Chapter 1
INTRODUCTION AND OVERVIEW
Precious Matsoso, Usuf Chikte, Lindiwe Makubalo, Yogan Pillay, Robert (Bob) Fryatt
Rationale
In the first book covering South Africa’s health reforms between 2009 and 2014, we noted that initiatives in South Africa on universal coverage started in the 1920s. The book reviewed the five-year period to 2014 which coincided with the end of the timeframe of the Millennium Development Goals (MDGs) and concluded that progress had been made in several key areas, but that many challenges remained.
It was also a phase of transition from MDGs to Sustainable Development Goals (SDGs). During this period progress was made in improvement in health outcomes as reflected by significant increases in life expectancy, as well as reduced maternal and child mortality. The country has the largest HIV epidemic in the world with the largest antiviral treatment programme. The period covered in the first book showed a decline in new infections, and was associated with life expectancy at birth increasing. The establishment of the Office of Health Standards Compliance provided for a systematic, independent monitoring mechanism and recommendations for redress where services failed to meet required standards. There had been progress in improving the availability of essential medicines through price reduction and increased availability of life-saving antiretroviral and other medicines. The country had seen improvements in the collection, analysis and use of information and in rolling out reforms across districts and hospitals. On the health workforce, progress had been made in developing certain specialist cadres, increasing production of health workers (doctors) and formalising the policies on community health workers as essential members of the team for primary health care level. The National Department of Health had rolled out frontline service reforms to improve primary health care services and strengthen community participation through ward-based outreach teams (WBOTs).
The authors also noted the many challenges still facing the country in 2014. The country still faced unprecedented challenges in getting over five million people on antiretroviral therapy (ART) and keeping them adherent, and of improving tuberculosis (TB) prevention and control programmes to the point of successfully treating at least 85% of all TB patients diagnosed. There were also
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many challenges remaining to improve reproductive, maternal and child health and in mobilising a larger workforce, including improving access to general practitioners and in improving the functioning of WBOTs. Progress, however, was described as being slow on improving leadership and management competencies. Many more challenges were identified – around hospital management, further improvement in the provision of quality services, giving greater voice to communities, intersectoral action and the slow pace of reforms related to the implementation of National Health Insurance (NHI). The authors called for increased efforts to document, monitor and evaluate interventions to improve future planning and implementation.
Objectives of this book: Since the first book was completed, the SDGs (2015–2030) were launched. This second edition aims to document key events and initiatives between 2015 and 2020 and consider the future challenges and implications for the different institutions, practitioners and agencies involved in improving the health of people living in South Africa. The book will be a first-hand account of the ongoing story on the transformation of health and health policy in South Africa. As before, we have brought together, for each chapter, a mix of policy-makers and implementers to work with academics and researchers. This approach seeks to strengthen the links between research, evidence and policy and improve the role of science in implementation.
Intended readership: There is considerable attention on South Africa given the HIV/AIDS epidemic, the COVID-19 response, and South Africa’s growing role in global and regional health. The aim is for the book to be used by all major schools of public health that study global health, and in academic centres that host courses and conduct research on comparative social policies.
Structure: The content and structure of each chapter will start with the challenges facing South Africa in 2015; then provide a description of the initiatives that were underway or that were initiated to improve the situation between 2015 and 2020. There will be some analysis of how well these initiatives progressed, with some examples of successes and descriptions of challenges or remaining problems. There will then be a summary of the overall progress by 2020, with the authors providing some recommendations or reflections going forward.
Key themes: Four main themes run throughout the book. These are:
Health Reform: The book is about health reforms in South Africa between 2015 and 2020 – we are not looking simply for a description of the important issues in each chapter, but whether reforms took place or not. Our definition of reform is a traditional one from the World Health Organization (WHO): ‘Health sector reform deals with fundamental change of processes in policies and institutional arrangements of the health sector, usually guided by the government’.
Gender: We see this as important for all chapters, as gender inequality and discrimination faced by women and girls puts their health and well-being as well as that of their families at risk. The United Nations refers to gender as ‘the social attributes and opportunities associated with being male and female and the relationships between women and men and girls and boys’.
Equity: We will highlight the trends on health equity during this period. Again, taken from the WHO: ‘Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms’.
Community engagement: We see this as an important ingredient of success for health reforms. The WHO has defined community engagement as ‘a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes’.
Intersectoral collaboration: We see intersectoral collaboration as a key action government should adopt both to address broader determinants of health and to improve the effectiveness of health programmes. This was at the core of the declaration on primary health care in the Alma-Ata Declaration and in the more recent Almaty Declaration.
Chapter 2: (Demographic and Health Trends: 2015–2020.) The chapter provides a summary on the recent demographic trends in South Africa, including latest data on the various aspects of equity, determinants of health, health status and access to services that are critical to improving health and well-being.
