SAHR_17.10.22_FRONT SECTION

THE SOUTH AFRICAN HEALTH REFORMS 2015-2020: THE ROAD AHEAD Editors: Malebona Precious Matsoso, Usuf Chikte, Lindiwe Makubalo, Yogan Pillay, Robert (Bob) Fryatt

THE SOUTH AFRICA HEALTH REFORMS 2015-2020: THE ROAD AHEAD

ISBN: 978-0-6397-2368-6 (print) ISBN: 978-0-6397-2369-3 (e-book) All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system, without prior permission in writing from the publisher. Subject to any applicable licensing terms and conditions in the case of electronically supplied publications, a person may engage in fair dealing with a copy of this publication for his or her personal or private use, or his or her research or private study. See Section 12(1)(a) of the Copyright Act 98 of 1978.

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Table of contents Foreword........................................................................................................................... vi About the authors.............................................................................................................. viii List of Abbreviations.......................................................................................................... xv List of Figures.................................................................................................................... xix List of Tables..................................................................................................................... xxi Chapter 1: Introduction and Overview............................................................................... 1 Chapter 2: Demographic and Health Trends: 2015 – 2020................................................. 8 Introduction....................................................................................................................... 8 Key demographic trends..................................................................................................... 10 Key health outcomes.......................................................................................................... 12 Conclusions and way forward............................................................................................. 25 Chapter 3: Social, Economic and Environmental Determinants of Health........................... 31 Executive Summary............................................................................................................ 31 Social, economic, and environmental achievements and challenges between 2015 – 2020........................................................................................................ 35 Coordinated and intersectoral actions developed in response to COVID-19........................................................................................................................ 44 Conclusion and way forward ............................................................................................. 51 Chapter 4: Primary Health Care......................................................................................... 58 Background ....................................................................................................................... 58 Key Contextual Factors Impacting PHC ............................................................................ 62 National Programmes and Interventions on PHC .............................................................. 63 Performance Indicators ..................................................................................................... 70 Bottom-up Health System Strengthening .......................................................................... 72 Remaining Challenges ....................................................................................................... 76 Conclusions and way forward ............................................................................................ 77 Chapter 5: National Health Programmes ........................................................................... 81 Introduction ..................................................................................................................... 82 Tuberculosis (TB) ............................................................................................................. 83 HIV ................................................................................................................................. 88 Maternal, Child and Women’s Health (MCWH) ............................................................... 92 Conclusions and way forward ............................................................................................ 98 Chapter 6: Pharmaceutical Services and Policy .................................................................. 103 Introduction .................................................................................................................... 103 Ensuring the safety, efficacy and quality of medicines ........................................................ 104 Medicines selection and health technology assessment ....................................................... 108 Summary and Recommendations ....................................................................................... 118 Chapter 7: Hospital Services .............................................................................................. 123 Background ....................................................................................................................... 123 Persistent Governance and Management Challenges in Hospitals ....................................... 125 Responses to Improve Governance of Hospitals 2015-2020 ............................................... 126 Conclusion ........................................................................................................................ 134

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

Chapter 8: Health Emergencies, AMR and Covid-19 Response.......................................... 137 Introduction ..................................................................................................................... 137 Global context in the preparedness and response to health emergencies circa 2012-2015 ... 138 South African preparedness and response to health emergencies 2015-2020 .................................................................................................................... ... 143 Organisation of responses to COVID-19 .......................................................................... 150 Emerging lessons in public health emergency preparedness and response, 2015-2020 ..................................................................................................... .. 151 Conclusions and way forward ........................................................................................... 153 Chapter 9: Non-communicable Diseases ........................................................................... 158 Introduction ..................................................................................................................... 158 Key policy and guideline changes ................................................................................... ... 160 Challenges experienced during the past 5 years ................................................................. 163 Risk factors for NCDs ....................................................................................................... 168 Impact of COVID (good and bad) on NCDs ................................................................ ... 170 The New National Strategic Plan (NSP) for NCDs ............................................................. 171 Conclusions and way forward ............................................................................................ 174 Chapter 10: Mental Health ............................................................................................... 178 Introduction ................................................................................................................. ... 178 Recent crises in SA mental health ...................................................................................... 179 Service organisation .......................................................................................................... 182 Human resources in the mental health professions ............................................................ 188 Recent research developments for improved mental health systems ................................... 191 Conclusion and way forward ............................................................................................ 196 Chapter 11: Occupational Health and Safety .................................................................... 201 The world of work in South Africa – Governance, Legislation and Policy .......................... 202 Occupational Epidemiology ............................................................................................. 204 Occupational Health Services (Prevention, Promotion, Care, Rehabilitation) ................................................................................................................ 212 Human resources and Professional Societies ..................................................................... 215 Challenges facing South Africa ......................................................................................... 218 Conclusions and way forward .......................................................................................... 219 Chapter 12: Infrastructure ............................................................................................. .. 223 Introduction .................................................................................................................... 223 Description of the status-quo ........................................................................................... 224 Broad Overview of Infrastructure Challenges in the Health Sector .................................... 229 Other Issues that affect Infrastructure Provision and Efficacy ............................................ 230 Reforms by the Government to Resolve Challenges and the extent of Success ................... 232 Factors that may affect Infrastructure in the Future ........................................................... 238 Conclusions and Recommendations ................................................................................. 241 Chapter 13: Quality of Care ............................................................................................. 246 Introduction ..................................................................................................................... 246 Governance and leadership of quality ................................................................................ 249 Revolutionising quality of care ....................................................................................... ... 253 Private Sector Quality ....................................................................................................... 260 Measurement of quality .................................................................................................... 262 Conclusions and way forward ........................................................................................... 263

