EM

BA
R
O G
N O
4 ED
M U
A N
Y T
20 IL
16 6
PM
South African
Health Review
2016
EM
BA
R
O G
N O
4 ED
M U
A N
Y T
20 IL
16 6
PM
 South African
Health Review
2016

PM
16 6
LIMPOPO

20 IL
Y T
A N
GAUTENG
MPUMALANGA
M U

NORTH WEST
SWAZI-
LAND
4 ED

FREE STATE
O

KWAZULU-NATAL
G

NORTHERN CAPE LESOTHO

R
BA

N
O
EM

EASTERN CAPE

WESTERN CAPE

Published by
Health Systems Trust
 Information presented in this Review is based on best available data derived from numerous
sources. Discrepancies between different sources reflect the current quality of data. All data
should thus be interpreted carefully and with recognition of potential inaccuracy.

The views expressed in this Review are those of the individual authors and do not represent
the views of their respective organisations / institutions or Health Systems Trust.

Also available on CD and on the HST website

PM
http://www.hst.org.za/publications/south-african-health-review-2016

16 6
20 IL
Health Systems Trust
Y T Email: hst@hst.org.za
A N
34 Essex Terrace Website: http://www.hst.org.za
Westville 3630 Tel: +27 (0)31 266 9090
M U

Durban Fax: +27 (0)31 266 9199

South Africa
4 ED

ISSN 1025-1715

May 2016
O
G
R
BA

This publication was supported by a grant from the South African National Department of Health.
O
EM

Suggested citation, for example:

Gray A, Vawda Y. Health Policy and Legislation. In: Padarath A, King J, Mackie E, Casciola J, editors.
South African Health Review 2016. Durban: Health Systems Trust; 2016.
URL: http://www.hst.org.za/publications/south-african-health-review-2016

The information contained in this publication may be freely distributed and reproduced,
provided that the source is acknowledged and it is used for non-commercial purposes.

Layout by Lynda Campbell, The Press Gang : Telephone +27 (0)82 410 9936
Foreword

I am pleased to introduce this 19th edition of the South African Health Review, published at a time of critical and far-
reaching changes in national and global health and human development.

The 17 Sustainable Development Goals launched in 2015 represent a vision of health that embraces economic, social
and environmental determinants, with a new agenda to uplift and protect “people, planet, prosperity, peace and
partnership”.

We all share the responsibility for comprehensive understanding and social action to alleviate and overcome South
Africa’s quadruple burden of disease, prevailing threats to our natural world, and abiding socio-economic inequality.

PM
As South Africa contends with multiple challenges in adapting and refining our health system, the ideas that permeate this
Review are centred, as ever, on the trials of health service delivery. One is struck by the progress made by the chapters’
authors towards identifying opportunities and solutions in response to the obstacles investigated.

16 6
Producing this edition of the Review has been singularly demanding, and its successful completion is attributed to

20 IL
the insightful guidance, deft industry and ardent commitment invested by the authors, reviewers, Editorial Advisory
Committee members, editorial team and administrative personnel who contributed to its creation. On behalf of the Board,
I wish to express our gratitude to the teams for their production of another excellent edition of the South African Health
Y T
Review and encourage them to continue with their good work.
A N
We are grateful to the South African National Department of Health for its steadfast support of this publication, thereby
M U

fostering much more than a contribution to intellectual capital and strategic development planning for health; this project
helps to develop solidarity of purpose that offers hope for a healthy nation and an inclusive future.
4 ED
O
G
R
BA

Mr Shadrack Shuping
O

Chairperson of the Board of Trustees,

Health Systems Trust
EM

S A H R 20 1 6 i
ii
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Table of Contents

Acknowledgements v

Editorial vii

LEAD ERSH I P A N D G OVER N A N CE 1

1 Health Policy and Legislation 3

PM
Andy Gray, Yousuf Vawda

2 Analysing the progress and fault lines of health sector transformation in South Africa 17

16 6
Laetitia Rispel

20 IL
3 Water, sanitation and health: South Africa’s remaining and existing issues 25
David Hemson Y T
A N
4 Diet-related non-communicable diseases in South Africa : determinants and policy responses 35
M U

Mark Spires, Peter Delobelle, David Sanders,

Thandi Puoane, Philipp Hoelzel, Rina Swart
4 ED

Human Resources for Health 43

O

5 The contribution of specialist training programmes to the development of a

G

public health workforce in South Africa 45

Virginia Zweigenthal, Leslie London, William Pick
R
BA

6 Disabling health: the challenge of incapacity leave and sickness absence

management in the public health sector in KwaZulu-Natal Province 61
O

Rajen N. Naidoo, Saloshni Naidoo, Sujatha Hariparsad

EM

7 Language barriers in health: lessons from the experiences of trained interpreters

working in public sector hospitals in the Western Cape 73
Ereshia Benjamin, Leslie Swartz, Linda Hering, Bonginkosi Chiliza

8 Bridging the gap between biomedical and traditional health practitioners in South Africa 83
Mosa Moshabela, Thembelihle Zuma, Bernhard Gaede

Service Delivery 93

9 Achieving universal access to sexual and reproductive health services: the potential and
pitfalls for contraceptive services in South Africa 95
Naomi Lince-Deroche, Melanie Pleaner, Jane Harries, Chelsea Morroni,
Saiqa Mullick, Cindy Firnhaber, Masangu Mulongo, Pearl Holele, Edina Sinanovic

S A H R 20 1 6 iii
10 Breastfeeding in South Africa : are we making progress? 109
Lisanne du Plessis, Nazia Peer, Simone Honikman, René English

11 MomConnect: an exemplar implementation of the Health Normative Standards Framework

in South Africa 125
Christopher Seebregts, Peter Barron, Gaurang Tanna,
Peter Benjamin, Thomas Fogwill

12 The contribution of congenital disorders to child mortality in South Africa 137

Helen L. Malherbe, Colleen Aldous, David Woods, Arnold Christianson

13 Integrating mental health into South Africa’s health system: current status and way forward 153

PM
Marguerite Schneider, Emily Baron, Erica Breuer, Sumaiyah Docrat,
Simone Honikman, Ashraf Kagee, Michael Onah, Sarah Skeen,
Katherine Sorsdahl, Mark Tomlinson, Claire van der Westhuizen, Crick Lund

16 6
14 Sex work and South Africa’s health system: addressing the needs of the underserved 165

20 IL
Andrew Scheibe, Marlise Richter, Jo Vearey

15
Y T
Trauma, a preventable burden of disease in South Africa : review of the evidence,
A N
with a focus on KwaZulu-Natal 179
Timothy C. Hardcastle, George Oosthuizen,
M U

Damian Clarke, Elizabeth Lutge

4 ED

16 Strengthening the measurement of quality of care 191

Ronelle Burger, Shivani Ranchod, Laura Rossouw, Anja Smith
O

Financing and Medical Products 201

G
R

17 HIV and AIDS financing in South Africa : sustainability and fiscal space 203
BA

Mark S. Blecher, Gesine Meyer-Rath, Calvin Chiu,

N

Yogan Pillay, Fareed Abdullah, Aparna Kollipara,

O

Jonatan Davén, Michael Borowitz, Nertila Tavanxi

EM

18 Towards a transparent pricing system in South Africa : trends in pharmaceutical logistics fees 221
Varsha Bangalee, Fatima Suleman

Information 233

19 The development of a National Health Research Observatory in South Africa :

considerations and challenges 235
Nobelungu J. Mekwa, Ashley Van Niekerk, Edith N. Madela-Mntla,
Mohammed Jeenah, Glaudina Loots, Bongani M. Mayosi

20 Health and Related Indicators 243

Candy Day, Andy Gray

Abbreviations 349

iv S A H R 20 1 6
Acknowledgements

Editors Access to data

Ashnie Padarath, Judith King, Emma-Louise Mackie and Julia We are grateful to the National Department of Health for providing
Casciola. access to various data sets used in this Review.

Editorial Advisory Committee Other support

We extend sincere thanks to Editorial Advisory Committee members. Compiling the South African Health Review is a highly demanding
Their contributions helped to guide the development of the Review undertaking that requires sustained collective input and support from

PM
and to uphold high standards of academic rigour: a wide range of people. In particular, we thank:

Peter Barron, Rene English, Andy Gray, Thulani Masilela, Judith Annakie, Janet Dladla, Shumeez Dollie, Ndumiso Jali,
Tracey Naledi, Laetitia Rispel and Flavia Senkubuge. Delene King, Sakhiwo Mahlumba, Themba Moeti,

16 6
Bongi Mthembu, Melody Naidoo, Primrose Ndokweni,
Contributing authors Thesandree Padayachee, Kemona Pillai, Ronel Visser,

20 IL
Nompumelelo Xulu, and Duduzile Zondi.
We commend the commitment of individual authors to contributing
to the Review and their co-operation in responding to editing
Y T We express a special thank you to Lynda Campbell of The Press
requirements, often at short notice. Gang for striving against arduous deadlines to produce the Review’s
A N
distinctive quality of layout and design. Thanks are also due to
Peer reviewers Anjana Bugwandeen who assisted with editing and references.
M U

We extend our thanks to the peer reviewers for their insightful

Funders
comments that strengthened the quality of the chapters in this Review:
4 ED

This publication was supported by a grant from the South African

Shahieda Adams, Peter Barron, Mags Beksinska, Arvin Bhana,
National Department of Health.
Rakshika Bhana, Ega Bonthuyzen, Andrew Boulle,
Michael Burnett, Annibale Cois, Peter Cooper,
O

Cover art
Andrew Crichton, Robin Dyers, Stefan Gebhardt,
G

Nelouise Geyer, Andrew Gibbs, Ameena Goga, Andy Gray, The cover art for the 2016 edition of the South African Health Review
Teresa Guthrie, David Harrison, Karen Hermanus, is an oil-on-canvas painting by David Wheildon Oosthuizen. The
R

Nadia Hussey, Ehimario Igumbor, Emma Kalk, Michael Levin, painting is one in a series of paintings by David entitled Reflections
Ozayr Mahomed, Carol Marshall, Verona Mathews, on African Life.
BA

Catherine Mathews, Neil McKerrow, Ushma Mehta,

Pascalia Munyewende, Linda Mureithi, Shan Naidoo,
O

Andrew Nicol, Sara Nieuwoudt, Nonhlanhla Nxumalo,

EM

Thesandree Padayachee, Nazia Peer, Catherine Pereira,

Gregory Petro, Bada Pharasi, Victoria Pinkney-Atkinson,
Msokoli Qotole, David Sanders, Helene Schneider,
Vera Scott, Catherine Searle, Maxine Spedding, Anna Voce,
and Gustaaf Wolvaardt.

S A H R 20 1 6 v
vi
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Editorial

The Global Report on Urban Health: Equitable, healthier cities of primary health care, and the unsolved health workforce crisis,
for sustainable development issued in March 2016 by the World constitute a conjoined threat to the feasibility of National Health
Health Organization and the United Nations Human Settlements Insurance (NHI).
Programme (UN-Habitat) emphasises the need for enhanced
In November 2015, the South African Medical Association (SAMA)
governance and leadership to achieve universal health coverage
warned that climate change will produce a surge in waterborne
and the Sustainable Development Goals (SDGs). Noting that a
diseases. David Hemson’s timely research on water, sanitation and
healthy population forms the foundation for “sustainable economic
health in South Africa, presented in Chapter 3, portrays the factors
growth, social stability, and full realisation of human potential”,

PM
indicating a need for improved water and health management, with
the report presents “practical, proven solutions for working across
greater surveillance of water quality – particularly in vulnerable
sectors to tackle these … health challenges”, and includes examples
communities – and the delivery of universal water services to
of such successes in South Africa.a
ensure health and prevent disease outbreaks. His recommendations

16 6
The 20 chapters that make up the 2016 edition of the South African include regular review and routine public reporting of water quality
Health Review mirror this global health and development agenda

20 IL
management, and further research into the development and
in a local context and offer evidence-based recommendations for sustainability of sanitation services.
resolving our country’s health challenges. Binding this content is the
Y T
aspiration for an accessible, high-performing public health system
that ameliorates health disparities and provides quality health care,
In Chapter 4, Mark Spires, David Sanders, Phillipp Hoelzel, Peter
Delobelle, Thandi Puoane and Rina Swart focus on evidence relating
A N
to change from a traditional diet to a ‘western’ diet with more
bolstered by multisectoral mobilisation under adept management,
processed foods, more foods of animal origin, and more added
M U

leadership and governance.

sugar, salt and fat, which has been implicated in the rise of NCDs
The chapters in this Review are assembled into the following focus in South Africa. They note that positive policy steps in this regard
4 ED

areas: Leadership and governance, Human resources for health,
Service delivery, Financing and medical products, and Information.
Leadership and governance
O
have been made at national level, but consequent action has been
lacking, and a sustained public health effort is required to address
the environmental factors and knowledge, attitudes and behaviours

that aggravate the NCD burden. A co-ordinated plan is needed

In Chapter 1, Andy Gray and Yousuf Vawda describe milestones to make healthy foods more available, acceptable and affordable.
G

in South Africa’s health policy and legislation over the past year,
and the delays and challenges beleaguering the development and Human resources for health
R

application thereof. They point out that although the long-awaited

In Chapter 5, Virginia Zweigenthal, Leslie London and William
BA

NHI White Paper was released, related funding and policy issues
N

Pick contend that several of South Africa’s key transformative

lack detail and finalisation, while the Office of Health Standards
health policies make scant mention of the skilled public health (PH)
O

