Chapter 20 LOOKING TO THE FUTURE
The book has reviewed progress in various dimensions related to health in South Africa over the period 2015 to 2020. In this chapter we provide a summary of the progress and challenges raised by the authors, and a set of recommendations taken from the various chapters to strengthen health reform in the South African health system.
Demographic and Health Trends
The health of most South Africans continues to improve, with positive trends in many of the key measures of health, including life expectancy. However, many of these positive trends have been affected, some severely, by the impact of the COVID-19 pandemic. In addition to the immediate impact on health outcomes, the longer-term impact on health through worsening determinants of health, such as poverty, inequality, unemployment, natural disasters and education, are also likely to be severe.
Recommendation (1) Surveillance: There remains a lack of regular surveillance of some key indicators, with a continued reliance on expensive and sometimes infrequent surveys.
• Child health surveillance: there is a pressing need to focus beyond childhood mortality to ensure that each child can thrive, focusing on in utero and early-life exposures, environmental conditions (air pollution, contaminated water and sub-optimal sanitation) and access to better-quality diets.
• Disabilities: The country must consider the additional data needs in terms of realisation of the socio-economic rights in the Constitution and monitoring the Sustainable Development Goals (SDGs) regarding disabilities.
• Inequalities and inequities: It remains important to highlight some of the challenges and potential solutions to health inequalities and inequities through better monitoring, including of non-communicable diseases (NCDs), as well as investments in areas where the greatest impact of narrowing the gaps can be made.
Malebona Precious Matsoso, Usuf Chikte, Lindiwe Makubalo, Yogan Pillay, Robert (Bob) Fryatt
Recommendation (2) Improved data: A number of approaches are recommended to overcome the limitations of the current data sources; these include:
• Local analyses: The use of modelling techniques (such as small area estimation) to increase the spatial resolution of indicators of interest based on their relationship with other variables available at a local level;
• Deprivation indices: The use of multidimensional indices of deprivation that combine multiple variables to create measures that are robust when corrected for missing data;
• Linking data systems: The use of patient-level data from Electronic Health Record Systems once they are implemented that track patients who visit different health care providers which can also be linked to other data systems such as vital registration.
Social, Economic, Commercial and Environmental Determinants of Health (SECEDH)
To improve sub-national horizontal collaboration and partnership between departments we recommend that Provincial Departments of Health (PDoHs) be the champions of consultative engagements at provincial and local levels, given that policy implementation occurs at the provincial and local levels. Ideally, consultative arrangements should help clarify roles and responsibilities and support the implementation of the social determinants of health approach to improve health outcomes. There is the need to engage critical stakeholders – the public sector (government), private sector and civil society – at all stages and for direct engagement of communities at ward level. The interactions among the stakeholders should go beyond information sharing to cooperation, coordination or integration, which are likely to strengthen policy implementation.
Recommendation (3) National leadership for SECEDH: The National Department of Health (NDoH) should urgently lead the formulation and implementation of intersectoral action with a high level of active and measurable engagement of all stakeholders, in line with the district development model.
Recommendation (4) Sub-national collaboration on SECEDH: The NDoH should develop guidelines for provinces and districts on creating consultative engagements for sub-national government stakeholders building on structures and processes that were developed to deal with COVID-19 and documented best practices and innovations by PDoHs before COVID-19 and in response to COVID-19.
Primary Health Care
PHC should be approached as a wider system philosophy embracing participation, intersectoral action and comprehensive approaches to health, embedded within coherent sub-district and district systems. While achieving greater system efficiency is key, further development of the PHC system, especially components such as the Ward-Based Primary Health Care Outreach Teams, cannot occur in an environment of austerity and disinvestment. Emphasis also needs to shift from the ‘what’ of policy to the ‘how’ of implementation, focused on learning through deliberation and by doing, adapting or de-implementing ineffective or harmful strategies, supported by partnerships and embedded and co-produced evaluation and research. The reasons for declining patterns of PHC utilisation need to be better understood, including the need to better understand the role of communities as well as community, household and personal health and to strengthen these.
Recommendation (5) Strengthened PHC governance: The governance weaknesses in PHC need to be tackled by the formulation of a coherent sub-district system, and beyond this, establishing meaningful community participation and intersectoral collaboration, shifting from a curative, disease orientation to a more expansive approach, centred on prevention, promotion and action on the social and other determinants of health. This should be accompanied by a commitment to establishing stable, skilled and public-interested leadership in PHC and district health systems.