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Table of contents

Chapter 14: Legislative framework and the right to health 2015-2020 ............................... 269 Introduction ..................................................................................................................... 269 The Relationship Between Law and the Right to Health ................................................... 269 The Legal Framework and how it has Changed between 2015 and 2020 ........................... 272 A Case Study: What Covid-19 Teaches us about the NHI .............................................. ... 281 Conclusions and way forward ............................................................................................ 285 Chapter 15: Governance, Leadership and Management ...................................................... 291 Introduction ...................................................................................................................... 291 The relationships and interfaces of health system governance .............................................. 292 Governance at the frontline ............................................................................................... 295 Leadership and management practice ................................................................................. 311 Conclusions and way forward ............................................................................................ 312 Chapter 16: Information and Indicators for Accountability ................................................ 320 Introduction ..................................................................................................................... 320 Background to Information and Indicators for Accountability ........................................... 322 Innovations and reforms, 2015–2020 ................................................................................ 325 Conclusions and way forward ............................................................................................ 333 Chapter 17: Human Resources for Health ......................................................................... 338 Introduction ...................................................................................................................... 338 National Strategy on Human Resources for Health in South Africa .................................... 339 Status of the Health Workforce .......................................................................................... 344 Moving HRH towards the Centre of Health Systems: Needs, dilemmas and strategies .................................................................................................................... 347 National HRH Strategic Planning: 2020- 2030 ................................................................. 354 Conclusions and way forward ............................................................................................ 356 Chapter 18: Health financing ............................................................................................ 361 Introduction ..................................................................................................................... 361 National health insurance (NHI) ....................................................................................... 362 Trends in health spending and budgets .............................................................................. 368 Health Market Inquiry ...................................................................................................... 379 Standardising benefit package and options .......................................................................... 381 Public sector cost pressures ................................................................................................ 382 Conclusions and way forward ............................................................................................. 391 Chapter 19: Global and Regional Health ........................................................................... 396 Introduction ...................................................................................................................... 396 Global Health Landscape ................................................................................................... 397 South Africa’s Role in the Multilateral System for Global Health ........................................ 397 South Africa and Health Diplomacy ................................................................................... 398 Specific Initiatives of Regional Importance ......................................................................... 400 Conclusions and way forward ............................................................................................ 403 Chapter 20: Looking to the future ..................................................................................... 407 Index ................................................................................................................................. 418

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Foreword Dr Joe Phaahla, Minister of Health The COVID-19 pandemic has highlighted the extreme vulnerability of our national health systems. It has shown once more that investing in health care is key to economic prosperity and to progress in human development. As much as COVID-19 has exposed our weaknesses, it has also brought our strengths to the fore.

There has been unprecedented collaboration between countries and a massive show of solidarity with vulnerable communities and societies. The COVID-19 pandemic has made governments, policy-makers and health practitioners realise that to achieve and sustain Universal Health Coverage we must be prepared to respond quickly in tackling pandemics.

The book is timely, as it comes at a stage when we are taking stock of the efforts we have made in the past to make our health system more resilient – some with great effect, and some less so. This publication covers a five-year period dating back from 2015. It reflects major successes but also many remaining challenges with regard to South Africa’s health system. It follows the first publication which covered the period 2009 to 2014.

The health system in South Africa remains divided and maintains its two-tier status more than 25 years into democracy. During 2019, the Lancet Commission released a report on quality of health care in South Africa, with detailed diagnosis, and recommendations to improve the quality of health care in the country and made a case that increase in coverage will not be sufficient to improve health outcomes. The Health Market Inquiry also released its final recommendations, citing many challenges in the private health sector, and market failure.

The policy reforms that ensued over the last decade involved the production of a green paper and white paper, which served as a prelude to the production of the National Health Insurance Bill. This aims to fulfil our constitutional obligation to protect the right to health care for all. It followed a far and wide consultative process through public hearings across all provinces. The public participation included submissions from various stakeholders and ordinary members of the public.

As some commentators have noted, implementation will not be easy, but the National Health Insurance will become a reality and we are committed to ensuring that our people receive quality health care and are not discriminated against based on lack of affordability.

South Africa still has the largest HIV epidemic in the world, with 8 million people living with HIV. South Africa is also still burdened by tuberculosis and accounts for 3% of cases worldwide. While we have made great progress in tackling HIV and TB – focusing on prevention, testing and treatment – we have fallen behind in reaching our 90/90/90 treatment targets and we will be focusing and quickening our pace to meet the 2025 treatment targets.