Compliance and the South African Health Products Regulatory

workforce required to monitor the progress of NHI and the SDGs,
Authority are yet to be fully operationalised. They note that the
EM

identify health service priorities and implement effective delivery

development of secondary and tertiary legislation for the Medicines
and Related Substances Amendment Acts of 2008 and 2015 is
needed for promulgation, and that there is no movement on the
proposed redesign of the Health Professions Council of South Africa.
They also note that while draft Bills to amend the National Health
Laboratory Service Act and to create a new National Public Health
Institute of South Africa have been prepared, neither Bill has yet
been tabled in Parliament.
Laetitia Rispel contributes a powerful perspective on public health
sector transformation in Chapter 2, noting that although progressive
measures in health policy, legislation and resource allocation
have been taken since the advent of democracy in South Africa,
three key fault lines in implementation underpin the relatively poor
performance of our health system and are impeding realisation
of improved health for the nation. In her analysis, tolerance of
ineptitude and failures in leadership, management and governance,
a district health system that does not adequately drive the delivery
strategies. Public Health Medicine (PHM) graduates – who since
1994 have included medical doctors, other health professionals
and social scientists – can apply their broad and versatile skills-base
in technical and service roles at district, provincial and national
levels. The authors suggest that existing Public Health units in the
Western Cape and Gauteng staffed with multi-disciplinary teams
of PHM specialists and other PH professionals could be replicated
across the country as a resource for health system development and
restructuring.
In Chapter 6, Rajen Naidoo, Saloshni Naidoo and Sujatha
Hariparsad provide a review and critique of the current approaches
to managing ill-health among healthcare workers and assessing
their ability to work. Healthcare workers experience a significant
burden of disease caused by a range of workplace hazards, and
inadequate institutional management of sickness absence results in
a high number of lost work-days, translating into massive costs. The

a http://www.who.int/kobe_centre/measuring/urban-global-report/en/

S A H R 20 1 6 v ii
authors propose that institutional responsibility for a work-focused
approach be adopted to address the health of healthcare workers,
and thereby improve productivity and patient care; this would entail
involvement of the Employee Health Service for periods of five days
of absence, or of the Occupational Medical Practitioner for repeated
short-term absences and assessment of fitness to work.
The focus of Chapter 7 is on addressing language barriers in South
African health care using trained interpreters. Ereshia Benjamin,
Leslie Swartz, Linda Hering and Bonginkosi Chiliza identify themes
emerging from mentor sessions in a pilot project conducted in
Western Cape hospitals. Community interpreters were found to
experience their work as challenging on practical and emotional
levels, and to be uncertain about their location and role in the health
system. The authors highlight the potential to develop a multilingual
health service for South Africa’s culturally and linguistically diverse
population; they argue for the promotion of language access in
health services and the professionalisation of health interpreters,
and suggest areas for further research.
16 6
Mosa Moshabela, Thembelihle Zuma and Bernhard Gaede
20 IL
provide a compelling account (Chapter 8) of the need for
respectful engagement between biomedical and traditional health
practitioners, following the promulgation of the Traditional Health
Y T
Practitioners Act (22 of 2007). In foregrounding the resilience of
A N
indigenous knowledge, practice and experience, they advocate for
the ‘reclamation’ of traditional medicine and healing through policy,
M U
legislation and research that will resolve continuing tensions between
the two paradigms of health care and, through the lens of mutuality
4 ED
rather than opposition, prioritise the needs of the large proportion of
South Africa’s patient population. A merged, complementary system
of plural health care would benefit both arms of healthcare practice,
the patients themselves, and other countries in the African region
O
that seek to institutionalise traditional healing.
G
Service delivery
R
Chapter 9, crafted by Naomi Lince-Deroche et al., acknowledges
BA
South Africa’s progressive and comprehensive laws, policies and
N
guidelines on contraceptive service provision in the public sector
O
and the country’s commitment to integrated, rights-based service
delivery in the context of the SDGs and the Family Planning 2020
EM
(FP2020) initiative. However, scarce resources and South Africa’s
HIV epidemic, and their impact on delivery of contraceptive
services, are health systems constraints that demand accountability
for related budgeting and dispensing methods. The authors suggest
that shift and scale-up of contraceptive use in South Africa requires
ongoing assessment of the couple year protection rate and unmet
contraception need, along with counselling, education and
supportive interactions with the healthcare system for all women, in
order to optimise improved contraceptive uptake.
Knowledge and evidence, politics and governance, and capacity
and resources are the three linked elements of an enabling
environment for breastfeeding. In Chapter 10, Lisanne du Plessis,
Nazia Peer, Simone Honikman and René English observe that
enhancing and broadening breastfeeding interventions at all levels
of impact will contribute extensively to the achievement of the health,
food security, education, equity, development and environmental
SDG targets. To support breastfeeding through a multi-layered
approach across the various levels of government and society, the
v iii S A H R 20 1 6
authors urge for dissemination of evidence to promote a culture
of breastfeeding; political will; removal of societal and structural
barriers to breastfeeding; regulation of the breast-milk substitute
industry; interventions tailored to local needs; appropriate capacity
and resources; good-quality data; standardised messages, and
explicit guidelines.
MomConnect – a national digital maternal health program that
implements the South African mHealth Strategy and the National
Health Normative Standards Framework (HNSF) for Interoperability
in eHealth – has drawn global attention due to its innovative features
and its avoidance of many of the common pitfalls of implementing
digital health projects at scale in low-resource settings. Enrolment of
more than half a million women from all regions of the country in the
first year of operation (representing approximately half the number
PM
of pregnancies in the public health sector) has generated a national
registry of pregnant individuals and a national feedback system
to clients. In Chapter 11, Christopher Seebregts, Peter Barron,
Gaurang Tanna, Peter Benjamin and Thomas Fogwill focus on the
design and development of the technical infrastructure supporting
MomConnect, and offer evidence-based recommendations for the
future development of the MomConnect technical infrastructure and
related projects as part of the HNSF implementation; several of these
recommendations are already being investigated or developed by
the NDoH.
Chapter 12, written by Helen Malherbe, Colleen Aldous, Dave
Woods and Arnold Christianson, explores the virtually hidden
disease burden of congenital disorders (CDs) as a cause of child
mortality in South Africa. As the CD mortality rate drops, the
proportion of deaths from undiagnosed or misdiagnosed CDs is
increasing in South Africa. Inaccurate data for CDs as the cause of
death has masked the true scale of the role of CDs in child mortality
and morbidity. The authors note that the re-engineering of the
healthcare service and the NHI initiative provide opportunities for
the rebirth of medical genetic services for the prevention and care
of CDs, specifically through integration into services for women’s,
maternal and child health throughout the continuum of care in all
appropriate stages of life.
In order to improve national and global health, mental, neurological
and substance use (MNS) disorders should be integrated into health
policy and practice. Chapter 13 demonstrates that integration
of mental health into primary care in South Africa is challenging
but can be both efficient and cost-effective, and that not doing
so will result in mental health continuing to be underfunded and
marginalised. Marguerite Schneider et al. provide an overview
of existing policies and services in place for mental health care in
South Africa, describe current research on effective strategies for
providing such services, and identify key barriers and facilitators in
implementing and scaling up mental health services.
The rights and health issues of South Africa’s sex workers form
the focus of Chapter 14, authored by Andrew Scheibe, Marlise
Richter and Jo Vearey, who assert that South Africa will not reach
the United Nations Joint Programme on HIV and AIDS (UNAIDS)
90-90-90 targets unless adequate attention and political will are
invested in sensitive, appropriate and evidence-based responses
to sex worker health. The South African National AIDS Council’s
SANAC Sex Worker Programme 2016–2019 represents limited
but important progress in expanding appropriate programmes for
sex workers in South Africa, but this requires rapid implementation,
and much more is needed to reach and empower sex workers to
keep themselves safe, safeguard public health, and achieve health-
related SDGs. Delays in addressing data gaps, implementing global
recommendations on sex work law reform and a lack of evidence-
based interventions continue to impact negatively on sex worker
morbidity and mortality, and have wide-ranging implications for
public health and related expenditure.
Another aspect of public health requiring urgent attention in order for
NHI to succeed is South Africa’s extensive injury burden. Addressing
the causes and treatment of trauma requires specialist services and
multidisciplinary care. Chapter 15 presents data from numerous
studies giving insight into the options for establishing systems of
quality trauma care and accreditation programmes for hospitals. The
In Chapter 18, Varsha Bangalee and Fatima Suleman discuss South
Africa’s pharmaceutical pricing dynamics and related transparency
issues. As more countries look to South Africa for lessons from its
pricing policies, an understanding of the manufacturer’s price,
logistics fees and the relationship between the two has become
increasingly necessary to support the principle that the Single Exit
Price (SEP) – which clarifies the price at which a manufacturer may
sell a medicine to logistics service providers or medicine dispensers
– leads to more transparent prices. Their findings reveal that prices
reflected in South African medicine price registries may not be a
true reflection of those negotiated between manufacturers and
distributors/wholesalers. To guide further policy decisions, gauge
market changes in response to the various policies, and ensure
transparent pricing, more robust information is needed on medicine
pricing in the South African pharmaceutical sector, gleaned from

PM
authors, Timothy Hardcastle, George Oosthuizen, Damien Clarke
larger, in-depth pharmaco-economic evaluations.
and Elizabeth Lutge, address current and optimal staffing of trauma-
care facilities, compliance with minimum equipment standards,
Information
and the potential for patient harm, and call for the establishment

16 6
of a National Trauma Data Bank. They emphasise the need for Chapter 19 reviews the concept of health research observatories as
prevention programmes and the cost implications of trauma care, globally recognised proactive institutions that provide appropriate

20 IL
noting the cost-benefit ratio of good trauma care compared with the evidence-based information to guide policy-making decisions
litigation risk to government when such care cannot be provided. for improving a country’s health care. The chapter describes the
Y T
The last chapter in the section related to health service delivery
vision, mandate, purpose, scope and benefits of, as well as key
challenges to, South Africa’s proposed National Health Research
A N
speaks to clinical quality of care and client satisfaction. Ronelle
Observatory (NHRO). Nobelungu Mekwa et al. identify the NHRO
Burger, Shivani Ranchod, Laura Roussouw and Anja Smith propose
M U

as a comprehensive information and translation system designed to

in Chapter 16 that measuring quality of care will be strengthened
enable the national co-ordination and integration of research and
by complementing current approaches with alternatives such as
health information from the country’s multiple research platforms,
4 ED

standardised clients and vignettes, health worker knowledge tests,

driven by the National Health Research Committee’s commitment
direct observation, and gathering client feedback on the clinical
to elevating health research that is aligned with both South
dimensions of client-provider interaction. Measuring quality and its
Africa’s National Development Plan 2030 and the World Health
improvement is pivotal for the planned health-system reforms to be
O

Organization’s global interest in research for health. This synopsis

effective in promoting health, ensuring client safety and saving lives.
serves to stimulate local awareness among and participation by the
G

Continued critical reflection and debate on how best to measure

health research community and relevant stakeholders for sectoral
quality in the public sector should centre on the affordability,
adoption and support of the NHRO.
R

feasibility, reliability, credibility and relevance of current and

alternative approaches. The final chapter, presenting health and related indicators, is the
BA

long-established ballast of the Review, compiled by Candy Day and

Financing and medical products Andy Gray. Casting their statistical analyses against the backdrop
O

of the SDGs, which catalyse efforts to tackle NCDs alongside major

Chapter 17, contributed by Mark Blecher, et al., investigates
EM

communicable diseases, the authors note that although the SDGs

HIV financing in South Africa. The authors probe whether there
pose extended data and monitoring challenges, they also yield
is sufficient fiscal space to afford and sustain the expanded and
more opportunities for productive engagement between researchers
rapid roll-out of antiretroviral treatment and prevention interventions
and operational actors. This year’s Indicators chapter offers its
needed to reach the UNAIDS 90-90-90 targets in the context of
characteristically wide range of information, with a specific focus on
declining economic growth, the monetary constraints announced in
the data needed to monitor NCDs. The scope covers demographic,
Budget 2016, and diminishing donor funding. Their analysis uses
socio-economic and risk factor indicators, health services indicators
the results of the recent HIV investment case, which includes the most
(health facilities and health personnel), and health financing
recent national costing, cost-effectiveness and allocative efficiency
indicators. Health status data on mortality, disability, tuberculosis,
modelling of the epidemic, and information from recent national
HIV and AIDS, infectious diseases and malaria are reported, as
budgets. Overall, there are indications that introducing the HIV
are reproductive health statistics featuring contraception, sexual
90-90-90 targets will be hard to achieve, but that they are likely to
behaviour, sexually transmitted infections, termination of pregnancy
be affordable and cost-effective if implemented in a phased way and
and maternal health. The remaining categories are child health,
if annual increments to Government AIDS budgets are sustained.
nutrition, NCDs, injuries, risk behaviour and determinants of health.
Bearing in mind that spending more now will lead to a decrease in
total spend, the total cost of the national HIV and AIDS programme It has been said that a river cuts through a rock not because of
will increase, notwithstanding the mix of interventions chosen, its power, but because of its persistence. In the continued quest to
because of South Africa’s generalised epidemic and Government’s ensure an optimal health system for all, evolutionary interventions are
pre-existing commitment to fund lifelong ART to existing patients. needed to counteract the rapidly growing burden of NCDs together

S A H R 20 1 6 ix
with prevailing infectious diseases. The imminently devastating effects
of climate change, and the vulnerability of economically deprived
and socially unprotected members of our communities requires
innovative and decisive action. It has never been more important
to abandon vertical and fragmented approaches and to opt for
an inclusive coalition of roleplayers to address the interdependent
factors benefiting human health, the environment and the economy.

Ashnie Padarath, Judith King,

Emma-Louise Mackie and Julia Casciola

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

x S A H R 20 1 6
 EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM

1
Leadership and Governance
2
Leadership and Governance

EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Health Policy and Legislation 1

Authors:
Andy Gray i
Yousuf Vawda ii

PM
16 6
T 20 IL
he health policy and legislation arena has been dominated in 2015/2016 by Although a White Paper
the release, after much delay, of the White Paper on National Health Insurance
Y T
(NHI). Although a White Paper is expected to provide finality on a policy in is expected to provide
A N
a manner which is ready for implementation, including the development of any finality on a policy in a
necessary legislation, the NHI document leaves many questions unanswered. The
manner which is ready for
M U

need for major changes to existing legislation is signalled in the White Paper, but
few details are provided on exactly how those changes might be made. In addition implementation, including
4 ED

to changes to the National Health Act and the Medical Schemes Act, and perhaps the development of any
even the Constitution, the possibility of a new NHI Act is also flighted. Two small steps,
in the form of drafts Bills to amend the National Health Laboratory Service Act and necessary legislation, the
National Health Insurance
O

to create a new National Public Health Institute of South Africa, have been taken.
However, neither Bill has yet been tabled in Parliament.
document leaves many
G

The Medicines and Related Substances Amendment Acts of 2008 and 2015 will
questions unanswered.
R

need careful promulgation, once the necessary secondary (regulations) and tertiary
(guidelines) legislation have been developed. The new South African Health Products
BA

Regulatory Authority is not expected to come into operation before 2017, and will
have to face not only the backlog in registration applications for medicines that is the
O

legacy of the Medicines Control Council, but also complete and entrench the effective
EM

regulation of complementary medicines and medical devices.

While there have been strident calls for a fundamental redesign of the Health
Professions Council of South Africa in order to create an independent, self-regulatory
council for the medical and dental professions, it is unclear whether these calls will
be heeded.