Recommendation (6) Aligned PHC reforms with the National Health Insurance (NHI): Developments in PHC need to be aligned with other system developments, in particular Human Resources for Health (HRH) development and financing and the NHI. This could be achieved through forms of health system learning that rely less on nationally defined audits than on co-produced approaches better able to harness bottom-up participation and innovation. There also is a need to be clear about the role of the private health sector, including the role of traditional healers.
National Health Programmes
During the period 2015 to 2020 there were some remarkable successes, however, declines in incidence were below the global targets, e.g., those set by WHO, UNAIDS, Stop TB Partnership Board and the SDG goals to end the HIV and TB epidemics by 2030. As with other programmes, maternal, child and woman’s health had some successes but also stagnation and deterioration associated with COVID-19. Of great concern is the inadequate uptake of contraceptives and the increasing number of adolescents becoming pregnant. There continues to be a sub-optimal use of condoms in South Africa, which has the potential to play a major role in improving outcomes for many of these challenges. As improved health often does not come from single disease interventions, health services need to be integrated so that patients can seamlessly have all their needs attended to in a patient-centred and holistic way.
Recommendation (7) TB: There has been a range of suggestions to reverse and catch up on TB services and interventions, including using the lessons from the COVID-19 crisis and response and not letting it go to waste. These include using COVID-19 testing to simultaneously test for TB and using community-based and community-led responses that take diagnosis, care and support to the doors of those affected by COVID-19 to also carry out contact tracing and symptom checks for TB.
Recommendation (8) HIV: It makes increasing sense for HIV to be treated as a long-term chronic disease and integrated with other conditions and programmes in a more patient-centred approach.
Recommendation (9) Package of essential services: Each disease and health programme needs to have a package of essential services (e.g. contraceptive services for teenage girls) that is affordable, available and acceptable to beneficiaries and which need to be in place regardless of external circumstances. In other words, these need to be protected against shocks such as pandemics, thus the importance of resilient health systems.
Accelerating Access to Medicines and Health Technologies
The South African Health Products Regulatory Authority (SAHPRA) continues to improve its performance, although this is held back due to the constraints of lack of access to specialist regulatory expertise. The Centralised Chronic Medicine Dispensing and Distribution programme provided a paradigm shift to differentiated service delivery and will need to continue to evolve, building on the high number of local innovations, and making the programme more equitable, in particular for rural areas where connectivity and internet access is a major barrier. Some successes in the fight against antimicrobial resistance (AMR) have been achieved but efforts need to be scaled up.
Recommendation (10) SAHPRA: Efforts will need to be scaled up to overcome the constraints to strengthen specialist regulatory expertise. Furthermore, approval times for various regulatory activities must be shorted.
Recommendation (11) Pharmacists: Strategies are urgently needed to ensure the best possible utilisation of existing pharmacy personnel to provide quality pharmaceutical services.
Recommendation (12) Anti-microbial resistance: Securing funding through the National Treasury is key and urgently requires developing a business case for scaling up efforts for tackling AMR.
Hospital Services
South Africa continues to be plagued by a two-tier health care system, based on the socio-economic status of its users. This is now compounded by the systemic disruptions imposed by the COVID-19 pandemic. This has in turn led to a sharper decline in the resource envelope for funding of health care facilities in the foreseeable future. Further improvement in the quality and efficiency of hospital services is predicated on ethical leadership which gives spirit to the practice of corporate and clinical governance through continuous improvement and commitment to monitoring and evaluation of inputs, processes and outcomes. This in turn will allow for transparent interactions with served communities, and encourage engagement with, and ownership of public hospital services, to create shared resources for improving health outcomes. This will also decrease the drain on the fiscus represented by considerable medico-legal litigation, linked to poor-quality health care and a lack of trust from communities. In the context of NHI, development of an integrated hospital platform across the public and private health sectors will be necessary.
Recommendation (13) Decentralised management of hospital services: It is important to bring to fruition the initiatives aimed at defining and capacitating structures for the efficient, decentralised management of hospital-level services.
Recommendation (14) Quality of services: An overarching coordinated national commitment to quality improvement and continuous learning, both in the clinical and corporate management of hospital-level services is required to effect the necessary changes to the system.