Foreword

South Africa has also worked across partner institutions in the continent to tackle obstacles together. For example, we are working with the World Health Organization on the establishment of an mRNA vaccine technology transfer hub in South Africa that will use a hub-and-spoke model to transfer a comprehensive technology package and provide appropriate training to selected manufacturers in other African and low- and middle-income countries. Africa has the ability, the scientists and the industries to provide the vaccines, therapeutics and diagnostics needed to manage the African health challenges. We cannot continue being consumers of medical countermeasures for diseases produced at high prices that are not affordable to the continent.

Over the next five years, the Department has set the target to increase life expectancy to at least 66.6 years, and to 70 years by 2030. Additionally, it aims to progressively achieve Universal Health Coverage, and financial risk protection for all citizens seeking health care, through application of the principles of social solidarity, cross-subsidisation, and equity. These targets are consistent with the United Nation’s Sustainable Development Goals to which South Africa subscribes, and Vision 2030, described by the National Development Plan, that was adopted by government in 2012.

A stronger health system, and improved quality of care will be fundamental to achieve these impacts. The Department’s Strategic Plan 2020/21–2024/25 is firmly grounded in strengthening the health system. The plan lays out our strategies to each of the outcomes geared to strengthen the health system, improve quality of care, and respond to the quadruple burden of disease in South Africa. We will join hands with our Provincial Departments of Health and partners to achieve these outcomes. We will also collaborate with other government departments to reduce the impact of social determinants of health, and forge strong partnerships with social partners to improve community participation to ensure that the health system is responsive to their needs.

The analysis and recommendations that have come from this huge effort, involving so many commentators, experts, managers and policy-makers will surely assist us on the road to achieving the country’s ambitious goals.

Dr Joe Phaahla, Minister of Health

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About the authors Editors Malebona Precious Matsoso Director of the Health Regulatory Science Platform, Wits Health Consortium and previously Director-General of the South African National Department of Health, and served on the WHO Executive Board for a three-year term, acting both as Vice-Chairperson and as Chair. Co-chair Intergovernmental Negotiating Body for the WHO convention on pandemic prevention, preparedness and response.

Previously published over 80 journals, articles, book chapters, reports and guidelines on pharmaceuticals, and on South African health policy. Co-editor of The South Africa Health Reforms 2009–2014: Moving towards UHC (Juta, 2015); Co-author of the Independent Panel for Pandemic Preparedness and Response (WHO, 2021).

Peer-reviewed journal articles include High-quality health systems in the Sustainable Development Goals era: time for a revolution (Lancet, 2018), COVID-19: how a virus is turning the world upside down (BMJ, 2020).

Lindiwe Makubalo Assistant Regional Director, World Health Organization Africa Regional Office. Dr Makubalo has served on numerous scientific and advisory boards, bodies and groups such as the South African Medicines Control Council, national ethics councils, several data systems boards, expert group on Oncocerciasis Control, Strategic advisory group on malaria eradication, and as African representative on the UNITAID Board. Most recently she held a diplomatic role as Minister, Health Expert for the South African Government to the United Nations in Geneva where she participated and led development of important policy and resolutions such as the NCD indicators monitoring and Ebola resolutions as chair, along with other important activities to strengthen global policy for SDGs and health emergencies.

Usuf Chikte Emeritus Professor in Health Systems and Public Health. The former Head of the Department of Global Health in the Faculty of Medicine and Health Sciences has been a dental practitioner and an academic during a long and very illustrious career, and served on various professional and educational bodies for many years as well. At Stellenbosch University, which he joined in 1996 as head of the Department of Community Dentistry, he has consistently tried to address such inequalities in health care. He became Associate Dean of the Faculty in 2000 and Executive Head of the Department of Interdisciplinary Health Sciences in 2006. Chikte has played a key role in helping to advance this process of transformation, both as an academic, a Senator and a member of the University Council.

Yogan Pillay Country Director and Extraordinary Professor, Department of Global Health, Stellenbosch University, and previously Deputy Director-General: National Department of Health. Over 100 peer-review journal articles on all aspects of public health and over 40 other publications, including book chapters and public articles. This includes co-author of the book Mental Health Policy Issues for South Africa (MASA, Cape Town, 1997), Textbook of International Health, 3rd ed.

About the authors

(Oxford University Press. NY, 2009), Textbook of Global Health, 4th ed.

(Oxford University Press. NY, 2017). Recent peer-reviewed articles include lead author of Health benefit packages: moving from aspiration to action for improved access to quality SRHR through UHC reforms (Sex Reprod Health Matters. 2020), Towards an AIDS-free generation by 2030: how are South African children, adolescents, caregivers and health care workers coping with HIV? (South African Journal of Psychology. 2021) and co-author of The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa (BMJ Glob Health. 2020).

Robert (Bob) Fryatt Vice President Health Systems and Policy and Global Project Director of the USAID Local Health System Sustainability Project, Abt Associates, MD 20852, USA. Has published over 40 peer-reviewed publications, chapters, editorials, and articles on topics covering health policy, health financing, health systems, HIV and TB; co-editor of The South Africa Health Reforms 2009–2014: Moving towards UHC (Juta, 2015); co-editor of Special Series Experiences in Promoting Health Finance and Governance Reforms (Health System Reform, 2018). Author of chapter on Primary health care and international development assistance in ‘International perspectives to primary care research’ (CRC Press 2015).