The Medical Innovation Bill, one of the few Private Member’s Bills to be tabled, still
languishes in Parliament.

i Discipline of Pharmaceutical Sciences, Universit y of KwaZulu- Natal

ii School of Law, Universit y of KwaZulu- Natal

3
Introduction
A number of targets for reform of legislative instruments under the
control of the National Department of Health were included in the
Strategic Plan 2014/15–2018/19.1 Those listed included:
➢➢ promulgation into law of a National Health Insurance Bill by
2018/19;
➢➢ implementation of a functional National Pricing Commission to
regulate health care in the private sector by 2017;
➢➢ adjustments to the prices of original and generic medicines;
and
➢➢ regulation of all complementary and alternative medicines,
medical devices and in vitro diagnostics by 2018/19.
With the release of the White Paper on National Health Insurance
in December 2015,2 and the Presidential assent to the Medicines
and Related Substances Amendment Act (14 of 2015)3 this process
can be considered to be under way. However, as is described in
16 6
more detail below, both of these processes still face considerable
challenges and will require concerted effort if the ambitious
20 IL
deadlines are to be met. As always, the Annual Report of the
National Department of Health provides a listing of legislation which
Y T
falls under the portfolio of the Minister of Health, as well as other
legislation with which the National Department must comply.4
A N
As in 2014/2015, the pace of health legislation in Parliament has
M U
again been slow in the 2015/2016 period, with only the Medicines
Amendment Bill having been finalised. Parliament is still in the process
4 ED
of discussing the Medical Innovation Bill (Private Member’s Bill 1 of
2014), but no progress seems to have been made in this regard.5
The Medical Research Council has released a policy brief on the
O
issue of ‘medical marijuana’.6 Drawing heavily on a published meta-
analysis,7 the policy brief notes the dearth of high-quality evidence
G
for the claimed efficacy and safety of cannabinoids.
It is unclear whether the International Health Regulations Bill,
R
which was initially published for comment in 2013,8 will be tabled
BA
in Parliament. The draft Bill provides for the domestication of the
International Health Regulations (IHR) of 2005.9 However, the
O
changes brought about by the National Health Amendment Act (12
of 2013) have already ensured the transfer of Port Health services to
EM
the national sphere. The Annual Report 2014/2015 stated that this
transfer was completed by March 2015 and that 44 ports of entry
were assessed as being compliant with the IHR.
The relevance of the IHR was underlined by the World Health
Organization’s decision in February 2016 to declare the Zika
virus outbreak in South America, and its assumed association with
neurological disorders (Guillain-Barré Syndrome) and neonatal
malformations (microcephaly), as a “Public Health Emergency
of International Concern” (PHEIC).10 This is only the fourth such
declaration, with previous PHEICs being for pandemic influenza,
Ebola virus disease and poliomyelitis.
As in previous editions of the Review, this chapter focuses on
health-related legislative instruments at the national level that have
been the subject of change since the last edition was published in
2015, including secondary and tertiary legislation, in the form of
Regulations published for comment or finalised by the Minister of
Health, or Board Notices issued by statutory health councils. Any
changes to provincial health legislation or health-related municipal
4 S A H R 20 1 6
by-laws are outside of the scope of this chapter. Important health-
related jurisprudence is also described. In addition, the chapter
briefly covers major national health-related policy documents. In
2015/2016, the policy and legislation arena was dominated by
the release of the White Paper on National Health Insurance.2
National legislation related to health
National Health Act
National Health Insurance
The major event of 2015/2016 has been the release, after many
delays and announcements that a document was “imminent”, of the
PM
White Paper on National Health Insurance (NHI).2 The expectation
was that the document would provide a clear way forward, fill the
gaps identified in relation to the Green Paper,11 and in particular
include clear guidance, backed by the Treasury, on the financing
options to be exercised. The White Paper falls short of a number of
these expectations, and leaves many questions unanswered. To what
extent this is a reflection of ongoing differences of opinion between
the Department of Health and the Treasury is unclear. In the Budget
Speech delivered by the Minister of Finance on 24 February 2016,
it was announced that a document on the financing options would
be released “shortly”.12 The attainment of universal health coverage
(UHC) is a complex process, but a necessary one which has been
enshrined as one of the Sustainable Development Goals (SDGs).13
The basic premise of the NHI proposals is redress of the current
fragmentation between the public and private sectors. The ultimate
goals are those of UHC: “Population coverage under NHI will
ensure that all South Africans have access to comprehensive quality
health care services”. The cardinal features of NHI are summarised
as “universal access”, “mandatory prepayment of health care”,
“comprehensive services”, financial risk protection”, a “single
fund”, using a “strategic purchaser” and a “single payer”.
The White Paper describes a three-phase process of implementation
over a 14-year period:
➢➢ Phase 1 (five years; 2012/2013 to 2016/2017), focused on
strengthening the public health sector, but also implementing
key enablers such as the Office of Health Standards
Compliance (OHSC).
➢➢ Phase 2 (five years; 2017/2018 to 2020/2121), focused on
registration of the population and the creation of a transitional
NHI Fund to purchase non-specialist Primary Health Care
(PHC) services from “certified and accredited public and
private providers”, but also with some amendments to the
Medical Schemes Act.
➢➢ Phase 3 (four years; 2021/2022 to 2024/2025), focused
on bringing the NHI Fund into full operation as a strategic
purchaser and single payer of comprehensive health services,
including specialist services, which will require wide-ranging
legislative reforms.
The creation of the OHSC was dealt with in detail in the 2014/2015
edition of the Review.14 Importantly, the draft Regulations on the
functioning of the OHSC published for comment in February 2015
have yet to be issued in final form.15 As a result, the enforcement

policy envisaged by draft Regulation 21 has also not been issued.
Such steps are critical to ensuring that the OHSC has the necessary
powers to ensure compliance with the standards that are endorsed
or created.
From a legislative perspective, one of the key steps in the
implementation process will be the amendment of the Medical
Schemes Act (131 of 1998). The White Paper is rather vague
on the exact reforms to be implemented. The contribution of the
existing Prescribed Minimum Benefits (PMBs) to the “rising costs
of the private health sector” is acknowledged, but the problem is
also firmly located within the context of the dominance of the fee-
for-service reimbursement model in that sector. However, another
key cost driver is identified as the “uncontrolled introduction of new
healthcare technology”, which is alleged to be associated with “cost
increases without an improvement in the quality of care”. A poorly
referenced claim is made that “[s]pending through medical schemes
in South Africa is the highest in the world and is six times higher
than in OECD countries”. A later reference seems to indicate that
16 6
this refers to the percentage of expenditure on medical schemes,
claimed to be “more than 6 times the 2013 OECD average of
20 IL
6.3%”, rather than the quantum of per capita expenditure.
One of the most debated points in relation to NHI is that of the basket
Y T
of services to be covered, also referred to as the benefit package.
A N
The White Paper states that “NHI will provide a comprehensive
package of personal health services”, but also that priority-setting
M U
and progressive realisation will characterise that process: “NHI will
not cover everything for everyone”. Instead of providing details
4 ED
of the proposed benefit package, the policy document proposes
the creation of an NHI Benefits Advisory Committee to determine
“service entitlements for all levels of care”. This set of “benefits”
will be clearly linked to detailed treatment guidelines, an Essential
O
Medicines List, and an essential devices and diagnostics list, based
G
on the best available evidence and assessments of cost-effectiveness.
To do so will require the creation of a substantial health technology
R
assessment (HTA) capacity, where at present the only sustained
effort has been in relation to the public sector Standard Treatment
BA
Guidelines/Essential Medicines Lists. As described in a previous
edition of the Review, the submission of data for pharmacoeconomic
O
assessment of newly authorised medicines remains voluntary.16
EM
However, the most difficult question relates to whether medical
schemes will be restricted to offering complementary (‘top-up’) cover
for services not covered by the NHI benefit package, or will be
allowed to offer comprehensive cover for those who choose such
cover in addition to making their mandatory payments to the NHI
Fund. Although the initial impression was that only the ‘top-up’
option would be possible, this was later denied by the Minister.17
This position appears to be consistent with the statement in the policy
document to the effect that “Individuals will not be allowed opt out
of making the mandatory prepayment towards NHI, though they
may choose not to utilise the benefits covered by the NHI Fund”.
Nonetheless, the ultimate goal is that “medical schemes will offer
complementary cover to fill gaps in the universal entitlements offered
by the State”.
In order to ensure that financial risk protection is extended to those
who use the public sector, the White Paper proposes that the Uniform
Patient Fee Schedule (UPFS) in the public sector be abolished in the
early stages of the transition. In addition, it states that “a massive
reorganization of the health system would be required to create a
S A H R 20 1 6
Health Policy and Legislation
new platform for service provision and health care financing”. In
particular, the policy document proposes that legislative changes
to the “functions, responsibilities and relationships within the three
spheres of government”. This implies wide-ranging changes to the
National Health Act, and perhaps to the Constitution. However, no
specific examples are identified, nor are draft amendments provided
in the White Paper. An early intervention, which has been repeatedly
signalled but not yet implemented, is the transfer of central hospitals
to the national sphere. However, in addition, an NHI Act is planned,
which will establish the NHI Fund and its governance structure, the
NHI Commission. It is envisaged that the NHI Fund will report to the
NHI Commission on a quarterly basis and to Parliament annually.
Surprisingly, and perhaps naïvely, the White Paper states that
“[e] stablishing the Fund and the accompanying public entity will be
a straight process legislatively”.
PM
The creation of the NHI Fund requires attention to more than
just the financial flows. The White Paper identifies the need for
governance and accreditation structures, purchasing systems, risk
mitigation systems, health technology assessment, and monitoring
and evaluation systems. The basic structure will need to be in place
by the early stages of Phase 2, when the transitional Fund will need
to be able to purchase PHC services “from certified and accredited
public and private providers at non-specialist level”, and also
from Emergency Medical Services (EMS) and the National Health
Laboratory Service (NHLS).
While vague in relation to many PHC services, some detail is
provided in relation to pharmaceutical supply and laboratory
services. It is envisaged that accredited and contracted private sector
community (retail) pharmacies will be enabled to procure medicines
on nationally agreed pharmaceutical contracts (presumably tenders),
and will be paid a “capitated administration fee”. In addition to
contracting with the NHLS, it is envisaged that the NHI Fund will also
contract with “certified and accredited private laboratory service
providers”, but only “based on need”. It is suggested that volume
thresholds will be set for such providers, above which reimbursement
will be limited to the marginal cost of providing the service.
In line with the identification of fee-for-service reimbursement as a
problem, the White Paper repeatedly expresses a preference for
capitated payment options, with active risk management based on
increased access to high-quality data on utilisation and outcomes.
For example, it is envisaged that ambulatory specialist services will
be reimbursed by means of a “capped case-based fee”. To inform
such risk management systems, the e-Health strategy should be
effectively implemented without delay.
Other legislation will also have to be amended, notably addressing
the existing barriers to the establishment of multidisciplinary
practices. This is a long-standing issue, which received considerable
attention in the 2002 report of the Taylor Committee of Inquiry into
a Comprehensive Social Security System.18 The proposed National
Health Laboratory Service Bill19 and National Public Health Institute
of South Africa Bill20 can be considered to be part of the systems
strengthening activities of phase 1.
Much of the media coverage of the White Paper and the reactions
from various stakeholders have focused on the financing options
listed. Only “illustrative projections” are provided, and no clear
preference between the listed funding options (direct taxation,
indirect taxation, payroll taxation and premiums) or their
5

combinations is evident. Five scenarios are painted instead; the
first combines a surcharge on taxable income, an increase in
value-added tax (VAT) and a payroll tax. The other scenarios each
eliminate one or more of those components. It is stated that: “NHI’s
financing requirements are uncertain, and in part depend on public
health system improvements and medical scheme regulatory reforms
which have not yet been fully articulated”. This is perhaps the
clearest indication that the White Paper is not the final word on
the matter, and that the policy development process is continuing.
Consultation with various structures will be required, including the
Presidential Coordination Committee (PCC) on Intergovernmental
Relations and Fiscal Arrangements (IGFR) and the Financial and
Fiscal Commission (FFC). In order to formalise the development
process, terms of reference for National Health Insurance “work
streams” have been gazetted.21 The six work streams are:
➢➢ Prepare for the establishment of the NHI Fund;
16 6
➢➢ Design and Implementation of NHI Health Care Service
Benefits;
20 IL
➢➢ Prepare for the purchaser-provider split and accreditation of
providers;
Y T
➢➢ The role of medical schemes in an NHI environment;
A N
➢➢ Complete NHI Policy paper for public release; and
M U
➢➢ Strengthening the District Health System.
Work Stream five which relates to the finalisation of the NHI policy
4 ED
paper for public release by Government is perhaps the most telling
summary of the state of policy development related to NHI, let alone
of the design and drafting of the legislative reforms that will be
O
needed.
The debate over the White Paper on NHI also cannot be divorced
G
from the ongoing Competition Commission market inquiry into the
R
private healthcare sector, the terms of reference for which were
amended in October 2015 to revise the completion date to 15
BA
December 2016.22
O
Secondary legislation
EM
Apart from the NHI process, the issuing of secondary legislation
in terms of the National Health Act continues. In July 2015, draft
regulations for the operation of human milk banks were issued for
comment.23 It is proposed that authorisation from the Director-General
will be necessary before a human milk bank can be established, and
that a national human milk networking co-ordinating unit be created,
with provincial equivalents. Quality measures were also outlined.
Draft Regulations to cover the provision of emergency medical
services at mass gathering events (defined as those where the
expected attendance was more than 1 000 people simultaneously at
any given time) were published for comment.24 The draft Regulations
provide for the minimum staffing required for various events, based
on an extensive scoring system.
The National Health Act (61 of 2003, as amended in 2013), makes
provision for the appointment of an Ombud to the Director-General,
in terms of section 81(1). The Minister issued a call for applications
for the position in November 2015.25
6 S A H R 20 1 6
Health Professions Act
Although no draft amendment to the Health Professions Act has yet
been prepared by the Ministry or the Department of Health, there
is a widespread belief among the medical and dental profession
that fundamental change is needed. It has been reported that the
South African Medical Association (SAMA) had commenced with
the development of a “legal white paper” in 2012.26 The intention
is to provide for an autonomous self-regulatory body for the medical
and dental professions, separate from those for the other health
professions currently regulated by the Health Professions Council
of South Africa (HPCSA). A newly appointed HPCSA is in the
process of reacting to the findings of a Ministerial task team into the
functioning of the Council and its secretariat.
Despite these seismic events, the Minister and HPCSA continue to
PM
issue subordinate legislation in the form of Regulations and Rules.
These included an exception to the process of registration as a
specialist in family medicine,27 draft regulations creating a list of
new sub-specialities in medicine (allergology, forensic psychiatry,
geriatric psychiatry and neuropsychiatry),28 and draft regulations
defining the scope of the profession of oral hygiene.29
The last of these was not contested, as was a previous Regulation
issued in 2005, which created the profession of dental assistants.30
Although a period of 10 years was allowed before this provision
became effective, many dental assistants remained unregistered in
2015, with predictions of major disruptions to service provision.31 A
rejection of a Court challenge to the regulations by the South African
Dental Association (SADA) was upheld by the Supreme Court of
Appeal in November 2015.32
In this case, SADA’s appeal in the Supreme Court of Appeal sought
to set aside Regulations made by the Minister, purportedly in
terms of the Health Professions Act. The appeal devolved on this
exercise of the Minister’s power. The affected dental assistants,
through the Dental Assistants Association of South Africa (DAASA),
argued that statutory professional recognition would result in the
recognition of the value of their work, protection in the workplace,
and higher-quality service due to the mandatory training required.
SADA challenged the Regulations on the basis of administrative law
principles, arguing firstly, that the Minister was not empowered to
make the Regulations, secondly, that the Minister paid no heed to
their representations, and thirdly that the decision was ultimately
irrational due to the fact that of all the dental assistants in the country,
only a portion met the requirements outlined in the Regulations.
After reviewing various sections of the Health Professions Act, the
Court rejected SADA’s contention that the Act made no provision
for opening a new register for any profession. The Court rejected
this contention as anomalous, in that the Act would be rendered
unworkable and no new health profession would be able to be
established. Further, the Court held that regulation cannot occur and
compliance cannot be ensured until and unless the scope of the
profession has been defined. On SADA’s contention that the Minister
ignored its representations regarding potential unemployment as
well as dentists and dental assistants being faced with criminal
prosecutions, the Court found that the Minister and the HPCSA had
been fully aware of these two risks, as adequate provision was
made in the requirements set for the qualification, as well as in the
Act. The Court noted that the dentists’ interests were now nationally
advanced within the HPCSA, and therefore rejected the notion that