Chapter 3: (Social, Economic and Environmental Determinants.) The chapter focuses on the main challenges facing South Africa in this period, in particular the macroeconomic situation, poverty, income inequality and unemployment, education and social security, nutrition and hunger, built environment, and safety and security. There is then a commentary on the lessons learned from the coordinated and intersectoral actions developed in response to COVID-19, including what the intersectoral structures achieved at national, provincial and local level, using examples that applied a social determinants of health lens. Finally, the chapter considers the role of technology and regulation, ending with some recommendations for the future.
Chapter 4: (Primary Health Care.) The chapter describes the key contextual factors impacting PHC, and then describes the national programmes and interventions on PHC active in the five-year period. These include Ward-Based Primary Health Care Outreach Teams (WBPHCOTs), District Clinical Specialist Teams (DCSTs), Ideal Clinic Realisation and Maintenance, Centralised Chronic Medicines Dispensing and Distribution Programme (CCMDDP), PHC e-health programme, and private sector contracting. The authors then summarise the main PHC performance indicators, covering financing, health workforce and PHC utilisation, and provide case studies of promising bottom-up health system strengthening, including Community-Oriented Primary Care (COPC) in Tshwane, sub-district models (KwaZulu-Natal sub-district management model, and the 3-feet model in Limpopo and Mpumalanga) and the social accountability model of Ritshidze Community-Led Monitoring of PHC. The chapter ends with a summary of remaining challenges, and conclusions on the way forward.
Chapter 5: (National Health Programmes.) In this chapter there is a focus on three health issues which are used to illustrate the successes and failures of the health system’s response between 2015 and 2020. These are HIV/AIDS, TB, and maternal and child health. The review is complemented by two case studies. The first is the Western Cape Department of Health’s response to TB using lessons learnt from the COVID-19 response and incorporating a wholeof-society approach. The second illustrates gender issues in relation to access to health services and human rights.
Chapter 6: (Accelerating Access to Medicines and Health Technologies.) The chapter focuses on three key areas of national policy and implementation, namely: the South African Health Products Regulatory Authority (SAHPRA) and re-engineering the regulatory framework for health products; Scaling differentiated service delivery models for chronic medicines; and Antimicrobial Resistance – Policy solutions for effective governance.
Chapter 7: (Hospital Services.) The chapter provides an update on relevant national legislation and polices, including the role of hospitals envisioned under the NHI. It then goes on to assess in more detail the increased governance responsibilities at hospital level in the context of the NHI purchaser/provider split and the different roles that will be played by provincial and district management. The chapter then explores the need for adherence to the King 4 governance principles, covering ethical organisational culture and the Protocol on Corporate Governance in the Public Sector. Sections then focus on community engagement and accountability and strengthening financial and supply chain management, and decentralisation of management through functional business units. The chapter discusses progress with hospital governance and policy and patient-centred care and clinical governance.
Chapter 8: COVID-19 and Emergencies. In this chapter, we evaluate why disaster risk reduction and preparedness foster health system resilience. We reflect on the global context and review South African preparedness efforts, drawing extensively from South Africa’s participation in, and findings and outcomes of the joint external evaluation of adherence to the International Health Regulations 2005. We identify health emergencies that took place from 2015–2020 and discuss in some depth two South African health emergencies that unfolded over this time. We reflect on health system responses to the unfolding COVID-19 pandemic over 2020, illustrating how these drew on experience gained by stakeholders in earlier South African emergencies. Finally, we offer pointers to support strengthening South Africa’s emergency preparedness and response over the next five years.
Chapter 9: (Non-communicable Diseases.) The chapter provides an overview of the rise in the non-communicable disease (NCD) burden in South Africa, and the main drivers of this major epidemic. The chapter provides a detailed analysis of some of the main NCDs in the country – coronary heart disease, diabetes, hypertension, cancer and asthma – with details of the trends in recent years and the key initiatives in the five-year period aimed at improving prevention, cure and rehabilitation. Conclusions include recommendations on the way forward.
Chapter 10: (Mental Health.) In this chapter we highlight the various successes in the mental health sector for the period 2015–2020, but also raise areas of concern that require urgent attention. The chapter embraces a dimensional approach to mental health, i.e. that mental health exists on a continuum from severe disability to well-being. The chapter covers five areas, starting with two recent crises in South African mental health, namely, the Life Esidimeni tragedy and the COVID-19 pandemic. The second section addresses service organisation. We highlight the importance of making optimal use of scarce resources and bring into focus the need for a comprehensive approach to service provision, including mental health promotion and prevention.
Chapter 11: (Occupational Health.) The chapter provides an outline of progress in the world of work in South Africa and the governance, legislation and policy on occupational health and safety, including the health systems response. The chapter covers the demography of work and a summary of the epidemiology of occupational injuries and disease, and the progress with occupational health services, including relevant human resources and professional societies. The remaining challenges facing South Africa are described with recommendations for the future.