Recent peer-reviewed articles include lead author of: editorial Tuberculosis control in South East Asia: vignettes from China, Cambodia and Myanmar (Health Policy and Planning, 2017); Commentary Financing health systems to achieve the health Sustainable Development Goals. (Lancet Global Health, 2017); Article Health sector governance: should we be investing more? (BMJ Global Health, 2017).

Reviewers Professor Gill Walt, Emeritus Professor of International Health Policy, London School of Hygiene and Tropical Medicine.

Professor Craig Househam, Previously Head of Department, Western Cape Department of Health.

Sponsors Japan International Cooperation Agency (JICA) South Africa Office Wits Health Consortium (Pty) Limited (WHC), wholly owned by the University of the Witwatersrand Foreign, Commonwealth and Development Office (South Africa), Government of UK Board of Healthcare Funders

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Authors Andy Gray, BPharm, MSc(Pharm), FPS, FFIP, Senior Lecturer Division of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal Annibale Cois, MEng, MPH, PhD, Researcher Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University Ashraf Kagee, PhD, MPH, Professor of Psychology Stellenbosch University Barry Kistnasamy, Mmed Comm Health, Compensation Commissioner National Department of Health Beth Englebrecht, MbChB, MFam Med, DHA, DCH Emeritus Head of Health, Western Cape Government; Adjunct Assistant Professor, UCT School of Public Health, UCT, School of Public Health Boitumelo Mashilo, MCom (Economics of Trade and Investment) Head: Infrastructure Advisory Services, Government Technical Advisory Center Candy Day, BSc Pharm, MMedSci (Clinical Pharmacology), Technical Specialist Health Systems Trust Carmen Sue Christian, PhD, Senior Lecturer Department of Economics, EMS Faculty, University of the Western Cape Crick Lund, MSocSci (Clin Psych), PhD, Professor of Global Mental Health King’s College London and University of Cape Town Dudu Shiba, Bcur, MPH, Deputy Director: Mental Health and Substance Abuse National Department of Health Dumisani Hompashe, PhD (Economics), Senior Lecturer Department of Economics, Faculty of Management & Commerce, University of Fort Hare Eric Buch, MBBCh, MSc(Med), FFCH(CM)(SA), DTM&H, DOH, Professor, Health Policy and Management, School of Health Systems and Public Health, University of Pretoria and The Colleges of Medicine of South Africa (CMSA), Cape Town Gaurang Tanna, BSc, BSc (hons) Computer Science, MPH Senior Program Officer, TB, South Africa, Bill and Melinda Gates Foundation Gertrude Mngola, BPharm, MPH, Health Products Grant Specialist South African National AIDS Council Giovanni Perez, Chief Director, Cape Metro Western Cape Government: Health and Wellness

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About the authors

Gladys Bogoshi, BSc Physiotherapy, MSc Physiotherapy( Neurology), MPH, CEO Charlotte Maxeke Johannesburg Academic Hospital Helen Schneider, MBChB, MMed, PhD, Professor School of Public Health, University of the Western Cape Jabulani Mndebele, Chief Director, District Health Service KwaZulu-Natal Department of Health Jonatan Daven, BSc (Development Studies), MSc (International Relations) MSc (Public Health), Director: Health, National Treasury, GoSA Kamy Chetty, MD, Masters (Urban and Regional Planning), Chief Executive Officer, National Health Laboratory Service Keith Cloete, MBCHB(UCT), DCH(SA), DHM(UCT), Head of Department Western Cape Government: Health Kerrigan Mcarthy, MBBCh, DTM&H, FCPath (Micro), MPhil (Theology), PhD (Public Health), Pathologist, Centre for Vaccines and Immunology, National Institute for Communicable Disease Kholekile Malindi, PhD, Lecturer Department of Economics, Stellenbosch University Kwanele Asante, BA, LLB, MSc, Law and Policy Advisor South African Non-Communicable Disease Alliance Laura Angeletti-du Toit, PhD Eng. La Sapienza, Rome, Italy, SACAP Pr Arch., Italian Engineering Council Pr Building Eng. Western Cape Government Health and Wellness Leslie London, MB ChB, DOH, M Med (PHM), MD, Professor of Public Health Medicine, University of Cape Town Lilian Dudley, PhD, FFPHM, MSc, MBChB, Emeritus Assoc Professor in Health Systems and Public Health, University of Stellenbosch, Dept of Global Health Lindi Makubalo, Assistant Regional Director, World Health Organization Lucy Gilson, BA (Hons), MA, PhD, Professor, Health Policy and Systems School of Public Health, University of Cape Town and Department of Global Health and Development, London School of Hygiene and Tropical Medicine Lungiswa Nkonki, PhD, Senior Lecturer, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University Marc Mendelson, PhD, MBBS, Professor, Infectious Diseases Groote Schuur Hospital, University of Cape Town