SADA’s representations had fallen on deaf ears. Additionally, the
Court noted that the actions taken by the Minister and the HPCSA
were in line with global trends related to the regulation of health-
related professions. Finally, SADA attracted the opprobrium of the
majority of the Court for its conduct towards dental assistants which
were described as “condescending, patronising, disingenuous”. The
Court thus issued an order, unusual in constitutional litigation, that
SADA pay the costs of the respondents. The decision is significant
in that the members of DAASA, comprising predominantly black
female dental assistants, now enjoy statutory recognition which will,
among other benefits, provide them with a measure of protection in
the workplace. The case also has a wider import in that the ability
of statutory health councils to create new registers, for example
for newly-designated mid-level health cadres, has been confirmed.
However, despite this very clear signal from the Court, subsequent
media coverage has indicated that the HPCSA may well be
reconsidering the deadline for registration of dental assistants.33 The
HPCSA has just made a statement, but no change to the Regulation
16 6
has been made.
20 IL
Nursing Act
In the period under review, no new legislative instruments were issued
Y T
in terms of the Nursing Act. The existing, and most unsatisfactory
arrangement, whereby nurses are issued with permits in terms of
A N
section 56(6) in order to be able to prescribe medicines, remains in
M U
place, without updated regulations.
Pharmacy Act
4 ED
The process of updating the Good Pharmacy Practice (GPP)
standards continues. Although final versions of the draft GPP
standards published in February 2015 have yet to be issued, the
O
Registrar of the Pharmacy Council announced in February 2016 that
G
the ban on the sale of HIV self-tests by pharmacists had been lifted
in May 2015.34 Updated GPP standards will also have to take into
R
account the outcome of the Medirite challenge, which was finally
decided in March 2015.35
BA
As was pointed out in the previous edition of the Review, pharmacies
O
are among the few health facilities that require the equivalent of a
‘certificate of need’ before they can be opened, moved or altered.12
EM
The publication of proposed criteria for the issuing of licences for
pharmacy premises in February 2014 was heavily contested.36 A
subsequent draft set of guidelines was published by the Minister of
Health in November 2015.37 In addition to setting new proposed
criteria, the guidelines included recognition of the specific
requirements of pharmacies which offer only a limited service, such
as the conduct of clinical trials, the supply of veterinary medicines
or the compounding of oncology products. Such pharmacies would
be exempted from the requirements for meeting the norms for
establishing new pharmacy premises. The proposed norms were
for at least one community pharmacy per sub-district, with a usual
ratio of one pharmacy per 5 000 population and one per 2 500
population in rural sub-districts. In rural sub-districts, exceptions
could be considered if the proposed pharmacy is more than 20km
from an existing pharmacy. Normally, new pharmacies should not
be located closer than 500m from an existing pharmacy, except in
rural sub-districts. A short comment period (45 days) was provided
for, but no final guideline has yet been published.
S A H R 20 1 6
Health Policy and Legislation
This guideline would seem to ignore a number of circumstances
that can lead to increased demand for services. For instance, the
population using a shopping mall may be drawn from an area
far wider than a sub-district, especially in a metropolitan area or
other large city, and therefore support more than one pharmacy. In
private hospitals, a separate community and institutional pharmacy
may be present, in part driven by the presence of a large number of
prescribers’ consulting rooms. In such settings, the 500m proximity
rule would seem to be unjustified. In the absence of an implementable
‘certificate of need’ as contemplated in the National Health Act,
the imposition of strict ‘need’ criteria for one category of health
professionals appears to be arbitrary and possibly discriminatory.
Allied Health Professions Act
PM
The Allied Health Professions Council of South Africa (AHPCSA)
issued a final Code of Ethics in December 2015.38 This document
exposes one of the contradictions that exist between the Allied
Health Professions Act and the Medicines and Related Substances
Act. Even though complementary medicines are currently defined
in the Regulations to the Medicines Act as being those associated
with one of the allied health professions regulated by the AHPCSA,
section 22A of the Medicines Act only allows a practitioner
(someone registered as such in terms of the Allied Health Professions
Act) to prescribe substances listed specifically for that purpose in
the Schedules. No such lists exist. Practitioners can only dispense
if they hold a section 22C(1)(a) dispensing licence. However, as
pointed out in the Code of Ethics, section 2 of the Allied Health
Professions Act states that a practitioner (as opposed to a therapist)
may prescribe or dispense medicines.
The AHPCSA has also issued a large number of policy documents,
outlining the criteria for registration of persons who obtained
qualifications outside of South Africa (with two of these, Board
Notices 146 and 148 issued and then replaced by later versions,
Board Notices 176 and 177 of 2015).39–47 In addition, it
prescribed the professional titles and designations to be used,48
amended the Continuing Education requirements for practitioners
and therapists,49 and set the composition of inquiring bodies for
disciplinary procedures for the Professional Board: Homeopathy,
Naturopathy and Phytotherapy.50
However, the most important statement made by the AHPCSA in
2015 relates to the concept of homeopathic ‘vaccines’. Noting the
standard meaning of the term ‘vaccine’,a the AHPCSA resolved that
“no homeopathic substance should be termed or purported to be
a homeopathic ‘vaccine’”.51 For a homeopath to do so would thus
constitute unprofessional conduct.
Medical Schemes Act
No finality has yet been reached in relation to the challenge to
Regulation 8, which governs the application of the prescribed
minimum benefits (PMBs), by Genesis Medical Scheme (Western
Cape High Court Case No. 15268/14). Nor has finality been
reached in relation to the draft set of amendments to Regulation 8
which were published for comment in July 2015.52 However, in
a The definition relied upon is as follows: “Vaccines are biological
preparations of antigenic materials that are believed to develop adaptive-
immunity in recipients of the vaccine to a specific disease, are typically
manufactured from attenuated or inert antigenic materials and are
administered in either a prophylactic or therapeutic conventional medical
approach against disease”.
7
March 2016, the Constitutional Court dismissed Genesis Medical
Scheme’s application to appeal a 2015 judgment by the Supreme
Court of Appeal to the effect that medical schemes could only direct
patients to public sector hospitals for treatment of PMB conditions if
they had a designated service provider contract in place with the
relevant public health authorities.53,54
In September 2015, the Council for Medical Schemes (CMS)
released guidelines for low-cost benefit options (LCBOs), which would
enable a scheme to apply for exemption in terms of section 8(h) of
the Act.55 In terms of these guidelines, LCBOs would be allowed
greater flexibility in terms of the requirements for open enrolment,
PMB coverage and/or broker remuneration. However, in October
2015, this draft guideline was withdrawn by the CMS.56 Although
the CMS indicated that it would publish a revised guideline, no date
for such publication was set, and no such draft guidelines have yet
been published. As outlined above, the implementation of NHI will
require extensive review of the Medical Schemes Act, the details of
which are as yet unclear.
16 6
Medicines and Related Substances Act
20 IL
Planning for SAHPRA
Y T
Despite being erroneously tagged as a section 76 Bill (an ordinary
Bill affecting the provinces), the Medicines and Related Substances
A N
Amendment Act (14 of 2015) was passed by Parliament after an
extensive series of public hearings in the provinces, and assented to
M U
by the President in December 2015.3 However, the next steps are
complex. Act 14 of 2015 comes into effect as soon as the previous
4 ED
Medicines and Related Substances Amendment Act (72 of 2008)
is promulgated. It is unclear how this provision (section 27 of the
Amendment Act) will operate if, as is expected, Act 72 of 2008
O
is brought into effect in phases. Most critically, the promulgation
should be co-ordinated with the development of extensive new
G
regulations and guidelines. In addition, the creation of SAHPRA will
require careful attention to labour law issues as staff are transferred
R
from the National Department of Health to the new Authority, and to
the appropriate financing and initial capitalisation of the structure.
BA
Together, Acts 72 of 2008 and 14 of 2015 will replace the existing
O
Medicines Control Council (MCC) with a new South African Health
EM
Products Regulatory Authority (SAHPRA). Despite the use of the term
“health product” in the title of the new Authority, Act 14 of 2014
reverses the introduction of the term “product” by Act 72 of 2008,
returning to the terms “medicines, Scheduled substances, medical
devices or IVDs” (in vitro diagnostic devices). Whereas Act 72 of
2008 provided for minimal governance structures, Act 14 of 2015
provides for a Board of the Authority, comprising not more than 15
persons appointed by the Minister of Health. The Minister will also
appoint the chairperson and vice-chairperson. The competencies
of Board members combine the managerial and the technical: no
more than 10 persons shall have expertise in the fields of medicine,
medical devices, IVD, pharmacovigilance, cosmetics and foodstuffs
regulation, clinical trials, good manufacturing practice, public health
or epidemiology; one shall have knowledge of the law; one shall
have knowledge of good governance; one shall have knowledge
of financial matters and accounting; one shall have knowledge of
information technology; and one person shall have knowledge of
human resource management.
8 S A H R 20 1 6
A confusing element is introduced by section 2(c) of Act 14 of 2015.
This section of the Amendment Act introduces a new section 2(5)
to the substantive Act, as follows: “The Authority acts through its
Board”. At the level of governance, this is clear. However the basic
premise of the shift from the MCC to SAHPRA is that decision-making
power in relation to the regulation of medicines and medical devices
is to be vested in the Authority (comprising full-time employed staff),
rather than in the Council (comprised of external experts). Section
2H of Act 14 of 2015 enables the Board to “appoint one or more
committees from among its members to assist it with the performance
of its functions”. It would therefore seem unlikely that these committees
would be sufficiently broad in composition and scope to provide the
staff of SAHPRA with technical advice on regulatory applications
(such as applications for registration), in the same way that the
expert committees of the MCC do now. A new section 3(9) of the Act
PM
therefore enables the Chief Executive Officer of SAHPRA (who will
replace the Registrar of Medicines) to appoint “committees, as he or
she may deem necessary, to investigate and report to the Authority
on any matter within its purview”. One of the sections that has not
been amended by either the 2008 or the 2015 Amendment Acts is
that related to “secrecy”. Instead, SAHPRA will need to ensure the
maximal degree of transparency, and in particular ensure that the
technical advice provided by expert committees is made available
to the public, and can be contrasted with the decisions eventually
taken by the staff, as delegated by the Chief Executive Officer. It is
exactly this ability to hold SAHPRA accountable that will foster the
development of trust in its regulatory decisions, in the eyes of the
public, health professionals and the pharmaceutical and medical
device industries. Very carefully drafted regulations and guidelines
will be needed before such processes can be implemented. Another
urgent need is for final regulations in respect of medical devices,
taking into account the comments elicited in April 2014.57
As expected, the final wording of the 2015 Amendment Act
entrenched the role of the Pricing Committee in advising the Minister
on matters relating to pricing policy, notably in section 18A of the
Medicines Act. While the regular updates to the single exit price58,59
and the dispensing fee for pharmacists60 have been issued, no
progress has been made with finalising the list of “prohibited
acts” referred to in section 18A of the Act, which was published
for comment in August 2014.61 The draft included an extensive list
of “incentive schemes” that would be considered to be discounts
or rebates, including such “hidden” equivalents as “unacceptable
marketing fees or co-marketing fees”, “formulary listing payments”,
“loyalty fees”, or “shelf space fees”. In addition, final regulations
dealing with the methods for international benchmarking of
medicines prices have not been issued yet.62
As was covered in detail in the previous issues of the Review,
the process to bring complementary medicines under effective
regulatory control has been slow and highly contested. In particular,
the proposed changes to the definition of a complementary
medicine, published for comment in September 2014, have yet to
finalised.63 The new definition would introduce the concept of a
‘health supplement’, which would not be a product in line with one
of the complementary disciplines regulated by the AHPCSA.
South Africa is a major port of entry for goods intended for distribution
across the continent. However, at times, products are also received
which are intended for the local market, and which do not meet the