COVID-19 and Health Emergencies
What is certain on review of South Africa’s response to health emergencies over 2015–2020 is that health security requires more than a narrow focus on infectious disease preparedness, detection and response. Universal health coverage (UHC) and health systems strengthening are a critical component of health emergency planning and response. The number of reviews including the Independent Panel for Pandemic Preparedness and Response, appointed by the WHO Director-General in response to the World Health Assembly resolution 73.1, has provided the global community with a comprehensive, evidence-based review of responses to the COVID-19 pandemic.
Recommendation (15) Pandemic preparedness: South Africa should update its national preparedness plans against the WHO and country adopted targets and benchmarks within six months and ensure appropriate and relevant skills, logistics and funding are available to cope with future health crises. It should also appoint national pandemic coordinators accountable to the highest levels of government with the mandate to drive whole-of-government coordination for both preparedness and response. South Africa should also implement outstanding recommendations from the 2017 Joint External Evaluation recommendations.
Non-communicable Diseases
Legislative changes have impacted positively on several of the factors contributing to NCDs, including those for sugar-sweetened beverages and salt. While the National Strategic Plan (NSP) 2013–2017 included all the elements of interventions to respond to the burden of disease from NCDs it suffered from a range of implementation challenges. These included the lack of sufficient intersectoral collaboration as well as the means to measure progress or lack thereof and for course correction during the period 2013–2017. In addition, the hiatus between 2017 and 2020 – with no plan to guide intervention as a result of a protracted period of consultation for the drafting of the new NSP, also resulted in inadequate progress. The NDoH should design programmes and systems that place the patient/person at the centre, as described in the WHO’s Integrated Person-Centred Health Services Framework.
Recommendation (16) Non-Communicable Disease National Strategic Plan: The NDoH should rapidly implement the new NSP which recommends the use of a cascade approach for diabetes and hypertension and which calls for the establishment of a coordinating mechanism similar to that for HIV and TB. High-level political support and additional funding is required to implement the NSP and reduce the rising burden of NCDs in the country.
Mental Health
The last five years have shown us a great deal about what can be done for mental health, but the next five years will have to show more progress in terms of real changes in systems and services. Moving towards a greater emphasis on community care will be essential. Moreover, reducing the social and economic determinants of mental health, giving greater emphasis to prevention and promotion programmes, and working across sectors will need to be prioritised if population mental health is to be strengthened.
Recommendation (17) Increased investment in mental health services: Greater investment is required for mental health services as part of the current ‘building back better’ response to the crisis. To improve mental health in South Africa, moves towards greater emphasis on community care will be essential.
Occupational Health and Safety (OHS)
There is a legacy of neglect of OHS in South Africa, although with some more recent innovations in service delivery. The COVID-19 pandemic provides the required impetus for working together (government and the private sector) to deliver a safer and healthier workplace.
Recommendation (18) Funding occupational health services: A funding model to support occupational health service delivery across sectors is required in South Africa. Funding of the health services under the NHI could include medical care and rehabilitation for occupational injuries and diseases. Increased investment in supporting OHS professionals is required to meet the needs for OHS especially in the public sector as well as retention strategies for trained OHS professionals already in the system.
Infrastructure
South Africa requires a health service redesign to address inequality and to build the foundations for effective implementation of UHC. This will enable government to maintain and strengthen its efforts to provide and maintain health care infrastructure as an enabler of the provision of quality health care.
Recommendation (19) State capacity for improving health infrastructure: Human resource capacity to deliver health care infrastructure must be strengthened either by improving required capacity in the various Departments of Public Works across the provinces or moving the function to PDoHs along with the necessary capacity. Institutions of Higher Education must be engaged to review their curricula for ensuring alignment between the new professional and technical workforce demands in health infrastructure.
Recommendation (20) Health infrastructure priorities and efficiencies: Infrastructure plans must be aligned with plans for improving services focused on the PHC platform. The infrastructure delivery process should be simplified by: not overburdening implementation from too many reporting requirements; using BIM (Building Information Management) in the design and construction phases; standardising the Service Delivery Agreements between PDoHs and relevant Implementing Agents; updating the Infrastructure Unit Support Systems guidelines and keeping the portal as a platform for all the stakeholders involved in health care infrastructure; update the South African Cost Norms for providing effective management of cost versus budget; and using the procurement method in the Construction Industry Development Board (CIDB) Standard for Uniformity to reduce cost of professional fees.