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Mark Blecher, PhD, M.Med, MPhil, MBBCH, Chief Director: Health and Social Development, National Treasury, GoSA Marumo Maake, MM Public Policy BTech: Finance and Accounting Chief Director: Public Sector Remuneration Analysis and Forecasting, National Treasury, GoSA Melvyn Freeman, MA (Clin Psych), Extraordinary Professor Department of Psychology. University of Stellenbosch Mohamed Jeebhay, MBChB DOH MPhil (Epi) MPH (Occ Med) PhD FCPHM (Occ Med) SA, Professor and Head of Occupational Medicine School of Public Health, University of Cape Town Muzimkhulu Zungu, MBChB, Mmed Comm Health, FCPHM, DOMH Head of Workplace HIV TB, National Institute for Occupational Health Nikhil Khanna, BA (Economics), MPP Programme Manager: Sustainable Health Financing, Clinton Health Access Initiative, South Africa Nombulelo Magula, PGDip, MBA, MSc, B. Social Science Hons WHO COVID-19 Emergency Response Consultant and Public Health World Health Organization, South Africa Noxolo Madela, MSSc, Budget Analyst: Health, National Treasury, GoSA Nwabisa Daniels, Bcom Hons (Economics), Analyst: Capital Project Appraisals Government Technical Advisory Center Olga Perovic, MD, DTM&H, FCPath (Micro), MMED (Micro) Principal Pathologist, National Institute for Communicable Disease, a division of NHLS Pamela Naidoo, PhD, CEO; Extraordinary Professor SU Heart & Stroke Foundation SA; Stellenbosch University Patrick Moonasar, DrPH, Director Malaria and Vector-Borne Diseases Zoonotic Diseases, National Department of Health Peter Barron, Honorary Professor, School of public Health, University of the Witwatersrand, Johannesburg Precious Matsoso, BPharm, PDHM, LLM, Honorary Lecturer, Department of Pharmacy and Pharmacology, Director of the Health Regulatory Science Platform, Wits Health Consortium, University of the Witwatersrand Rajen N Naidoo, MBChB; DOH; MPH (Occ Med); PhD Professor and Head of Discipline: Occupational and Environmental Health School of Nursing and Public Health, University of KwaZulu-Natal

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About the authors

Rajesh Patel, MBChB, FCFP, MPH, Head: Health System Strengthening Board of Healthcare Funders Ramphelane Morewane, B Dent Ther, B Tech, PG Dip, Msc, Chief Director, National Department of Health Raveen Naidoo, BTEMC, MSc Cardiology, MSc Emergency Medicine Director: EMS & Disaster Medicine, National Department of Health Rene English, MBCHB, MMed, FCPHM(SA), PhD , Director: EMS & Disaster Medicine, National Department of Health Rita Thom, MBChB (UCT); DCH (CMSA); FFPsych (CMSA); PhD (Wits) Visiting Adjunct Professor, Department of Psychiatry, University of the Witwatersrand Ritika Tiwari, PhD, PGDM, BSc (Hons), Postdoctoral Fellow, Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University Robert (Bob) Fryatt, MBBS, MD, MOH, MRCP (UK), FFPH, Vice President Health Systems and Policy, Abt Associates, Abt Associates Robyn Hayes Badenhorst, MBA expected completion 2024. UP Logistics.

Project Management. Head: Group Strategy, Wits Health Consortium Ronelle Burger, PhD (Economics), Professor, Economics Department, Faculty of Economic and Management Sciences, Stellenbosch University Russell Rensburg, BCom Finance and Economics, Director Rural Health Advocacy Project Sandhya Singh, M(Com Path), Director: Non-Communicable Diseases Department of Health Sasha Stevenson, BA, BA (Hons), LLB, LLM, Head of the Health Rights Programme, SECTION27 Shabir Banoo, BPharm, PhD, Chief Technical Specialist: Pharmaceutical Policy and Programmes, Right to Care; Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand Shoni Mulibana, BPharm, MPharm, MPH, Manager: Pharmaceutical Services Programmes, Right to Care Shrikant Peters, BA (PPE), MBChB, MMed (Public Health), FCPHM Manager: Medical Services, Public Health Medicine Specialist Groote Schuur Hospital, Western Cape Department of Health Department of Public Health & Family Medicine, University of Cape Town Sifiso Phakhati, Bcur(I ET A), Advanced Psychiatric Nursing Former Director: Mental Health and Substance Abuse, National Department of Health

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Siphiwe Mndaweni, BA, MSc, MBChB, Diploma in Health Systems Management and Executive Leadership, Chief Executive Officer, Office of Health Standards Compliance Spo M Kgalamono, MBCHB, DOH, FCPHM (Occ Med), MMed (Occupational Medicine), DPH, Executive Director, National Institute for Occupational Health Steve Letsike, Executive Director, Access Chapter 2 and Chairperson of the Commonwealth Equality Network Sue Putter, DipPharm, MPharm, MPA, Deputy Chief of Party and Senior Health System Strengthening Specialist, USAID Global Health Supply Chain - Technical Assistance Programme Sumaiyah Docrat, BSc (Hons) MPH (Health Economics) PhD, Global Health Specialist: Health Economics, Systems and Policy, Independent Scholar Tamlyn Roman, PhD, Programme Manager, Clinton Health Access Initiative, South Africa Terence Carter, MBCHB(Natal), DCH(SA), DHM(UCT), Technical Assistant, Clinton Health Access Initiative, South Africa Theodosia Adom, PhD, Postdoctoral Fellow, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University Thulani Clifford Masilela, Master of Arts (MA), Clinical Psychology; Postgraduate Diploma in Health Management, Outcomes Facilitator (Senior Sector Specialist) for Health, Department of Planning Monitoring and Evaluation (DPME), Presidency, Republic of South Africa Thulani Matsebula, BA, MSc, Senior Economist: Health, World Bank, Southern Africa Thulile Zondi, BNUR, MPH, Chief Director, Health Information, Research, Monitoring & Evaluation, National Department of Health Tsakani Furumele, BSc (Medical Laboratory Science), MSc (Zoology), MPH (Epidemiology and Biostatistics), Director: Communicable Disease Control, National Department of Health Usuf Chikte, PhD, Emeritus Professor in Health Systems and Public Health Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University Vishal Brijlal, BCom Economics, Former Advisor on Health Financing (NDoH) and Senior Director, Clinton Health Access Initiative, South Africa Wezile Chita, MPH, PhD, Assistant Dean, Faculty of Health Sciences, University of Witwatersrand Yogan Pillay, PhD, Country Director and Extraordinary Professor Clinton Health Access Initiative, South Africa. Department of Global Health, Stellenbosch University