applicable standards. In August 2015, the MCC used section 23 of
the Medicines Act to declare a list of topical preparations containing
corticosteroids as undesirable.64–66 The products were imported into
the country and were purportedly manufactured in India, Indonesia
and Italy.
African harmonisation
In February 2016, the media carried this news:
Africa has taken a major step in accelerating access to the
needed safe, efficacious and quality medicines for the treatment
of priority diseases by adopting the African Union Model Law
on Medical Product Regulation. The Summit of Heads of State
and Government of the African Union that convened in Addis
Ababa, Ethiopia from 30 to 31 January 2016 adopted the
Model Law in recognition of the need to promote and protect
the public health of Africa’s citizens.67
The Model Law is designed as an enabling framework, intended to
16 6
assist countries which have no or inadequate regulatory frameworks
for the approval of medical products (defined as medicines,
20 IL
vaccines, diagnostics and medical devices). A 2010 World Health
Organization (WHO) study of 26 sub-Saharan countries found that,
while most of them had legal provisions for the most essential aspects
Y T
of medicines control, their regulatory systems presented some critical
A N
weaknesses (fragmentation of responsibilities; many gaps and grey
areas; a multitude of provisions which were difficult to implement; little
M U
power and autonomy; oversight over a limited range of regulatory
functions with little accountability or managerial commitment; lack
4 ED
of sustainable funding; staff shortages and regulatory requirements
and processes not in line with recommended WHO standards).68
The Model Law is intended to serve as a reference guide in the
O
review and development of national legislation that will enable the
Member States to undertake their obligation to protect the health
G
of their people and, especially, to contribute to building stronger
regulatory systems to tackle the proliferation of substandard medical
R
products on the continent which poses a major public health threat.
BA
In addition, the Model Law is expected to facilitate harmonisation
of regulation of medical products by Member States through their
O
Regional Economic Communities (RECs) with the support of the
EM
African Medicines Regulatory Harmonization (AMRH) Programme.
Through the programme, RECs are harmonising medicines
regulations and facilitating work-sharing among countries for faster,
quality, predictable and transparent approval of medical products in
African countries. The ultimate goal is to facilitate faster access to life
saving medical products.63
Traditional Health Practitioners Act
Progress in relation to the effective operation of the Traditional
Health Practitioners Council has been slow. A necessary step was
taken in November 2015, with the publication for comment of draft
Regulations in terms of the Traditional Health Practitioners Act (22
of 2007) into operation.69 Given the nature of traditional health
practice and the training of practitioners, some of the proposed
Regulations seem ill-suited, and reliant on mechanisms of control
that are more appropriate to more formalised settings. For example,
while a minimum level of education for a student practitioner in the
categories divination, herbalism, traditional birth attendant practice
S A H R 20 1 6
Health Policy and Legislation
and traditional surgeon (circumcision) practice is set at ABET Level
1, equivalent to a school Grade 3, the Regulations require that the
tutor or institution be “registered and accredited by the Council to
provide the training or course”. The specified durations of training
are as follows:
➢➢ divination – 12 months (to include diagnosis, preparation of
herbs and traditional circumcision);
➢➢ herbalism – 12 months (to include the identification and
preparation of herbs, sustainable collection of herbs and
traditional consultation);
➢➢ traditional birth attendant practice – 12 months (to include
issues of conception, pregnancy, delivery of the baby, and
pre- and post-natal care); and
PM
➢➢ traditional surgeon (circumcision) practice – five years
(including observation of three initiation schools and
supervised practice for two years).
In addition, it is stipulated that a student practitioner in divination
or herbalism must be at least 18 years of age, and a student
practitioner in traditional birth attendant practice or traditional
surgeon (circumcision) practice must be at least 25 years of age at
registration in order to practise.
The application form for “trainers” requires submission of “copies
of teaching/learning materials”, which seems to anticipate the
availability of such materials. Whether that is practical in this setting
remains to be seen. At times the draft regulations can only be
described as skeletal, stating, for instance, that “Council may take
disciplinary measures to any contravention of the Regulations”.
Draft legislation
Two draft Bills that provide important building blocks for health
systems strengthening have been published for comment, but have
not yet tabled in Parliament.70
National Health Laboratory Service Amendment Bill
The National Health Laboratory Service Amendment Bill has as its
primary objectives:
➢➢ to amend the National Health Laboratory Service Act, 2000,
so as to define certain expressions and to delete a definition;
➢➢ to make the Preferential Procurement Policy Framework Act,
2000, applicable to the National Health Laboratory Service;
➢➢ to adjust the objects and duties of the Service; and
➢➢ to strengthen the governance and funding mechanism of the
National Health Laboratory Service.18
The proposed amendments are routine in nature, except for two
issues. Apart from a reference to the Preferential Procurement Policy
Framework in the proposed amendment to section 3, no other
funding mechanism is spelt out for the National Health Laboratory
Service (NHLS). As regards governance, the Board and executive
positions indicated in the Act are to be appointed and accountable
to the Minister (section 9), placing control of this Service firmly in the
hands of the Minister. This is somewhat of a departure from other
governance mechanisms, such as the proposed SAHPRA Board.
9
National Public Health Institute of South Africa Bill
The National Public Health Institute of South Africa Bill has as its
primary objectives:
“to provide for the establishment of the National Public Health
Institute of South Africa in order to conduct disease and injury
surveillance and to provide specialised public health services,
public health interventions, training and research directed
towards the major health challenges affecting the population
of the Republic.19
The intent is therefore to separate the routine services of the NHLS
from its research activities and devolve them on the new structure,
the National Public Health Institute of South Africa (NAPHISA). The
governance structure consists of a semi-autonomous Board, not
dissimilar to that envisaged for SAHPRA in terms of the Medicines
and Related Substances Amendment Act (14 of 2015).
Among the submissions made in response to the notice for comment
16 6
are that, the Bill should adopt an unequivocally public health focus
and approach; an integrated risk factor surveillance strategy, should
20 IL
ensure greater co-ordination between reference laboratories and
referral services, and the intellectual property rights acquired by
NAPHISA should not be used to shore up commercial monopoly.71
Y T
A N
Health-related policy
M U
This chapter does not attempt to track the implementation of all
existing health-related policies, even at a national level. However,
4 ED
it does draw attention to major policy documents released by the
National Department of Health in the period under review. All
health policy should be considered for coherence with the demands
O
of the Constitution, existing White Papers, and also the National
Development Plan (NDP).72 The NDP sets broad goals, such as to
G
“[p]rovide affordable access to quality health care while promoting
health and wellbeing”, but also some clear specific directives, such
R
as to “[p]hase in national health insurance, with a focus on upgrading
public health facilities, producing more health professionals and
BA
reducing the relative cost of private health care”. It is clear that these
concerns are directly addressed by the recently released White
O
Paper on National Health Insurance, but that implementation still
EM
poses considerable challenges.
Antimicrobial Resistance National Strategy Framework
2014—2024
Global attention is being paid to the problem of antimicrobial
resistance, and South Africa has responded with the elaboration of
the Antimicrobial Resistance National Strategy Framework 2014–
2024.73 The implementation plan for the strategy has called for a
comprehensive review of the Fertilizers, Farm Feeds, Agricultural
Remedies and Stock Remedies Act (36 of 1947), improved
regulation of the use of antimicrobials for animal growth promotion
and prevention of diseases in animal husbandry, alignment of the
use of antimicrobials in food production with international norms
and standards, with prescribed timelines for removing antimicrobials
used in agriculture, changes to the scope of practice of some para-
veterinary professionals relating to prescribing privileges, and the
imposition of requirements for annual reporting of antimicrobial use
by means of both Act 36 of 1947 and the Medicines and Related
Substances Act (101 of 1965).74 This will require close liaison with
10 S A H R 20 1 6
and co-operation from the Department of Agriculture, Forestry and
Fisheries (DAFF). The National Department of Health has issued a
call for nominations to the National Ministerial Advisory Committee
(MAC) on Antimicrobial Resistance, which will be tasked with
working not only with DAFF, but also with the Departments of Trade
and Industry, Science and Technology, Basic Education, Higher
Education and Training, Water and Sanitation, Mining, Justice,
Correctional Services, and Transport. The MAC will be tasked with
a daunting range of interventions, including:
➢➢ institutionalisation of effective systems of antimicrobial
stewardship (AMS) at national, provincial, and institutional
levels in both the public and private sectors using the ‘one
health’ approach;
➢➢ structured national surveillance and reporting systems for
PM
antimicrobial use and resistance in the human health and
agriculture sectors for the detection of newly emerged
resistance;
➢➢ the selection of antimicrobial agents on the Essential Medicine
List (EML) based on trends and patterns of resistance;
➢➢ progress towards achieving compliance with the standards
within the National Core Standards in all health establishments;
➢➢ the phased rationalisation or elimination of the use of
antimicrobials in agriculture or as growth promoters in food
animals;
➢➢ prevention strategies focusing on infection prevention and
control and enhanced vaccination programmes;
➢➢ core curricula on antimicrobial resistance (AMR) for health and
veterinary professionals;
➢➢ national community advocacy, awareness and education
campaigns to reduce inappropriate use of antimicrobials in
humans and animals;
➢➢ the development of rapid and point-of-care diagnostics; and
➢➢ research into molecular mechanisms of resistance, and
dissemination of information on resistance, new medicines
and diagnostics.
At least some of these interventions will require regulatory action,
rather than reliance on educational or managerial interventions.
National Adolescent Sexual and Reproductive Health and
Rights Framework Strategy 2014—2019
The aim of the Department of Social Development’s (DSD’s)
Framework Strategy is to improve the health prospects and well-
being of the current and future adolescent generation of South
Africa, by investing in their sexual and reproductive health.
Among the threats necessitating such a strategy, as identified by the
Department’s research, are: increased levels of sexual activity, high
levels of substance use, increased maternal mortality, poor quality of
antenatal care provided to young mothers, and increased levels of
HIV and AIDS and sexually transmitted infections. The obstacles that
hamper progress were found to be, among others, the lack of sexuality
education, non-involvement of males, reluctance to acknowledge
adolescents’ sexual curiosity, homophobia, and gender-based
violence. The research also recommended strengthening current
initiatives, sexuality and reproductive education, and the greater
involvement of young males and the broader community.
 Health Policy and Legislation

The strategy is grounded in a human rights approach, and focuses

on five priorities in achieving its aims. These are: increasing co-
ordination, collaboration, information and knowledge-sharing on
adolescent sexual and reproductive health and rights; developing
innovative approaches; strengthening service delivery and support
on various health concerns; creating effective community supportive
networks for adolescents; and formulating evidence-based revisions
of legislation, policies, strategies and guidelines on adolescent
sexual and reproductive health and rights.

While there are some welcome approaches, such as the need

to develop a comprehensive sexuality education curriculum and
implementation framework for the country, aspects of the framework
appear to take a conservative approach, as evidenced in its dated
definitions of core concepts such as gender and sexual orientation,

PM
often conflating distinct types of relationships. It also does not
sufficiently address the critical need for and role of psychological
services in adolescent sexuality. As with all government policy and
strategies, implementation will be key.

16 6
20 IL
Conclusion
For a number of years, successive editions of the Review have
Y T
recorded that, yet again, the much-anticipated White Paper on
National Health Insurance had not been issued. This year, the
A N
publication of this seminal policy document can be recorded, but so
M U

can the sense that much remains unsettled and far from final. Some of
the critical systems strengthening steps, such as the operationalisation
of the independent Office of Health Standards Compliance, are far
4 ED

from complete. Even when the necessary enabling legislation is in

place, as in the case of the South African Health Products Regulatory
Authority, the process of bringing that legislation into operation is
O

complex, and subject to delay and challenge. Previous issues of the

Review have reflected on the Department of Trade and Industry’s
G

Draft Intellectual Property Policy of 2013, because of the impact

of intellectual property rights on medicines pricing and access.
R

Progress on this policy has been, at best, glacial. There is still much
BA

to be done.
O
EM

S A H R 20 1 6 11
References
1 South African National Department of Health. Strategic Plan
2014/15–2018/19.
URL: http://www.health-e.org.za/wp-content/
uploads/2014/08/SA-DoH-Strategic-Plan-2014-to-2019.pdf
2 Minister of Health. White Paper on National Health Insurance.
Government Notice No. 1230, Government Gazette No.
39506, 11 December 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39506_
gon1230.pdf
3 Republic of South Africa. Medicines and Related Substances
Amendment Act (14 of 2015). Published for general
information as Government Notice No. 19, Government
Gazette No. 39585, 8 January 2016.
URL: http://www.gov.za/sites/www.gov.za/files/39585_
Act14of2015MedicinesRelatedSub.pdf
4 South African National Department of Health. Annual Report
2014/2015. Pretoria, October 2015.
URL: http://www.gov.za/sites/www.gov.za/files/
health%20_annual_report2015.pdf
16 6
5 Mr MGR Oriani-Ambrosini (IFP). Medical Innovation Bill
(PMB1-2014).
20 IL
URL: http://pmg-assets.s3-website-eu-west-1.amazonaws.
com/pmb1-2014.pdf
Y T
6 South African Medical Research Council. Policy brief:
Cannabinoids for medicinal use. January 2016.
A N
URL: http://www.mrc.ac.za/policybriefs/Cannabinoids.pdf
7 Whiting, PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S,
M U
Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S,
Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for
medical use: a systematic review and meta-analysis. JAMA
4 ED
2015; 313(24): 2456–2473.
8 Minister of Health. International Health Regulations Bill, 2013.
General Notice No. 1020, Government Gazette No. 36931,
O
14 October 2013.
URL: http://www.gov.za/sites/www.gov.za/files/36931_
G
gen1020.pdf
9 World Health Organization. The International Health
R
Regulations (2005). IHR Brief No. 1.
URL: http://www.who.int/ihr/publications/ihrbrief1en.pdf
BA
10 World Health Organization. WHO statement on the first
meeting of the International Health Regulations (2005)
O
(IHR 2005) Emergency Committee on Zika virus and
observed increase in neurological disorders and neonatal
EM
malformations. 1 February 2016.
URL: http://www.who.int/mediacentre/news/
statements/2016/1st-emergency-committee-zika/en/
11 South African National Department of Health. National Health
Insurance in South Africa. Policy Paper. 12 August 2011.
URL: http://www.gov.za/sites/www.gov.za/files/
nationalhealthinsurance_2.pdf
12 Minister of Finance. Budget Speech 2016. Delivered in the
National Assembly on 24 February 2016.
URL: http://www.gov.za/speeches/minister-pravin-gordhan-
2016-budget-speech-24-feb-2016-0000
13 United Nations. Sustainable Development Goals. Adopted
by the United Nations Sustainable Development Summit, 25
September 2015.
URL: http://www.undp.org/content/undp/en/home/
sdgoverview/post-2015-development-agenda.html
14 Gray A, Vawda Y. Health policy and legislation. In: Padarath
A, King J, English R (editors). South African Health Review
2014/2015. Durban: Health Systems Trust; 2015.
URL: http://www.hst.org.za/sites/default/files/1_Health_
Policy_Legislation.pdf
12 S A H R 20 1 6
15 Minister of Health. Procedural regulations pertaining to the
functioning of the Office of Health Standards Compliance
and its Board. Government Notice No. R.110, Government
Gazette No. 38486, 18 February 2015.
URL: http://www.gov.za/sites/www.gov.za/files/38486_
r10367_gon110.pdf
16 Gray A, Vawda Y. Health policy and legislation. In:
Padarath A, English R (editors). South African Health Review
2013/2014. Health Systems Trust, Durban, 2014.
URL: http://www.hst.org.za/sites/default/files/Health_
Policy_Legislation.pdf
17 Kahn T. Motsoaledi does not want NHI to limit choices.
BDLive, 1 February 2016.
URL: http://www.bdlive.co.za/national/
health/2016/02/01/motsoaledi-does-not-want-nhi-to-limit-
PM
choices
18 Taylor V. Transforming the Present – Protecting the Future:
Report of the Committee of Inquiry into a Comprehensive
System of Social Security for South Africa (Taylor Report).
Pretoria: Government of the Republic of South Africa; 2002.
19 Minister of Health. National Health Laboratory Service
Amendment Bill. Government Notice No. 1093, Government
Gazette No. 39392, 11 November 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39392_
gon1093.pdf
20 Minister of Health. National Public Health Institute of South
Africa Bill. Government Notice No. 1092, Government
Gazette No. 39392, 11 November 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39392_
gon1092.pdf
21 Minister of Health. National Health Act: National Health
Insurance Work Streams: Terms of Reference. Government
Notice No. 1231, Government Gazette No. 39507, 11
December 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39507_
gon1231.pdf
22 Competition Commission South Africa. Terms of reference
for Market Inquiry: Private Healthcare Sector: Amendment.
Government Notice No. 978, Government Gazette No.
39299, 16 October 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39299_
gon978.pdf
23 Minister of Health. National Health Act: Regulations relating
to human milk banks. Government Notice No. R.577,
Government Gazette No. 38954, 3 July 2015.
URL: http://www.gov.za/sites/www.gov.za/files/38945_
rg10462_gon577.pdf
24 Minister of Health. National Health Act: Regulations relating
to emergency medical services at mass gathering events.
Government Notice No.1023, Government Gazette No.
39337, 29 October 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39337_
gon1023.pdf
25 Minister of Health. National Health Act: Invitation to all
suitable persons to submit their applications for appointment
as Ombud in terms of section 81(1) of the National Health
Act, as amended. Government Notice No.1169, Government
Gazette No. 39450, 25 November 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39450_
gon1169.pdf
26 Bateman C. Long-awaited autonomy in sight for SA’s doctors.
S Afr Med J. 2016;106(1):7–8.

