SAHR_17.10.22_FRONT SECTION

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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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Foreword...........................................................................................................................

About the authors..............................................................................................................

List of Abbreviations..........................................................................................................

List of Figures....................................................................................................................

List of Tables.....................................................................................................................

Chapter 1: Introduction and Overview...............................................................................

Chapter 2: Demographic and Health Trends: 2015 – 2020.................................................

Introduction.......................................................................................................................

Key demographic trends.....................................................................................................

Key health outcomes..........................................................................................................

Conclusions and way forward.............................................................................................

Chapter 3: Social, Economic and Environmental Determinants of Health...........................

Executive Summary............................................................................................................

Social, economic, and environmental achievements and challenges between 2015 – 2020........................................................................................................

Coordinated and intersectoral actions developed in response to COVID-19........................................................................................................................

Conclusion and way forward .............................................................................................

Chapter 4: Primary Health Care......................................................................................... Background .......................................................................................................................

Key Contextual Factors Impacting PHC ............................................................................

National Programmes and Interventions on PHC .............................................................. Performance Indicators .....................................................................................................

Bottom-up Health System Strengthening .......................................................................... Remaining Challenges .......................................................................................................

Conclusions and way forward ............................................................................................

Chapter 5: National Health Programmes ...........................................................................

(TB) .............................................................................................................

Child and Women’s Health (MCWH)

and way forward ............................................................................................

Chapter 6: Pharmaceutical Services and Policy .................................................................. Introduction ....................................................................................................................

Ensuring the safety, efficacy and quality of medicines ........................................................ Medicines selection and health technology assessment ....................................................... Summary and Recommendations .......................................................................................

Chapter 7: Hospital Services ..............................................................................................

....................................................................................................................... Persistent Governance and Management Challenges in Hospitals .......................................

Chapter 8: Health Emergencies, AMR and Covid-19 Response..........................................

Introduction .....................................................................................................................

Global context in the preparedness and response to health emergencies circa 2012-2015 ...

South African preparedness and response to health emergencies

2015-2020 ....................................................................................................................

Organisation of responses to COVID-19 ..........................................................................

Emerging lessons in public health emergency preparedness and response, 2015-2020 .....................................................................................................

Conclusions and way forward ...........................................................................................

Chapter 9: Non-communicable Diseases ...........................................................................

Introduction .....................................................................................................................

Key policy and guideline changes ................................................................................... ...

Challenges experienced during the past 5 years .................................................................

Risk factors for NCDs ....................................................................................................

Impact of COVID (good and bad) on NCDs ................................................................

The New National Strategic Plan (NSP) for NCDs .............................................................

Conclusions and way forward ............................................................................................

Chapter 10: Mental Health ...............................................................................................

Introduction .................................................................................................................

Recent crises in SA mental health ......................................................................................

Service organisation ..........................................................................................................

Human resources in the mental health professions ............................................................

Recent research developments for improved mental health systems ...................................

Conclusion and way forward ............................................................................................

Chapter 11: Occupational Health and Safety ....................................................................

The world of work in South Africa – Governance, Legislation and Policy

Occupational Epidemiology .............................................................................................

Occupational Health Services (Prevention, Promotion, Care, Rehabilitation)

Human resources and Professional Societies .....................................................................

Challenges facing South Africa .........................................................................................

Conclusions and way forward ..........................................................................................

Chapter 12: Infrastructure .............................................................................................

Introduction ....................................................................................................................

Description of the status-quo ...........................................................................................

Broad Overview of Infrastructure Challenges in the Health Sector ....................................

Other Issues that affect Infrastructure Provision and Efficacy ............................................

Reforms by the Government to Resolve Challenges and the extent of Success ...................

Factors that may affect Infrastructure in the Future ...........................................................

Conclusions and Recommendations .................................................................................

Chapter 13: Quality of Care .............................................................................................

Introduction .....................................................................................................................

Governance and leadership of quality ................................................................................

Revolutionising quality of care .......................................................................................

Private Sector Quality .......................................................................................................

Measurement of quality

Conclusions and way forward ...........................................................................................

Chapter 14: Legislative framework and the right to health 2015-2020 ...............................

Introduction .....................................................................................................................

The Relationship Between Law and the Right to Health

The Legal Framework and how it has Changed between 2015 and 2020

A Case Study: What Covid-19 Teaches us about the NHI ..............................................

Conclusions and way forward ............................................................................................

Chapter 15: Governance, Leadership and Management ......................................................

Introduction ......................................................................................................................

The relationships and interfaces of health system governance ..............................................

Governance at the frontline ...............................................................................................

Leadership and management practice .................................................................................

Conclusions and way forward ............................................................................................

Chapter 16: Information and Indicators for Accountability ................................................

Introduction .....................................................................................................................

Background to Information and Indicators for Accountability ...........................................

Innovations and reforms, 2015–2020 ................................................................................

Conclusions and way forward ............................................................................................

Chapter 17: Human Resources for Health .........................................................................

Introduction ......................................................................................................................

National Strategy on Human Resources for Health in South Africa ....................................

Status of the Health Workforce ..........................................................................................

Moving HRH towards the Centre of Health Systems: Needs, dilemmas and strategies ....................................................................................................................

National HRH Strategic Planning: 2020- 2030 .................................................................

Conclusions and way forward ............................................................................................

Chapter 18: Health financing ............................................................................................

Introduction .....................................................................................................................

National health insurance (NHI) .......................................................................................

Trends in health spending and budgets ..............................................................................

Health Market Inquiry ......................................................................................................

Standardising benefit package and options ..........................................................................

Public sector cost pressures ................................................................................................

Conclusions and way forward .............................................................................................