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List of abbreviations AfCFTA

African Continental Free Trade Area

AGSA

Auditor-General of South Africa

AMR

Antimicrobial Resistance

AMS

Antimicrobial Stewardship

ART

Antiretroviral Therapy

ARV

Antiretroviral

CCMDD

Centralised Chronic Medicine Dispensing and Distribution

CDC

Centers for Disease Control and Prevention

CEO

Chief Executive Officer

CHAI

Clinton Health Access Initiative

CHW

Community Health Worker

CMS

Council for Medical Schemes

COPC

Community-Oriented Primary Care

COVAX

COVID-19 Vaccines Global Access

CSG

Child Support Grant

CSOs

Civil Society Organisations

CUPS

Contracting Units for Primary Health Care

CVD

Cardiovascular Disease

DBE

Department of Basic Education

DCST

District Clinical Specialist Team

DDM

District Development Model

DEL

Department of Employment and Labour

DHIS

District Health Information System

DHS

District Health System

DM

Diabetes Mellitus

DMRE

Department of Mineral Resources and Energy

DO

District Office

DRG

Diagnosis-Related Group

DR-TB

Drug-Resistant TB

EML

Essential Medicines List

EMS

Emergency Medical Services

EMT

Emergency Medical Team

EOC

Emergency Operating Centres

ESMS

Electronic Stock Management Systems

EtD

Evidence-to-Decision

GDP

Gross Domestic Product

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

GERMS-SA

Group for Enteric, Respiratory and Meningeal Disease Surveillance in South Africa