27 Health Professions Council of South Africa. Registration of
specialists in family medicine. Board Notice 230 of 2015,
Government gazette No. 39299, 16 October 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39299_
bn230.pdf
28 Minister of Health. Health Professions Act: Regulations
relating to the specialities and subspecialities in medicine
and dentistry: Amendment. Government Notice No. 992,
Government Gazette No. 39304, 20 October 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39304_
gon992.pdf
29 Minister of Health. Health Professions Act: Regulations
defining scope of profession of oral hygiene. Government
Notice No. 1171, Government Gazette No. 39453, 26
November 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39453_
gon1171.pdf
30 Minister of Health. Health Professions Act: Regulations:
Qualifications for registration of dental assistants. Government
Notice No. 793, Government Gazette No. 27464, 15
April 2005, corrected by Government Notice No. 338,
16 6
Government Gazette No. 27868, 12 August 2005.
URL: http://www.gov.za/sites/www.gov.za/files/27464d_0.
20 IL
pdf and http://www.gov.za/sites/www.gov.za/
files/27868a.pdf
31 Child K. New drill for assistants an ache for dental industry.
Y T
BDLive, 9 February 2016.
URL: http://www.bdlive.co.za/national/
A N
health/2016/02/09/new-drill-for-assistants-an-ache-for-dental-
industry
M U
32 South African Dental Association NPC v Minister of Health
and others [2016] JOL 34748 (SCA).
4 ED
33 Lopez Gonzalez L. Reprieve expected for dental assistants.
Health-e, 1 March 2016.
URL: http://www.health-e.org.za/2016/03/01/reprieve-
expected-for-dental-hygienists/
O
34 Lopez Gonzalez L, Polao K, Warby V. Home HIV testing gets
G
the green light. Health-e, 8 February 2016.
URL: http://www.health-e.org.za/2016/02/08/home-hiv-
testing-gets-the-green-light/
R
35 Medirite v South African Pharmacy Council [2015] ZASCA
BA
N
27.
36 Minister of Health. Proposed criteria for the issuing of licences
O
for pharmacy premises. Government Notice No. R.151,
Government Gazette No. 37399, 28 February 2014.
EM
URL: http://www.gov.za/sites/www.gov.za/files/37399_
rg10141_gon151.pdf
37 Minister of Health. Pharmacy Act: Guidelines for issuing of
licences for pharmacy premises. Government Notice No.
1065, Government Gazette No. 39376, 6 November 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39376_
gon1065s.pdf
38 Allied Health Professions Council of South Africa. Code of
ethics. Board Notice No. 268, Government Gazette No.
39531, 18 December 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39531_
bn268.pdf
39 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Ayurveda. Board Notice 144 of 2015,
Government Gazette No. 39074, 7 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn144.pdf
S A H R 20 1 6
Health Policy and Legislation
40 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Osteopathy. Board Notice 146 of 2015,
Government Gazette No. 39074, 7 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn146.pdf
41 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Chinese medicine and acupuncture,
acupuncture and Unani-Tibb. Board Notice 147 of 2015,
Government Gazette No. 39074, 7 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn147_0.pdf
42 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Chiropractic. Board Notice 148 of
2015, Government Gazette No. 39074, 7 August 2015.
PM
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn148.pdf
43 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Therapeutic aromatherapy, therapeutic
massage therapy and therapeutic reflexology. Board Notice
149 of 2015, Government Gazette No. 39074, 7 August
2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn149.pdf
44 Allied Health Professions Council of South Africa. Policy
on criteria for registration of persons with qualifications
obtained outside South Africa: Homeopathy, naturopathy
and phytotherapy. Board Notice 150 of 2015, Government
Gazette No. 39074, 7 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn150.pdf
45 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Therapeutic aromatherapy, therapeutic
massage therapy and therapeutic reflexology. Board Notice
175 of 2015, Government Gazette No. 39143, 28 August
2015.
URL: http://www.gov.za/sites/www.gov.za/files/39143_
bn175.pdf
46 Allied Health Professions Council of South Africa. Policy on
criteria for registration of persons with qualifications obtained
outside South Africa: Chiropractic. Board Notice 176 of
2015, Government Gazette No. 39143, 28 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39143_
bn176.pdf
47 Health Professions Council of South Africa. Policy on criteria
for registration of persons with qualifications obtained outside
South Africa: Osteopathy. Board Notice 176 of 2015,
Government Gazette No. 39143, 28 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39143_
bn177.pdf
48 Allied Health Professions Council of South Africa.
Unprofessional conduct: Use of professional titles and
designations. Board Notice 138 of 2015, Government
Gazette No. 39220, 18 September 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39220_
bn138.pdf
49 Allied Health Professions Council of South Africa.
Requirements for continuing professional development:
Correction. Board Notice 178 of 2015, Government Gazette
No. 39143, 28 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39143_
bn178.pdf
13
50 Allied Health Professions Council of South Africa. Professional
Board for Homeopathy, Naturopathy and Phytotherapy:
Unprofessional conduct: Composition of inquiring body. Board
Notice 189 of 2015, Government Gazette No. 39243, 2
October 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39243_
bn189.pdf
51 Allied Health Professions Council of South Africa.
Unprofessional conduct: Concept of homeopathic ‘vaccines’
within the philosophy of homeopathy or homeopathic
methodology. Board Notice 145 of 2015, Government
Gazette No. 39074, 7 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39074_
bn145.pdf
52 Minister of Health. Amendment of General Regulations made
in terms of the Medical Schemes Act, 1998. Government
Notice No. 603, Government Gazette No. 38990, 14 July
2015.
URL: http://www.gov.za/sites/www.gov.za/files/38990_
gon603.pdf
53 Kahn T. Benefits decision a boon for medical scheme
16 6
members. Business Day, 1 March 2016.
URL: http://www.bdlive.co.za/national/
20 IL
health/2016/03/01/benefits-decision-a-boon-for-medical-
scheme-members
54 The Council for Medical Schemes v Genesis Medical Scheme
Y T
(20518/14) [2015] ZASCA 161 (16 November 2015).
URL: http://www.justice.gov.za/sca/judgments/sca_2015/
A N
sca2015-161.pdf
M U
55 Council for Medical Schemes. Circular 54 of 2015: Low cost
benefit options (LCBOs) framework and principles approved
as well as guidelines for preparation of a business plan
4 ED
pursuant to an application for exemption to register a LCBO.
3 September 2015.
URL: http://www.medicalschemes.com/files/Circulars/
Circular54Of2015.pdf
O
56 Kahn T. Low-cost medical schemes delayed. BDLive 16
October 2015.
G
URL: http://www.bdlive.co.za/business/
healthcare/2015/10/16/low-cost-medical-schemes-delayed
R
57 Minister of Health. General regulations relating to medical
devices and in vitro diagnostic medical devices (IVDs).
BA
Government Notice No. R.315, Government Gazette No.
37579, 22 April 2014.
O
URL: http://www.gov.za/sites/www.gov.za/files/37579_
rg10180_gon315.pdf
EM
58 Minister of Health. Medicines and Related Substances Act:
Regulations: Transparent pricing system for medicines and
scheduled substances: Annual adjustment of single exit
price of medicines and scheduled substances for 2016.
Government Notice No. 24, Government Gazette No.
39594, 13 January 2016.
URL: http://www.gov.za/sites/www.gov.za/files/39594_
gon24.pdf
59 Director-general of Health. Medicines and Related Substances
Act: Regulations: Transparent pricing system: Information to
be furnished by manufacturers and importers of medicines
and scheduled substances when applying for single exit
price adjustment for 2016. Government Notice No. 25,
Government Gazette No. 39594, 13 January 2016
URL http://www.gov.za/sites/www.gov.za/files/39594_
gon25.pdf
14 S A H R 20 1 6
60 Minister of Health. Medicines and Related Substances Act:
Regulations: Transparent pricing system for medicines and
scheduled substances: Dispensing fee for pharmacists.
Government Notice No. 153, Government Gazette No.
39658, 5 February 2016.
URL: http://www.gov.za/sites/www.gov.za/files/39658_
gon153.pdf
61 Minister of Health. General regulations relating to bonusing
and sampling. Government Notice No. R.642, Government
Gazette No. 37936, 22 August 2014.
URL: http://www.gov.za/sites/www.gov.za/files/37936_
rg10251_gon642.pdf
62 Minister of Health. Regulations relating to a transparent
pricing system for medicines and scheduled substances:
(benchmark methodology). Government Notice No. R.324,
Government Gazette No. 37625, 12 May 2014.
URL: http://www.gov.za/sites/www.gov.za/files/37625_
PM
rg10189_gon354.pdf
63 Minister of Health. General Regulations made in terms of
the Medicines and Related Substances Act 101 of 1965:
amendment. Government Notice No. R.716, Government
Gazette No. 37995, 15 September 2014.
URL: http://www.gov.za/sites/www.gov.za/files/37995_
rg10267_gon716.pdf
64 Registrar of Medicines. Medicines and Related Substance
Act: Undesirable medicines. Government Notice No. 734,
Government Gazette No. 39114, 19 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39114_
gon734.pdf
65 Registrar of Medicines. Medicines and Related Substance
Act: Undesirable medicines. Government Notice No. 735,
Government Gazette No. 39114, 19 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39114_
gon735.pdf
66 Registrar of Medicines. Medicines and Related Substance
Act: Undesirable medicines. Government Notice No. 739,
Government Gazette No. 39121, 20 August 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39121_
gon739.pdf
67 PharmaAfrica. African Union Heads of State make a major
policy decision to improve medicines regulation. 1 February
2016.
URL: http://www.pharmaafrica.com/african-union-heads-
of-state-make-a-major-policy-decision-to-improve-medicines-
regulation/
68 World Health Organization. Assessment of medicines
regulatory systems in sub-Saharan African countries. Geneva:
World Health Organization, 2010.
URL: http://apps.who.int/medicinedocs/documents/
s17577en/s17577en.pdf
69 Minister of Health. Traditional Health Practitioners Act:
Regulations. Government Notice No. 1052, Government
Gazette No. 39358, 3 November 2015.
URL: http://www.gov.za/sites/www.gov.za/files/39358_
gon1052.pdf
70 Minister of Health. National Public Health Institute of South
Africa Bill, 2015 and National Health Laboratory Services
Amendment Bill, 2015: Correction notice. Government Notice
No. 1125, Government Gazette No. 39414, 13 November
2015.
URL: http://www.gov.za/sites/www.gov.za/files/39414_
gon1125.pdf
71 Médecins Sans Frontières. Submission on the National
Public Health Institute of South Africa Bill, 2015. On file with
authors.
 Health Policy and Legislation

72 National Planning Commission. National Development Plan

2030. Executive Summary, 2012.
URL: http://www.gov.za/sites/www.gov.za/files/
Executive%20Summary-NDP%202030%20-%20Our%20
future%20-%20make%20it%20work.pdf
73 South African National Department of Health. Antimicrobial
Resistance National Strategy Framework 2014–2024.
Pretoria 2015.
URL: http://www.health.gov.za/index.php/component/
phocadownload/category/199-antimicrobial-
resistance?download=679:a5-antimicrobial-resistance-
national-strategy-framework-2014-2024-final
74 South African National Department of Health. Implementation
Plan for the Antimicrobial Resistance Strategy Framework in
South Africa: 2014–2019. Pretoria: National Department of
Health; 2015.
URL: http://www.health.gov.za/index.php/component/

PM
phocadownload/category/199-antimicrobial-resistance?d
ownload=1175:implementation-plan-for-the-antimicrobial-
resistance-strategy-framework-in-south-africa-2014-
2019National

16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 15
16
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Analysing the progress and fault lines of
health sector transformation in South Africa
2

Author:
Laetitia Rispel i

PM
16 6
S 20 IL
outh Africa has implemented a number of policies that focus explicitly on A primary health care
equity and that seek to provide redress to those most affected by previous
Y T
apartheid policies. Examples include the adoption of a primary health care approach was adopted,
A N
approach, which in itself is a social justice philosophy, and the use of a combination which in itself is a social
of legislative, policy and resource allocation levers to achieve transformation and to
justice philosophy, and a
M U

improve population health.

combination of legislative,
This chapter explores the disconnections between progressive and far-reaching
4 ED

health policies in South Africa and the fault lines in implementation. Notwithstanding policy and resource-
the progress made since 1994, the chapter presents a critical analysis of and reasons allocation measures have
for the relatively poor performance of the South African health system compared with
been used to achieve
O

other countries of similar income level, and in light of the country’s quantum of health
care spending. transformation and improve
G

Three fault lines are identified: tolerance of ineptitude as well as leadership, population health.
R

management and governance failures; lack of a fully functional district health system,
which is the main vehicle for the delivery of primary health care; and inability or
BA

failure to deal decisively with the health workforce crisis.

O

These fault lines have negative consequences for patients, health professionals
EM

and policy implementation. Patients, who are relatively powerless, bear the brunt
through negative experiences and sub-optimal care. Health care providers on the
front line and at the bottom of the hierarchy also suffer. Faced with an unsupportive
management environment, staff shortages and health system deficiencies, they find it
difficult to uphold their professional code of ethics and provide good quality of care.

The chapter concludes with a call for the metaphorical ‘repair of the fault lines’ to
ensure the success of the proposed national health insurance system.

Centre for Health Policy, School of Public Health, Facult y of Health Sciences, Universit y of the Wit watersrand, Johannesburg

17
Introduction
South Africa is a profoundly better place than it was before 1994,1
with significant progress recorded in the health sector.2 Set against
the backdrop of the 1997 White Paper for the Transformation
of the Health System,3 the first wave of transformation saw the
development of an enabling policy and legal framework for the
complete overhaul of the health care system, the establishment of
an integrated national public health system from 14 fragmented,
racialised or Bantustan ‘health’ departments, and the removal
of racial barriers in access to health care.4 Free health care for
pregnant women and children was implemented within the first 100
days of the late President Mandela’s inauguration to demonstrate the
new government’s commitment to service delivery.
Huge health and health care inequalities remain between the public
and private health sectors, between urban and rural areas, among
the nine provinces, and even within provinces.4,10,12,13 Three
seminal documents: the national development plan13 (NDP); a 20-
Year Review by the Presidency;4 and the 2015 White Paper on the
proposed National Health Insurance (NHI)14 acknowledged that we
should be doing much better.
This chapter provides an analytical perspective on the fault lines in
South Africa’s revolutionary health policies in praxis and their failure
to realise fully both the promise and intentions of a transformative,
high-performing health system. These fault lines are explored
in the next section of the chapter. The concluding section makes
recommendations on what needs to be done about the fault lines

On paper, primary health care (PHC) delivered through the district
health system (DHS) became the cornerstone of health care policy.4
The 2003 National Health Act formalised the legal status of the
DHS, which is the vehicle for PHC service delivery.5 Free PHC
PM
to ensure the success of the proposed NHI system. The chapter
draws on health systems research conducted over more than two
decades, with methodologies ranging from reflective diaries and

16 6
services and the clinic-building programme played a big role in ethnographic research to large-scale surveys.15
removing access barriers to basic health care. This is illustrated by

20 IL
an increase in visits to PHC facilities from 67 million in 1998 to 129
Fault lines in health sector transformation
million by the end of March 2013,4 and near doubling of total PHC
expenditure per capita in real terms.6 Y T There are three major fault lines in health sector transformation,
shown in Box 1.
A N
Similar encouraging developments have been recorded in the
implementation of priority health programmes, such as the expanded
Box 1: Fault lines in health sector transformation
M U

immunisation programme, with the country on target to be declared

polio-free by 2018.4,7 Notwithstanding the AIDS denialism that ❖❖ Tolerance of ineptitude and leadership, management and governance
4 ED

characterised the second term of democratic governance, South failures

Africa now has around three million HIV-positive individuals on ❖❖ Lack of a fully functional district health system, which is the main
antiretroviral treatment,4 the largest HIV treatment programme in vehicle for the delivery of primary health care (PHC)
the world. The successful programme to prevent mother-to-child HIV
O

❖❖ Inability or failure to deal decisively with the health workforce crisis

transmission has seen a reduction in perinatal HIV transmission rates
to 2.7%, as opposed to an estimated 30% transmission rate prior to
G

Although the fault lines overlap, the following section describes

any intervention.4 them individually. Arguments are supported and are illustrated with
R

These policies are revolutionary because of the explicit focus findings from research projects.
on equity and redress in order to benefit those most affected by
BA

previous apartheid policies. Primary health care, in itself a social Tolerance of ineptitude and leadership, management
and governance failures
O

justice philosophy, has been combined with legislative, policy and

resource-allocation measures to achieve transformation and improve Since assuming the health ministerial portfolio, the current Minister
EM

population health. of Health, Dr Aaron Motsoaledi has provided charismatic and

However, these policies have not been enough to turn around the
overall performance of the South African health system. Although we
spend 8.5% of our gross domestic product (GDP) on health care, or
around R332 billion in monetary terms,8 half is spent in the private
sector catering for the socio-economic elite. The remaining 84% of
the population, who carry a far greater burden of disease, depend
on the under-resourced public sector.9
Despite South Africa’s middle-income status, we have poor health
outcomes compared with other middle-income countries such as
Brazil with similar health spending as a percentage of GDP.4,10
Many of the earlier gains and improvements have been compromised
by an ineffective national response to the country’s quadruple
disease burden, which refers to four groups of health conditions:
communicable diseases (especially HIV and AIDS and tuberculosis);
non-communicable diseases (also called chronic diseases, e.g. high
blood pressure and diabetes); maternal, neonatal and child deaths;
and deaths from injuries and violence.10,11
energetic leadership, raising the profile of key health issues and
ensuring relatively widespread support for health sector reforms
among a range of stakeholders.7 There are also many committed,
competent, hard-working health service managers and health
professionals contributing to change and doing an excellent job in
implementing transformative health policies.16
However, a less-talked about problem is the crisis of ineffective
management, incompetence and failure of leadership and govern-
ance at all levels of the health system, exacerbated by a general
lack of accountability.16
In 2009, an analysis of the underlying factors behind the overspend-
ing in provincial health departments pointed to serious management
flaws and leadership gaps, particularly with regard to the health
department’s core business of service delivery and the quality of
such service delivery.16 Fragmented health service planning, often
unrelated to financial and human resource requirements; inadequate