Chapter 12: (Infrastructure.) The chapter provides an overview of the health infrastructure needs of the country, taking into consideration the health needs, and what is available through the public and private sectors. The chapter then reviews progress with various national initiatives aimed at responding to current challenges including the Ideal Clinic Realisation and Maintenance, the Office of Health Standards Compliance, Infrastructure Unit Support Systems, Draft 10-Year Health Infrastructure Plan, the Accelerated Health Infrastructure Roll-Out Programme, Framework for Infrastructure Delivery and Procurement Management, Draft Maintenance Strategy and the National Infrastructure Asset Maintenance Management. We review the achievements and remaining challenges for each, before looking at non-infrastructure-related challenges such as from the COVID-19 pandemic and climate change.
Chapter 13: (Quality.) This chapter reviews developments in the quality of health care in South Africa since 2015. We highlight important policy developments, and several initiatives in the public and private sectors to improve the quality of care. We also describe the key findings and recommendations of the 2019 South African Lancet National Commission report, ‘Confronting the right to ethical and accountable quality health care in South Africa’, and discuss barriers and opportunities for achieving a high-quality health system in South Africa post COVID-19.
Chapter 14: (Legislative Framework and Right to Health.) The chapter provides a summary on the relationship between law and the right to health, explaining why law matters and a human rights approach to health. It then covers the legal framework and how it has changed between 2015 and 2020, covering legislation, policy and regulations, intellectual property policy, notifiable conditions regulations, emergency medical services regulations, control of sugar, tobacco and alcohol products, and legal advocacy and legal processes. A review is provided of the Life Esidimeni crisis, when law and policy is implemented badly, and the Health Market Inquiry. A review of the key litigation includes emergency medical treatment, physician-assisted suicide and euthanasia, and medical negligence claims. A case study covers ‘What COVID-19 teaches us about the NHI’ and the chapter ends with conclusions on the way forward.
Chapter 15: (Governance, Management and Leadership.) Following a brief overview of the governance, leadership and management successes and challenges in the past, we clarify the governance and leadership concepts that underpin the chapter and describe the key governance interfaces and relationships within the South African health system. We then examine the experience of frontline (district-level) governance and subsequently focus on provincial and national levels – considering how they support or constrain frontline governance in the multi-level public health system. We then summarise the critical issues of leadership and management highlighted in earlier sections and close by drawing out key conclusions for the future about the action needed to strengthen governance, leadership and management.
Chapter 16: (Information, Indicators and Systems.) This chapter describes and evaluates advances in the availability of accurate and timely local health information in South Africa between 2015 and 2020 against the backdrop of calls for more community participation, improved health system responsiveness to community needs and priorities, and enhanced provider accountability. The chapter deals with both the public and the private health sectors, although most routine data sources predominantly cover public sector provision of health care services.
Chapter 17: (Human Resources.) The chapter reviews the previous national Human Resources for Health (HRH) strategy, launched in 2011, and reviews progress with implementation, and the likely implications for HRH of future reforms, in particular the NHI Bill. The chapter then reviews the problems related to inadequate HRH data for planning and monitoring progress, with comparisons to other countries. The implications for formalisation of community health workers are considered, as well as progress in strengthening leadership across the health system. A summary of the recently completed HRH strategy is provided and some of the main challenges outlined, including dealing with the implications of the COVID-19 crisis.
Chapter 18: (Health Financing.) This chapter examines trends, problems, challenges and progress in a selection of public and private financing domains. In general, despite some progress on the policy front, inadequate progress was made on the sector’s key reform, namely NHI, and the chapter attempts to explore why this is the case. In addition, the policy focus on NHI detracted focus from several other areas including medical scheme reform, which despite the Health Market Inquiry, made limited progress. At the end of the period, a large health security crisis emerged in the form of COVID-19, which had major implications for sectoral funding. Budget allocations were initially positive to counter the pandemic in 2020/21, but then increasingly negative from 2021/22 as the effect of prolonged lockdowns on the economy worked its way through to public sector revenue and spending. Final conclusions include that the proposed NHI model in the NHI Bill may require some re-evaluation of aspects of the model to get the NHI reforms back on track.
Chapter 19: (Global and Regional Health.) The chapter provides an overview of the global and regional health architecture and the main actors and institutions that are linked to South Africa. An update is given on the main initiatives that have been undertaken of importance for South Africa, and their relative success. The chapter then reviews the role of international actors and donors in South Africa, and the role of South Africa in supporting other countries in the region. The current challenges, including cooperation during the COVID-19 crisis are reviewed with lessons and conclusions drawn out for the future.
Chapter 20: (The way forward.) The editors led the preparation of this final chapter, which takes the conclusions and recommendations made by the different teams in preparing the chapters and puts them into this final section. This chapter therefore identifies a series of operational and strategic opportunities for the country policy-makers, managers, academics, private sector and civil society to champion over the next few years.