GFATM

Global Fund to Fight AIDS, Tuberculosis and Malaria

GHS

General Household Survey

GLASS

Global Antimicrobial Resistance and Use Surveillance System

GMP

Good Manufacturing Practice

GP

General Practitioner

HDI

Human Development Index

HE

Health Establishment

HIS

Health Information System

HMI

Health Market Inquiry

HOD

Head of Department

HPCSA

Health Professions Council of South Africa

HPL

Health Promotion Levy

HPRS

Health Patient Registration System

HRH

Human Resources for Health

HTA

Health Technology Assessment

ICRM

Ideal Clinic Realisation and Maintenance

ICESCR

International Covenant for Economic, Social and Cultural Rights

IHI

Institute for Health Improvement

IHR

International Health Regulations

ILO

International Labor Organization

iMMR

Institutional Maternal Mortality Ratio

IMR

Infant Mortality Rate

IMS

Incident Management System

IMT

Incident Management Team

IP

Intellectual Property

IPC

Infection Prevention and Control

IPCHS

Integrated People-Centred Health Service

IUSS

Infrastructure Unit Support Systems

IVDs

In Vitro Diagnostics

JEE

Joint External Evaluation

LE

Life Expectancy

MAC

Ministerial Advisory Committee

MAC-AMR

Ministerial Advisory Committee on Antimicrobial Resistance

MCC

Medicines Control Council

MCH

Maternal and Child Health

MDGs

Millennium Development Goals

MEC

Member of the Executive Council

MNORT

Multisectoral National Outbreak Response Team

MNS

Mental, Neurological and Substance Use

MPTTT

Medical Products Technical Task Team

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List of abbreviations

MRC

Medical Research Council

MRU

Monitoring and Response Unit

NAPHISA

National Public Health Institute of South Africa

NATHOC

National Health Operations Centre

NATJOC

National Joint Operations Centre

NATJOINTS

National Joint Operational and Intelligence Structure

NCCC

National COVID-19 Command and Control Council

NCD

Non-Communicable Disease

NCR

National Cancer Registry

NCS

National Core Standards

NDMC

National Disaster Management Centre

NDoH

National Department of Health

NDP

National Development Plan

NEMLC

National Essential Medicines List Committee

NGO

Non-governmental Organisation

NHA

National Health Accounts

NHC

National Health Council

NHC-Tech

National Health Council Technical Committee

NHI

National Health Insurance

NHLS

National Health Laboratory Services

NIAMM

National Infrastructure Asset Maintenance Management

NICD

National Institute of Communicable Diseases

NIOH

National Institute for Occupational Health

NMRAs

National Medicines Regulatory Authorities

NQIP

National Quality Improvement Plan

NRAs

National Regulatory Authorities

NSC

National Surveillance Centre

OECD

Organisation for Economic Co-operation and Development

OHS

Occupational Health Services

OHSC

Office of Health Standards Compliance

OSD

Occupation Specific Dispensation

PDoH

Provincial Department of Health

PEPFAR

The United States President's Emergency Plan For AIDS Relief

PFMA

Public Finance Management Act

PHC

Primary Health Care

PHDC

The Western Cape Provincial Health Data Centre

PLHIV

People Living With HIV/Aids

PMB

Prescribed Minimum Benefit

PPE

Personal Protective Equipment

PSDP

Public Sector Dependent Population

PUPs

Pick-up Points

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QI

Quality Improvement

QA

Quality Assurance

SAHPRA

South African Health Products Regulatory Authority

SAM

Severe Acute Malnutrition

SDGs

Sustainable Development Goals

SDH

Social Determinants of Health

SECEDH

Social, Economic, Commercial and Environmental Determinants of Health

SOP

Standard Operating Procedure

SSP

Stop Stockouts Project

STGs

Standard Treatment Guidelines

STIs

Sexually Transmitted Infections

SVS

Stock Visibility System

TAC

Treatment Action Campaign

TB

Tuberculosis

U5MR

Under-Five Mortality Rate

UHC

Universal Health Coverage

UMIC

Upper-Middle-Income Country

UNICEF

United Nations Children’s Fund

USAID

United States Agency for International Development

VUCA

Volatility, Uncertainty, Complexity and Ambiguity

WBOT

Ward-Based Outreach Team

WBPHCOT

Ward-Based Primary Health Care Outreach Team

WISN

Workload Indicators of Staffing Need

WoGA

Whole of Government Approach

WoSA

Whole of Society Approach

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List of figures Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Figure 2.5

Population age structure by single years, 2020 Population distribution by race, 2020 Life expectancy at birth: South Africa 2002–2021 Number of natural and unnatural deaths: South Africa 2000–2020 Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U5MR): South Africa 2002–2020 Figure 2.6 Proportion of children under five years born with low birth weight: South Africa 2015–2018, by province Figure 2.7 Proportion of children under five years with severe acute malnutrition: South Africa 2015–2018, by province Figure 2.8 Number of maternal deaths by underlying cause: South Africa 1997–2017 Figure 2.9 Prevalence of bacteriologically confirmed pulmonary TB among adults 15 years and older: South Africa 2018, by sex and by age group Figure 2.10 Incidence of TB: South Africa 2000–2020 Figure 2.11 HIV Prevalence: South Africa 2017, by sex and age group Figure 2.12 HIV Incidence: South Africa 2017, by sex and age group Figure 2.13 Persons suffering from chronic health conditions: South Africa 2015 and 2019, by sex Figure 2.14 Proportion of ever-partnered women aged 18 and older who have experienced physical, sexual or emotional violence committed by any partner in the past 12 months: South Africa 2017, by province Figure 3.1 Schema of social determinants of health framework Figure 3.2 Real Gross Domestic Product 2015–2020, annual percentage change Figure 3.3 Health care expenditure 2015–16 to 2019–20 Figure 3.4 3G/4G LTE/5G population coverage and smartphone penetration in South Africa from 2015 to 2020 Figure 4.1 Primary health care components Figure 4.2 Per capita expenditure on PHC and percentage of total health expenditure on PHC, 2010/11 to 2019/20 Figure 4.3 2019/20 PHC utilisation rates and average annual change between 2015/16 and 2019/20 by province Figure 4.4 Ten elements of Cape Town Metro COPC Figure 5.1 Incidence, new and relapse TB cases notified, HIV-positive TB incidence Figure 5.2 TB care cascade, South Africa, 2018 Figure 5.3 Number of new and relapse notified TB cases per year, 2016–2020 Figure 4.4 Changes in HIV new infections, deaths and incidence/ prevalence ratio in South Africa 2010 to 2019 Figure 5.5 HIV testing and treatment cascade 2019, South Africa, with gaps to the three 90s targets Figure 5.6 HIV tests done by month, in public health facilities, between March and December 2019 and 2020 Figure 5.7 Maternal mortality in public sector institutions, South Africa 2005 to 2019 Figure 5.8 National couple year protection rate Figure 7.1 Proportion of provincial health expenditure by programme 2004/5 – 2019/20

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

Figure 8.1a Structure and functions of joint WHO-RSA listeriosis incident management team Figure 8.1b Phase 1, 2 and 3 of the listeriosis public health emergency response plan to halt the listeriosis outbreak and prevent future outbreaks Figure 8.2 National and provincial structures supporting SARS-CoV-2 responses as of October 2021 The emergency operations centre Figure 9.1 Percentage of deaths from various causes of mortality Figure 9.2 Mortality from NCDs in South Africa Figure 9.3 WHO’s best buys Figure 9.4 Trends in selected NCD risk factors Figure 9.5 What are South Africans eating?

Figure 9.6 Percentage of comorbidities among in-hospital COVID-19 deaths, by age group, South Africa Pulmonary tuberculosis in Black miners and silicosis in Black South Figure African gold miners at autopsy (1975–2019) 11.1a-b.