18 S A H R 20 1 6

health programme linkages, co-ordination and integration both
within the national health department, and between national and
provincial health departments; and 10 de facto health departments
rather than one strong national health system, mitigated optimal
performance of the health system.16 Four years later, both the
National Development Plan13 and the 20-Year review by the
Presidency have indicated that many of these problems remain.4
In one of the first studies to explore corruption in the South
African health sector,17 trends in irregular expenditure (defined
as expenditure incurred without complying with applicable laws
and regulations), was used as one of the indirect measures of
corruption.18 Although irregular or unprocedural spending does not
always result in personal gain, corruption – of necessity – involves
irregular or unprocedural activities.19
The study found that over the four-year period from the financial year
2009/10 to 2012/13, around R24 billion of combined provincial
health expenditure was classified as irregular by the Auditor-General
16 6
of South Africa.17 In the 2012/13 financial year alone, irregular
spending amounted to around 6% of combined provincial health
20 IL
expenditure in South Africa.17 There were also varying and erratic
expenditure patterns in the nine provinces. The reality is that we do
not know how much of the irregular expenditure is due to corruption,
Y T
because of difficulties with direct measures or validated indicators
A N
to measure corruption. We can only postulate different scenarios:
a worst-case scenario where R24 billion was lost due to corruption
M U
over a four-year period, or the best-case scenario where R24 billion
was lost due to ineptitude or incompetence of public servants and
4 ED
inefficient management systems; the consequences of either of these
scenarios are equally disastrous for the public health sector, and the
people whom serves.
O
The study also found suboptimal audit outcomes for the nine
provincial health departments, as shown in Table 1.17,18
G
Table 1: Provincial and national Department of Health audit
R
outcomes, 2008/09–2012/13
BA
08/09 09/10 10/11 11/12 12/13
Western Cape
O
Eastern Cape
EM
Northern Cape
KwaZulu-Natal
Free State
North West
Gauteng
Mpumalanga
Limpopo
National Department
Key: Unqualified Qualified Adverse or disclaimer
Source: Auditor-General of South Africa, 2014.18
More importantly, the findings on irregular spending and audit
outcomes underscore the fault lines in leadership, management
and governance, namely: difficulty managing a ‘federal’ health
system; institutional characteristics of provincial administrations
(which includes the legacy of overcoming practices and the culture
of Bantustan administrations); lack of enforcement of existing
legislation (rather than inherent legislative short-comings); capacity
constraints and different skill levels across provinces; and the
S A H R 20 1 6
Health sector transformation
inappropriate selection and appointment of officials in various
provincial administrations.17
There are other examples of leadership and governance failures.
The latter can also be seen in the failure to implement key reforms.
For example, health professional education reforms are widely seen
as an important strategy to improve the functioning of the health
system because these reforms enhance the performance of the health
workforce.20–24 In South Africa, as elsewhere, nurses make up the
majority of healthcare providers. The development of proposals to
reform the education and training of nurses took more than 10 years
to complete and the Regulations were eventually promulgated in
2013.24
Recent policy studies on these education reforms 24,25 have found
ineffective governance on the part of both the South African Nursing
PM
Council and the National Department of Health (NDoH), and
significant weaknesses in the policy-making and implementation
capacity of these institutions.24 Once again, the Nursing Council
has postponed implementation of the new nursing qualifications
framework until 2018.25 Despite the existence of a detailed plan
on nursing education, training and practice for the period 2012–
2017,26 the NDoH has established yet another task team (with
external consultants) to develop proposals for nursing education and
training. Hence implementation of the actual education reforms and
recommendations is unlikely to happen soon.
Sadly, the Nursing Council is not the only important governance body
that is in disarray – a Ministerial investigation into the effectiveness
of the Health Professions Council of South Africa (HPCSA) found
inter alia that there was evidence of administrative irregularities,
mismanagement and poor governance.27 The task team concluded
that:
The HPCSA is in a state of multi-system organisational dysfunction
which is resulting in the failure of the organisation to deliver
effectively and efficiently on its primary objects and functions in
terms of the Health Professions Act 56 of 1974.27
The Council for Medical Schemes, a statutory body to regulate
Medical Schemes in South Africa, has been without a permanent
registrar (chief executive officer) for more than a year. The Registrar
is responsible for the execution or implementation of the legislative
mandate of the Council, and the management of all resources,
including its staff. The Council provides oversight of a massive and
very important industry with a total annual contribution flow of
around R130 billion.28 In light of the 2015 White Paper on NHI,
the optimal functioning of the Council for Medical Schemes cannot
be overemphasised.
Lack of a fully functional district health system
Although there has been progress, 22 years into democracy, we still
do not have a fully functional DHS.a A functional DHS is expected
to ensure the delivery of quality, equitable PHC services,29 improve
health outcomes for all South Africans30 (but especially those worst
off), address the social determinants of health, involve communities,
and change the power relations between the centre (province) and
the periphery (the district).31
a Much of this analysis is contained in a forthcoming chapter by L Rispel
and J Moorman, entitled ‘Health system decentralization in South Africa’
(in Federations and Health System Decentralization, publication date
2016/17).
19
With the introduction of democracy, a large study on the development
of norms needed for PHC services underscored the possibilities of
changing a fragmented and racially divided health system into one
based on the PHC philosophy.32 Far-reaching recommendations
were made on an essential package of PHC services, which
comprised a range of comprehensive services, including women’s
health, mental health, and rehabilitation services, provided in
an integrated fashion.32 Quality control and continuous quality
assessments were built into the proposed package, and its cost
components.32 Facility and staff requirements were closely aligned
with the PHC service package. The recommendations highlighted
the importance of establishing a functional DHS and managing
change in the health sector.32
Almost 20 years later, recent studies have highlighted several
Indeed, several positive health workforce interventions, including
a number of financial incentives, have been implemented since
1994.40 The most recent and highly publicised financial incentive,
which boosted health professional remuneration levels considerably,
was the Occupation-specific Dispensation (OSD). However, many of
the positive aspects of the OSD have been marred by implementation
flaws, and evaluations of its impact have seen mixed results.16,41,42
In theory, we have a five-year national Human Resources for Health
(HRH) Strategic Plan to address the South African health workforce
crisis.43 However, the plan lacks detail, it largely ignores lower
levels of government, and the vast human resource implications
NHI appear to be underestimated.40 The critical issue of how to
secure the right skills and the right numbers of health professionals
at different levels of the health system is not even dealt with in the

PM
constraints on achieving a fully functional DHS.33,34 These include: plan.40
policy changes on the envisaged role of local government in PHC
More importantly, implementation of the strategies contained in
service delivery, in part because of the lack of clarity on the meaning
the plan has been slow or non-existent, and the NDoH has missed
of municipal health services in the South African Constitution; lack of

16 6
many of its own deadlines listed in the plan. This is in part because
role clarity among national, provincial and local government health
of the extremely limited technical capacity at the NDoH, the over-
departments; tension and lack of trust between staff employed by

20 IL
reliance on costly external consultants, and organisational structures
provincial and local government health departments, funding and
at both national and provincial health departments that are not
capacity problems; and ineffective and inefficient management
Y T commensurate with the size and scale of the effort required to deal
systems.31
with the health workforce crisis.
A N
Moreover, the constitutional autonomy of provincial health Depart-
A critical question is whether we have a health workforce crisis in
ments creates the conditions for different interpretations of what
M U

South Africa. And if so, what is the nature of the crisis?

constitutes a DHS and the structures and mechanisms that are most
appropriate to ensure implementation.16,35 The current districts are According to the World Health Organization, South Africa has
4 ED

not functioning as decentralised authorities as originally intended;
the head of the provincial Department of Health remains the
accounting officer, and there are marked variations in financial and
human resource delegations across provinces.36 The problems are
O
higher ratios of health professionals than its minimum norms.39
We also have well-established training institutions (among the best
in the world), highly skilled health workers, effective professional
regulation, and sufficient fiscal space for relatively high remuneration

exacerbated by human resource shortages, suboptimal stewardship levels compared with many other countries.44
G

and leadership, and political contestations.11,37 Formal mechanisms

Notwithstanding these strengths, there is a workforce crisis in South
of accountability such as district councils and clinic or community
Africa that manifests in a number of different areas.
R

health centre committees are either absent or not playing a

meaningful role. In addition, district hospitals still function separately Firstly, there is a crisis of ineffective and suboptimal leadership,
BA

from and are poorly co-ordinated with PHC services in many places. management and governance, which has been described earlier.
Without the appropriate delegations, district health managers cannot
O

Secondly, there is a crisis of inequalities and maldistribution of health

make decisions. Hence, the perceived benefits of decentralisation,
workers between urban and rural areas and between the public and
EM

namely accountability to communities, improved health outcomes

and access to quality services, have not been realised.
A further layer of complexity has been added with the centralised
implementation and direct management of the pilot NHI districts38 by
the NDoH. The implementation process has challenged the authority
of the provincial health departments,7 which are responsible for
policy implementation. Although the NHI pilot district implementation
is accompanied by strong political stewardship, only time will tell
whether these reforms will result in significant decentralisation and
its intended health service benefits.
private health sectors. This maldistribution between urban and rural
areas is illustrated by examining the training output of professional
nurses (with four years of training) across the nine provinces. In
2014, the urban areas of Gauteng and the Western Cape combined
produced 1 234 professional nurses.45 In comparison, the three
rural provinces of Limpopo, North West and the Northern Cape
combined produced only 501 professional nurses.45 This urban-
rural maldistribution compromises access and coverage, particularly
for vulnerable populations, and is exacerbated by delays in the
implementation of educational reforms.

Thirdly, there is a reported staff-shortage crisis, illustrated in that

Health workforce crisis
Health workers are the personification of any health system.39 At
face value, both politicians and senior managers recognise the
importance of addressing human resources for health (also known
as the health workforce) to improve the performance of the country’s
health system.40
there were more than 100 000 public sector vacancies in 2010.46
It is also demonstrated by government spending of R1.5 billion in
the 2009/10 financial year on nursing agencies to hire temporary
agency nurses for public sector hospitals.47 Importantly, addressing
staff shortages emerged as the most important priority among
health service managers in studies conducted over the past three

20 S A H R 20 1 6
 Health sector transformation

years.48,49 Because there are no national norms and standards, it is
difficult to determine the extent and nature of staff shortages in the
public sector and in different types of health facilities.
Furthermore, moonlighting and agency nursing among nurses, and
private practice among public sector doctors, exacerbate the staff-
shortage crisis. In a 2010 study, 40.7% of the 3 700 participating
nurses reported moonlighting or working for an agency in the year
before the study.50 The reported health system consequences were
serious, with half the participating nurses reporting that they felt too
tired to work whilst on duty.51
Fourthly, we face a crisis of unprofessional behaviour, poor staff
motivation, suboptimal performance, and unacceptable attitudes of
health workers towards patients, all of which compromise quality
of patient care and health service efficiency.44 These problems are
positive change.
Addressing the leadership, management and governance failures
requires political will; meritocratic appointment of public service
managers with the right skills, competencies, ethics and value
systems; effective governance at all levels of the health system
to enforce laws; appropriate management systems; and citizen
involvement and advocacy to hold public officials accountable.17
Primary health care is at the core of revitalising and strengthening the
South African health system, as enunciated once again in the 2015
White Paper on NHI.14 However, this can only happen through
a well-functioning DHS. Hence, the NDoH must develop a clear
implementation plan for the establishment of a well-functioning DHS.
This implementation plan should include: a clear outline of the roles
and responsibilities of different levels of government; strategies for

exacerbated by a general lack of accountability, reported by health
service managers in several studies,48,49 and emphasised as an issue
that requires attention by the Presidency. The lack of accountability
is illustrated by research on moonlighting which found that 10% of
PM
strengthening management both at district level and at all facilities
within the district; a clear communication strategy to communicate
the vision of PHC and of a DHS, and to ensure buy-in from various

16 6
stakeholders and partners, as well as from the general public and
nurses took sick leave to do moonlighting when they were not sick.51 health service users; support structures with expert capacity in each

20 IL
Lastly, South Africa faces a crisis of inadequate human resource of the provinces; and clear indicators to monitor progress.34
information systems. Current information systems are fragmented This chapter has highlighted the inability or failure to deal with
Y T
and unable to inform health workforce planning and training.
There are also technical problems of data quality, coverage and
the health workforce crisis. An adequately skilled, productive and
well-motivated health workforce is a prerequisite for universal health
A N
comparability.16 Even where information is available, it is not used coverage.53 The experience in Brazil has shown that universal
to inform decision-making.
M U

health coverage reforms are more effective when careful attention is

In summary, three major fault lines explain the poor performance paid to health workforce challenges.54 In South Africa, the ultimate
success of the NHI will require immediate and effective action to
4 ED

of the South African health system: tolerance of ineptitude and

leadership, management and governance failures; lack of a fully address the critical human resource challenges facing the South
functional district health system, which is the main vehicle for the African health care system.40
delivery of PHC; and an inability to deal decisively with the health
O

The reforms envisaged by NHI provide exciting opportunities for

workforce crisis. health system change in South Africa, rarely available in most
G

These fault lines coalesce to produce a number of negative countries. The process requires the active participation of all
consequences for patients, for health professionals, and for policy stakeholders, including the Academy.
R

implementation. In the first instance, patients are relatively powerless

The new sustainable development goals55 are a sharp reminder
and bear the brunt of these fault lines in their often negative
BA

of ‘unfinished business’ with respect to the Millennium Development

experiences of the public health sector and the suboptimal quality
Goals and the unacceptable health inequalities that prevail.55
of care received.4 Similarly, health care providers on the ‘front-line’
O

Existing evidence suggests that a high-performing public health

and at the bottom of the health system hierarchy also suffer. Studies
sector is one of the most redistributive mechanisms to reduce health
EM

have illustrated that health workers find it difficult to uphold their

inequalities.56,57 Change in the status quo is therefore not optional,
professional Code of Ethics and to provide good quality of care
but a critical necessity.
in the face of an unsupportive management environment, staff
shortages and health system deficiencies.48,52 The fault lines also
have negative consequences for implementation of revolutionary
policies, and explain the large gap between these policies and their
Acknowledgements
implementation, making it difficult to achieve the desired results. This chapter is an adaptation of my inaugural address entitled:
“Revolutionary health policy in praxis: Analysing the progress
and fault lines of 21 years of health sector transformation in South
What needs to be done? Africa”, delivered on 28 September 2015. The inaugural address is
There must be a metaphorical repair of these fault lines to ensure available from: http://www.wits.ac.za
the success of the proposed NHI system. However, these fault lines
are not inevitable – South Africa is well resourced, we have a strong
foundation to build on, and there is tremendous goodwill among
many stakeholders to help in making the health system function
optimally. There is also considerable untapped potential among the
Academy in universities, many of whom are keen to contribute to