Chapter 19: Global and Regional Health ...........................................................................

Introduction ......................................................................................................................

Global Health Landscape ...................................................................................................

South Africa’s Role in the Multilateral System for Global Health ........................................

South Africa and Health Diplomacy ...................................................................................

Specific Initiatives of Regional Importance .........................................................................

Conclusions and way forward ............................................................................................

Chapter 20: Looking to the future .....................................................................................

Index .................................................................................................................................

Foreword

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.

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.

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.

(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

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

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

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

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

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

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

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

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

List of abbreviations

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

List of figures

Figure 2.1

Figure 2.2

Figure 2.3

Figure 2.4

Figure 2.5

Figure 2.6

Figure 2.7

Figure 2.8

Figure 2.9

Figure 2.10

Figure 2.11

Figure 2.12

Figure 2.13

Figure 2.14

Figure 3.1

Figure 3.2

Figure 3.3

Figure 3.4

Figure 4.1

Figure 4.2

Figure 4.3

Figure 4.4

Figure 5.1

Figure 5.2

Figure 5.3

Figure 4.4

Figure 5.5

Figure 5.6

Figure 5.7

Figure 5.8

Figure 7.1

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

Proportion of children under five years born with low birth weight: South Africa 2015–2018, by province

Proportion of children under five years with severe acute malnutrition: South Africa 2015–2018, by province

Number of maternal deaths by underlying cause: South Africa 1997–2017

Prevalence of bacteriologically confirmed pulmonary TB among adults 15 years and older: South Africa 2018, by sex and by age group

Incidence of TB: South Africa 2000–2020

HIV Prevalence: South Africa 2017, by sex and age group

HIV Incidence: South Africa 2017, by sex and age group

Persons suffering from chronic health conditions: South Africa 2015 and 2019, by sex

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

Schema of social determinants of health framework

Real Gross Domestic Product 2015–2020, annual percentage change

Health care expenditure 2015–16 to 2019–20

3G/4G LTE/5G population coverage and smartphone penetration in South Africa from 2015 to 2020

Primary health care components

Per capita expenditure on PHC and percentage of total health expenditure on PHC, 2010/11 to 2019/20

2019/20 PHC utilisation rates and average annual change between 2015/16 and 2019/20 by province

Ten elements of Cape Town Metro COPC

Incidence, new and relapse TB cases notified, HIV-positive TB incidence

TB care cascade, South Africa, 2018

Number of new and relapse notified TB cases per year, 2016–2020

Changes in HIV new infections, deaths and incidence/ prevalence ratio in South Africa 2010 to 2019

HIV testing and treatment cascade 2019, South Africa, with gaps to the three 90s targets

HIV tests done by month, in public health facilities, between March and December 2019 and 2020

Maternal mortality in public sector institutions, South Africa 2005 to 2019

National couple year protection rate

Proportion of provincial health expenditure by programme 2004/5 – 2019/20

Figure 8.1a

Figure 8.1b

Figure 8.2

Figure 9.1

Figure 9.2

Figure 9.3

Figure 9.4

Figure 9.5

Figure 9.6

Figure 11.1a-b.

Figure 11.2

Figure 11.3

Figure 12.1

Figure 12.2

Figure 12.3

Figure 12.4

Figure 12.5

Figure 12.6

Figure 13.1

Figure 13.2

Figure 13.3

Figure 13.4

Figure 13.5

Figure 13.6

Figure 13.7

Figure 15.1

Figure 16.1

Figure 16.2

Figure 18.1

Figure 18.2

Figure 18.3

Figure 18.4

Figure 18.5

Figure 18.6

Figure 18.7

Figure 18.8

Structure and functions of joint WHO-RSA listeriosis incident

management team

Phase 1, 2 and 3 of the listeriosis public health emergency response plan to halt the listeriosis outbreak and prevent future outbreaks

National and provincial structures supporting SARS-CoV-2 responses as of October 2021 The emergency operations centre

Percentage of deaths from various causes of mortality

Mortality from NCDs in South Africa

WHO’s best buys

Trends in selected NCD risk factors

What are South Africans eating?

Percentage of comorbidities among in-hospital COVID-19 deaths, by age group, South Africa

Pulmonary tuberculosis in Black miners and silicosis in Black South African gold miners at autopsy (1975–2019)

Injuries reported in mines for the five-year period (2014–2018)

Injuries reported among women in the mining industry (2001–2019)

Provincial spread of private health care facilities in 2020

Type of health care facilities consulted first by households in 2015 and 2020

State of health infrastructure

Cumulative number of facilities that achieved an Ideal Clinic status

Compliance of health facilities with NCS infrastructure requirements

IUSS users by country and sessions between 2018 and 2020

Conceptual framework for a high-quality South African health system

Proposed National Strategic Framework

The OHSC value chain

Annual returns submissions by hospitals in South Africa’s provinces in 2019/20

The total number of annual inspections by the OHSC per financial year

PDSA Model for Improvement

Themba hospital percentage of patients triaged within 10 minutes of arrival within the maternity admission room

The dominant relationships of everyday governance practice within the South African health system (2015–2020)

Health system accountability relationships

Medicine shortages reported by patients

Provincial health spending as a percentage of budgets, 2015/16 to 2020/21

Government health spending as percentage of GDP and as percentage of total government expenditure

Health financing indicators and life expectancy compared to other UMICs, 2017

The Africa Scorecard on Domestic Financing for Health, 2017, UMIC countries

Percentage deviation from the national public health spending per capita (uninsured)

Private medical scheme expenditure by factor of provision, 2009–2019

Main budget balance, Budget 2021

Provincial health budgets, 2000/01 – 2023/24

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

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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