

Current Situation
• Awaiting next government draft
• Planning a coalition of progressive organisations
• Campaigning around key elements:
– Free at the point of service
– Single payer system
– Stop private sector subsidies
– No public funds for private profit

EXAMPLE: Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION
O.R.T.
NUTRITION
SUPPORT
EDUCATION
FOR PERSONAL
& FOOD
HYGIENE
MEASLES
VACCINATION

BREAST
FEEDING
WATER

SANITATION

HOUSEHOLD
FOOD
SECURITY

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Editor's Notes