Quality of Care
The South African National Lancet Commission on Health Systems Quality reported some achievements and numerous challenges to the delivery of quality health care, with clear recommendations to achieve a quality health care system for South Africa. Some progress has been made to ‘revolutionise quality’, however, overall implementation of the Commission’s recommendations has been limited. There remains a need for an overarching national quality improvement (QI) strategy which engages all stakeholders, including frontline health workers, civil society and the many current quality of care role players who operate within separate health programmes or sectors.
Recommendation (21) Office for Health Standards Compliance: The OHSC needs to be provided with the necessary resources to achieve its regulatory mandate and to support the NHI requirements as these evolve. It should also review its modus operandi with fewer measures and a greater focus on outcomes rather than inputs and processes to assess performance. It should also segregate the Office of the Health Ombudsman into a separate entity.
Recommendation (22) Continuous quality improvement: Health districts, sub-districts and health facilities should be empowered to monitor the inputs and processes relevant to frontline quality of care. Greater efforts are needed to strengthen the capacity of frontline health managers in the planning and implementation of quality assurance and QI systems, and to expand their ‘decision space’ to enable them to respond to gaps in quality.
Recommendation (23) Quality data: Information should be provided to the public about hospital quality of care to help encourage hospitals to implement QI strategies. Within the private sector, data on quality should be made available to health care users (i.e., patients) and institutional purchasers (e.g., medical schemes) to advance quality through improved market functioning.
Legislative Framework and the Right to Health
While not a period of much legislative development, 2015–2020 has seen various changes to health and the health system brought about through legal advocacy, litigation and some legislative and regulatory change. It is also a period from which many lessons can be learned: the need for Intellectual Property law change to secure access to affordable medicines and vaccines; the urgency of emergency medical services reform; the need to reform the private health sector; the benefit of NCD control; and the risk of poor policy implementation. The reasons for the failure to progress some important legislation on determinants of health are instructive and can inform future efforts. COVID-19 provided an unwelcome but perhaps useful test of some of the principles of NHI: a potentially system changing legislative change in the next five years.
Recommendation (24) Urgent legislation: The government should fast-track the passage of the NHI Bill alongside strengthening capacity for its implementation. The government should also implement the recommendations of the Health Market Inquiry.
Governance, Leadership and Management
The structural and legislative foundations of governance in South Africa are well established. However, the everyday practice of governance is weak, across sectors. The development of a capable state, founded on strong ethical practice, is therefore necessary to address the country’s social, economic and well-being needs. Communities and the district health system must be placed at the heart of the health system, with frontline governance strengthened to support quality improvement and local, place-based intersectoral action.
Recommendation (25) PDoH/NDoH roles and relationships: The PDoH/NDoH interface demands specific attention by 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 shown possible by COVID-19, provincial health departments must look beyond health care as they seek, and work within, provincial government mandates for whole of society and whole of government approaches.
Recommendation (26) Civil society: 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.
Recommendation (27) Leadership development: Implementing improvement in governance requires new mindsets and deepened skillsets, including those of ethical practice and ‘systems thinking’. Formal leadership and management training (in teams) and mentorship programmes have a role to play in developing such leadership. Senior managers can also be held accountable, through performance agreements, for enabling the spread of system leadership.
Information and Indicators for Accountability
Progress is being made in South Africa to expand the information available to document and track health services and outcomes. Such information will however only strengthen downward accountability if local stakeholders (such as civil society groupings and patient organisations) are aware of it and use it effectively to draw attention to local problems and advocate for solutions. This will not happen automatically and will require substantial effort and investment by advocacy groups and community leaders.
Recommendation (28) Improved access and use of data: The government should introduce norms and standards for the public release of data to achieve greater transparency and better use of existing data. In addition, core data sets need to be expanded to cover social, commercial and environmental determinants of disease and chronic disease prevalence and chronic disease patient management (such as hypertension and diabetes control, and treatment adherence). The NDoH should invest in systems that make it possible to track patients across the health system and access more timely feedback on how users are experiencing health service provision.
Recommendation (29) Private sector accountability: Accountability for information is not only required from the public sector, and upcoming legislation on the NHI provides an opportunity to bring accountability from other sectors especially the private sector.
Human Resources for Health
The NDoH has produced an updated Human Resources Strategy for the health sector. Implementation of the plan has been slow largely due to fiscal constraints. However, HRH should be a central focus of health sector reform even amidst fiscal constraints.