Figure 11.2 Injuries reported in mines for the five-year period (2014–2018) Figure 11.3 Injuries reported among women in the mining industry (2001–2019) Figure 12.1 Provincial spread of private health care facilities in 2020 Figure 12.2 Type of health care facilities consulted first by households in 2015 and 2020 Figure 12.3 State of health infrastructure Figure 12.4 Cumulative number of facilities that achieved an Ideal Clinic status Figure 12.5 Compliance of health facilities with NCS infrastructure requirements Figure 12.6 IUSS users by country and sessions between 2018 and 2020 Figure 13.1 Conceptual framework for a high-quality South African health system Figure 13.2 Proposed National Strategic Framework Figure 13.3 The OHSC value chain Figure 13.4 Annual returns submissions by hospitals in South Africa’s provinces in 2019/20 Figure 13.5 The total number of annual inspections by the OHSC per financial year Figure 13.6 PDSA Model for Improvement Figure 13.7 Themba hospital percentage of patients triaged within 10 minutes of arrival within the maternity admission room Figure 15.1 The dominant relationships of everyday governance practice within the South African health system (2015–2020) Figure 16.1 Health system accountability relationships Figure 16.2 Medicine shortages reported by patients Figure 18.1 Provincial health spending as a percentage of budgets, 2015/16 to 2020/21 Figure 18.2 Government health spending as percentage of GDP and as percentage of total government expenditure Figure 18.3 Health financing indicators and life expectancy compared to other UMICs, 2017 Figure 18.4 The Africa Scorecard on Domestic Financing for Health, 2017, UMIC countries Figure 18.5 Percentage deviation from the national public health spending per capita (uninsured) Figure 18.6 Private medical scheme expenditure by factor of provision, 2009–2019 Figure 18.7 Main budget balance, Budget 2021 Figure 18.8 Provincial health budgets, 2000/01 – 2023/24

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List of tables Table 2.1 Table 3.1 Table 3.2 Table 4.1 Table 4.2 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 6.1 Table 8.1 Table 8.2 Table 8.3

Table 9.1 Table 9.2 Table 9.3 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table 11.5 Table 11.6 Table 11.7 Table 12.1 Table 12.2 Table 12.3 Table 15.1 Table 17.1 Table 17.2 Table 17.3

The 10 leading underlying natural causes of death per age groups in South Africa South Africa’s HDI trends (based on consistent time series data and new goalposts) List of the key actions in South Africa within the first 14 days (March 5–19) of COVID-19 Core strategic and operational levers for PHC Operational levers addressed Key TB indicators in South Africa 2015 to 2020 Key HIV indicators from 2015 to 2022, South Africa (Thembisa Model) The three 90s, South Africa, 2015 to 2022 Maternal and Child Mortality 2015 to 2020 Deliveries and terminations in adolescent girls aged 10–19 in the public sector, South Africa 2017/18 to 2021/22 Medicines availability data sources Core capacities required to implement IHR, and South African scores during the JEE process, 2017 Significant communicable disease events and health emergencies, 2015–2020 Strategic framework and activities to preserve effectiveness of antimicrobials, improve use of antibiotics and strengthen effective management of antibiotic resistant organisms according to the National AMR Strategy Framework Goals and targets in the 2013–2017 NCD Strategic Plan Most frequently reported cancers (National Cancer Registry: 2015–2018) Guiding principles for the implementation of the NSP Legislation on Occupational Health and Safety Legislation on Occupational Health and Safety for specific sectors Occupational diseases reported to the Compensation Fund for the non-mining sector in South Africa, 2016/17–2019/20 Occupational diseases per commodity reported in annual medical reports by South African mines (2018 and 2019) Occupational diseases reported and certified for the mining sector of South Africa (2019–2020) Public sector health worker COVID-19 disease data per province (March 2020–mid August 2021) Societies of the different OSH professionals Provincial spread of public health care facilities Bed capacity rate per 1 0 dependent population Waiting times per level of care Strengthening governance through new approaches to managing meetings Available data sources for HRH planning in South Africa HRH studies undertaken in South Africa 2019 Public sector health workforce – Inter-provincial variation in staffing ratios per 100 0 public sector population

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

Table 17.4 Table 17.5 Table 18.1 Table 18.2 Table 18.3 Table 18.4 Table 18.5 Table 18.6 Table 18.7 Table 18.8 Table 18.9 Table 18.10 Table 18.11 Table 18.12

Medical Specialists in South Africa (gender break up) in 2019 Demographics of sub-specialists who were successful in colleges of medicine examinations in South Africa Progress with NHI Consolidated health spending (public and private sectors) Provincial health budgets Key health financing indicators in upper-middle-income countries, 2018 PHC expenditure per capita in highest and lowest districts (real 2019/20 prices) Accruals and payables not recognised (unpaid accounts), 2015/16 – 2019/20 PDoH compensation of employees’ expenditure, 2015/16 – 2023/24 Trends in health personnel numbers in public sector Distribution of critical skills per 100 0 uninsured population Goods and services spending per capita (uninsured), 2015/16 – 2023/24 Medico-legal claims contingent liability, 2015/16 – 2020/21 Summary of health allocations for COVID-19 in the 2020 special adjustments budget

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