Recommendation (30) Implementation of the HRH strategy: The NDoH should coordinate efforts from all stakeholders across national government to support the implementation of the HRH plans effectively. In addition, engagement with the private health sector and with the Ministry of Employment and Labour Relations is required to assess and address future needs. To take on this role, a functional National Health Workforce Analysis and Planning Unit should be established drawing on national and international health workforce planning expertise, and utilising data science opportunities for more predictive and intelligent analytics and decisions.
Recommendation (31) Prioritised recommendations of the HRH strategy: Other actions identified as necessary in the HRH strategy include: curriculum realignment with population health needs; revitalised HRH regulatory structures; performance standards for HRH leadership and management; attention to service and positive workplaces to ensure health, safety and well-being of the health workforce, and mainstreaming gender and ensuring diversity at all levels for health workers.
Health Financing
The real challenge for health financing in South Africa is to be able to function within the budget allocated and provide the best-quality services possible. To achieve this there must be a rational balance between personnel, goods and service allocations. However, additional finances will be required for health as the cost of providing services as well as burden of disease increases. COVID-19 and its associated lengthy lockdowns have caused severe damage to the fiscus, which is likely to take at least three years to fully recover.
The NHI continues to offer major opportunities for the sector, however, opportunities in this regard have not been used to best advantage over the period reviewed. Trust needs to be built and there needs to be compromise around the Bill and subsequent reforms to avoid endless legal challenges. This includes building mixed provider platforms in an effective and efficient way, using smart strategic purchasing and systems. Confidence of provinces needs to be retained, through rapid re-introduction of delegated responsibility for service delivery (noting that the legal shift of function to national sphere is required to centralise funding). Without this not only will provincial powerbases obstruct the reforms, but major risks arise which may result in parts of the health service collapsing as functions and funds are transferred to the centre.
Recommendation (32) Health financing-related legislation: The Portfolio Committee on Health and the NDoH should review aspects of the model of NHI, and the need to revise the NHI Bill, to rebuild confidence, noting that a range of successful NHI models exist internationally. Moreover, recommendations arising from the Health Market Inquiry need to put back on track for implementation.
Recommendation (33) Strengthened NDoH capacity for health financing reforms: It will be useful to rebuild a health economics and financing unit in the NDoH. As well as assisting with NHI implementation, the unit should help monitor the new health component of the Provincial Equitable Share formula which has improved equity, benefiting poorer provinces such as Eastern Cape and Limpopo.
Global and Regional Health
South Africa has been shaped by, and is actively shaping, the world through global trends on the determinants of health, formal collaborations with global and regional institutions and through the expanding knowledge on health technology and public health interventions. The influence of South Africa in the response to COVID-19 in the region exemplifies this – with the President’s role in the African Union, the pivotal role of South African scientists in tracking and identifying new COVID variants and researching interventions, and the breakthrough in planning for mRNA COVID vaccine production in the country.
Recommendation (34) South Africa’s role in global and regional health: South Africa needs to continue to examine and expand on its role in the region and globally, both to improve the health of the people of South Africa, and for improving health regionally and globally. This should include striving for the betterment, harmonisation and coordination of Africa’s global health system, sustainable financing initiatives, aligning aid goals with the regional health needs and priorities, providing thought leadership on global health programmes, and strengthening global health initiatives through regional alliances.
Conclusion
Whilst there has been progress with some health reforms and health outcomes in the period before the COVID-19 pandemic, there is still much to be done to strengthen the health system and in the provision of equitable and quality care. Major reforms, such as the introduction of NHI, seem to have stalled. The recommendations from the analyses of the 2015 – 2020 period in this book provide some light on where attention, mainly by government, is required for the South African health system to be rejuvenated and to respond optimally to future challenges.
Most such reforms require political will, stewardship and the exercise of vigilance on corruption. Equally important is the attention required to address gender inequality and discrimination faced by women and girls; a particular low point is the increasing levels of adolescent pregnancy – a signal of many failings in the health system and beyond that require urgent attention. Successful reforms often also require changes in the way communities are engaged in order that different stakeholders can work together to achieve positive health impact and outcomes. Finally, the government should continue to expand intersectoral collaboration to both address broader determinants of health and to improve the effectiveness of health services, in particular the quality of primary health care. However, it is not only the government but also an active citizenry that is required to keep the government accountable in all spheres of government.