S A H R 20 1 6 21
References
1 Feinstein A. After the party: A personal and political journey
inside the ANC. Jeppestown: Jonathan Ball Publishers (Pty)
Ltd; 2007.
2 Padarath A, King J, English R, editors. South African Health
Review 2014/15. Durban: Health Systems Trust; 2015.
3 Department of Health. White Paper for the Transformation of
the Health System in South Africa, Government Gazette, #
17910. Pretoria: National Department of Health; 1997.
4 The Presidency, Republic of South Africa. Twenty year review
South Africa, 1994-2014. Pretoria: Government Printing
Works; 2014.
5 Republic of South Africa. National Health Act 61 of 2003.
Pretoria: Government Printer; 2005.
6 Day C, Barron P, Massyn N, Padarath A, English R, editors.
District Health Barometer 2010/11. Durban: Health Systems
Trust; 2011.
7 Rispel L, Moorman J. Health policy reforms and policy
16 6
implementation in South Africa: A paradox? In: Daniel J,
Naidoo P, Pillay D, Southall R, editors. New South African
Review 3: The second phase-tragedy or farce? Johannesburg:
20 IL
Wits University Press; 2013. p.239–60.
8 National Treasury. Inter-governmental Fiscal Reviews-Provincial
Y T
Budgets and Expenditure Review : 2010/11 - 2016/17.
Pretoria: National Treasury of the Republic of South Africa;
A N
2015.
9 Blecher M, Kollipara A, de Jager P, Zulu N. Health Financing.
M U
In: Padarath A, English R, editors. South African Health
Review 2011. Durban: Health Systems Trust; 2011. p.29–48.
4 ED
10 Downie R, Angelo S. Counting the Cost of South Africa’s
Health Burden. Washington, DC: Center for Strategic and
International Studies (CSIS) has; 2015.
O
11 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The
health and health system of South Africa: historical roots of
current public health challenges. Lancet 2009;374:817-34.
G
12 Statistics South Africa. Census 2011: Statistical release
R
(Revised) P0301.4. Pretoria: Statistics South Africa; 2012.
13 National Planning Commission. National Development Plan:
BA
Vision 2030. Pretoria: National Planning Commission; 2011.
14 DOH. National Health Insurance for South Africa: Towards
O
universal health coverage-Version 40. Pretoria: National
EM
Department of Health; 2015.
15 Rispel LC. Transforming Nursing Policy, Practice and
Management in South Africa. Glob Health Action. 2015;8.
[Internet]. [cited 18 April 2016].
URL: http://dx.doi.org/10.3402/gha.v8.28005
16 Integrated Support Teams. Review of health overspending and
macro-assessment of the public health system in South Africa:
Consolidated Report. Pretoria: ISTs; 2009.
17 Rispel LC, de Jager P, Fonn S. Exploring corruption in the
South African health sector. Health Pol Plan 2015;doi:
10.1093/heapol/czv047.
18 Auditor-General of South Africa. Consolidated General Report
2012 - 2013. Pretoria: Auditor-General of South Africa;
2014. [Internet]. [cited 18 April 2016].
URL: http://www.agsa.co.za/Documents/Auditreports/
PFMAgeneralreportsnational.aspx
19 Hyslop J. Political corruption: Before and after apartheid.
Journal of Southern African Studies. 2005;31:773–89.
22 S A H R 20 1 6
20 Frenk J, Chen L, Bhutta ZA, et al. Health professionals for
a new century: transforming education to strengthen health
systems in an interdependent world. Lancet. 2010;376:1923–
58.
21 Kinfu Y, Dal Poz MR, Mercer H, Evans DB. The health worker
shortage in Africa: are enough physicians and nurses being
trained? Bull World Health. 2009;87:225–30.
22 Institute of Medicine. The future of nursing: Leading change,
advancing health. Washington: The National Academies
Press; 2011.
23 World Health Organization. Transforming and scaling
up health professionals’ education and training. World
Health Organization guidelines. Geneva: World Health
Organization; 2013.
PM
24 Blaauw D, Ditlopo P, Rispel LC. Nursing education reform
in South Africa: lessons from a policy analysis study. Glob
Health Action. 2014;7:26401. [Internet]. [cited 18 April
2016].
URL: http://dx.doi.org/10.3402/gha.v7
25 Armstrong SJ, Rispel LC. Social accountability and nursing
education in South Africa. Glob Health Action. 2015;8.
[Internet]. [cited 18 April 2016].
URL: http://dx.doi.org/10.3402/gha.v8.27879.
26 South African National Department of Health. Strategic Plan
for Nursing Education, Training and Practice 2012/13–
2016/17. Pretoria: National Department of Health; 2013.
27 Mayosi BM, Adam M, Maserumule M, Matlala N, Mgijima
R, Mtukushe L. Report of the ministerial task team (MTT)
to investigate allegations of administrative irregularities,
mismanagement and poor governance at the Health
Professions Council of South Africa (HPCSA): a case of
multi-system failure. Pretoria: Ministerial Task Team on the
HPCSA; 2015.
28 Council for Medical Schemes. Annual Report 2014/15 – 15
years on the pulse. Pretoria: Council for Medical Schemes;
2015.
29 WHO. Alma-Ata 1978: Primary health care. Geneva: World
Health Organization; 1978.
30 South African National Department of Health. National
Department of Health Strategic Plan 2010/11–2012/13.
Pretoria: National Department of Health; 2010.
31 Van Rensburg HCJ, Pelser AJ. The transformation of the South
African health system. In: Van Rensburg HCJ, editor. Health
and health care in South Africa. Pretoria: Van Schaik; 2004.
32 Rispel L, Price M, Cabral J, et al. Confronting need and
affordability: Guidelines for primary health care services
in South Africa. Johannesburg: Centre for Health Policy,
University of the Witwatersrand; 1996.
33 Rispel L, Moorman J. Analysing health legislation and policy
in South Africa: context, process and progress. In: Fonn S,
Padarath A, editors. South African Health Review 2010.
Durban: Health Systems Trust; 2010.
34 Rispel LC, Moorman J, Munyewende P. Primary health care
as the foundation of the South African health system: myth or
reality? In: Meyiwa T, Nkondo M, Chitiga-Mabugu M, Sithole
M, Nyamnjoh F, editors. State of the Nation: South Africa
1994–2014: A twenty-year review. Cape Town: HSRC Press;
2014. p.378–94.
35 Van Rensburg HCJ, editor. Health and health care in South
Africa. Pretoria: Van Schaik Publishers; 2004.
 Health sector transformation

36 Naledi T, Barron P, Schneider H. Primary Health Care in
SA since 1994 and Implications of the New Vision for PHC re-
engineering. In: Padarath A, English R, editors. South African
Health Review 2011. Durban: Health Systems Trust; 2011.
37 Rispel L, Setswe G. Stewardship: Protecting the public’s health
In: Harrison S, Bhana R, Ntuli A, editors. South African Health
Review 2007. Durban: Health Systems Trust; 2007.
38 National Treasury, Republic of South Africa. Budget Review
2013. Pretoria: National Treasury; 2013.
39 World Health Organization. World Health Report 2006:
Working together for health. Geneva: World Health
Organization; 2006.
40 Rispel LC, Barron P. Valuing human resources: Key to the
success of a National Health Insurance System. Dev South Afr.
2012;29:616–35.
52 White J, Phakoe M, Rispel L. “Practice what you preach”:
Nurses’ perspectives on the Code of Ethics and Service
Pledge in five South African hospitals. Glob Health Action.
2015;8:26341. [Internet]. [cited 18 April 2016].
URL: http://dx.doi.org/10.3402/gha.v8
53 Global Health Workforce Alliance, World Health
Organization. A universal truth: No health without a
workforce. Geneva: World Health Organization; 2013
54 Couttolenc B, Dmytraczenko T. Brazil’s primary care strategy.
UNICO Studies Series 2. Washington, DC: The World Bank;
2013.
55 United Nations. Transforming our world: The 2030 Agenda
for Sustainable Development 2015. New York: United
Nations; 2015.
56 Commission on Social Determinants of Health. Closing the
gap in a health generation: Health equity through the social

41 Ditlopo P, Blaauw D, Rispel L, Thomas S, Bidwell P. Policy
implementation and financial incentives for nurses in two
South African provinces: A case study on the occupation
specific dispensation. Global Health Action. 2013;6.
PM
determinants of health. Geneva: World Health Organization;
2008.
57 Piketty T. Capital in the twenty-first century. Cambridge,
Massuchusetts: The Belknap Press of Harvard University Press;

16 6
42 Motsosi K, Rispel LC. Nurses perceptions of the 2014.
implementation of occupational specific dispensation at

20 IL
two district hospitals in Gauteng. Afri J Nurs Midwifery.
2012;14:130–44.
43 South African National Department of Health. Human
Y T
Resources for Health South Africa: HRH Strategy for the Health
Sector: 2012/13–2016/17. Pretoria: National Department
A N
of Health; 2011.
44 Van Rensburg HCJ. South Africa’s protracted struggle for
M U

equal distribution and equitable access – still not there. Hum

Resour Health. 2014;12:26. [Internet]. [cited 18 April 2016].
4 ED

URL: http://www.human-resources-health.com/
content/12/1/26
45 South African Nursing Council (SANC). SANC registration
and enrolment figures. Pretoria: South African Nursing
O

Council; 2014. [Internet]. [cited 18 April 2016].

URL: http://www.sanc.org.za
G

46 South African National Department of Health. Human

Resources for Health South Africa: HRH Strategy for the Health
R

Sector: 2012/13–2016/17. Pretoria: National Department

of Health; 2011.
BA

47 Rispel LC, Angelides G. Utilisation and costs of nursing

agencies in the South African public health sector,
O

2005–2010. Glob Health Action. 2014;7. [Ingternet]. [cited

EM

18 April 2016].
URL: http://dx.doi.org/10.3402/gha.v7.25053
48 Munyewende P, Rispel LC. Using diaries to explore the work
experiences of primary health care nursing managers in two
South African provinces. Glob Health Action. 2015;7:25323.
[Internet]. [cited 18 April 2016].
URL: http://dx.doi.org/10.3402/gha.v7
49 Armstrong SJ, Rispel LC, Penn-Kekana L. The activities
of hospital unit managers and quality of patient care in
South African hospitals: A paradox? Glob Health Action.
2015;8:26243. [Internet]. [cited 18 April 2016].
URL: http://dx.doi.org/10.3402/gha.v8
50 Rispel LC, Blaauw D, Chirwa T, de Wet K. Factors influencing
agency nursing and moonlighting among nurses in South
Africa. Glob Health Action. 2014;7. [Internet]. [cited 18 April
2016].
URL: http://dx.doi.org/10.3402/gha.v7.23585
51 Rispel LC, Blaauw D. The health system consequences of
agency nursing and moonlighting in South Africa. Glob
Health Action. 2015;8:26683. [Internet]. [cited 18 April
2016].
URL: http://dx.doi.org/10.3402/gha.v8

S A H R 20 1 6 23
24
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Water, sanitation and health: South Africa’s
remaining and existing issues
3

Author:
David Hemson i

PM
16 6
P 20 IL
ost-apartheid South Africa can lay claim to having substantially increased The water-related Sustainable
access to piped drinking water for all. Virtually all urban households and
Y T
most rural households now have access to piped drinking water, with Development Goals extend
A N
the remaining deprived communities located in more remote rural areas and the range of commitment
in urban informal settlements. While drinking water may not necessarily be safe
beyond access to basic
M U

(or consistently available) in rural communities, there has been no recurrence of

waterborne epidemics on the scale of the cholera epidemic of 2000–2001. However, water services, and include
4 ED

child under-five diarrhoea case fatality rates indicate ongoing health issues in rural improved water quality,
communities deprived of water services.
enhanced water use and
Water-related health issues are emerging due to conditions of water stress and climate
re-use and better water-
O

change. Constraints on supply call for greater water re-use and better management
of treatment plants to ensure river health and safe drinking water. The process of related ecosystems.
G

eutrophication is degrading water and habitat quality, and the results are difficult to
R

treat. With climate change, existing microbial diseases could become more prevalent
which is especially disturbing as water treatment plants are discharging insufficiently
BA

treated effluent into rivers. Contamination of groundwater and surface water from
acid mine drainage requires specialised treatment. All of these factors indicate the
O

need for improved water and health management, with greater surveillance of water
EM

quality and the delivery of universal water services to ensure health and prevent
disease outbreaks.

The water-related Sustainable Development Goals extend the range of commitment

beyond access to basic water services, and include improved water quality, enhanced
water use and re-use and better water-related ecosystems. These commitments will
demand a well-integrated approach and close public monitoring.

i Independent Consultant

25
Introduction
South Africa has made considerable progress in providing water
services, including both piped water and improved sanitation,
to those who were previously deprived of such essential services
during the apartheid era. This has resulted in significant benefits
for rural populations, which now have improved access to greater
volumes of water for domestic use, and some relief for women and
girl children who bear the burden of collecting water from distant
water sources. Although improved sanitation has not advanced to
the same extent, increased levels of coverage have been achieved.
However, certain structural weaknesses persist; a proportion of the
population either has no water services or due to uneven access
to functioning systems, remain vulnerable to waterborne disease.
In urban areas, households are disconnected when there is non-
South Africa’s post-apartheid government has set a higher standard
of service in water and sanitation than that of international monitoring
organisations. The Department of Water and Sanitation (DWS)
defines basic water supply as access to piped water, rather than to
a range of improved ‘rudimentary’ sources. The standard sets the
minimum quantity of potable or safe drinking water at 25 litres per
person per day (or six kilolitres per household per month), with flow
of 10 litres/second to a facility within 200m from the household.6
Free basic water is available at this volume of consumption, although
a rising tariff applies thereafter.
Since the quality and safety of drinking water are not directly
measured in household surveys, the government has adopted

payment, and there can be ongoing challenges in the provision of
water services to informal urban settlements. The current water crisis,
with water constraints and limited supply in some areas, raises
PM
a proxy measure, namely access to piped water, based on the
assumption that all piped water is safe. This follows the practice of
international monitoring organisations in assessing progress.7 While
national Regulations specify that water supply should be tested,6 this

16 6
questions about the overall management of water resources and appears to be applied more in urban than rural water systems.
infrastructure to ensure water quality in sufficient quantity for health,

20 IL
particularly under the demanding conditions of climate change. Access to piped water
Safe drinking water is essential to life, and water services are Levels of access to piped water have improved nationally when
Y T
crucial for personal health and hygiene. A health-sustaining living
environment depends on access to water services supported by
compared with the deprivation of the past. Analysis of the data
over time is difficult, largely because apartheid-era statistics did not
A N
resilient water ecosystems that can provide water in sufficient include sections of the black population in ‘independent’ Bantustans
M U

quantity and quality for health and the enjoyment of life.
This chapter focuses on waterborne diseases rather than water-
4 ED
as part of the national population. The baseline figures are therefore
difficult to establish and the Joint Monitoring Project (JMP) data,
which draw on South African surveys to model access data, are

washed diseases; these include diarrhoeal diseases such as cholera,

used here, although the JMP definition of improved access does not
typhoid fever and shigellosis, which can cause epidemics with high
coincide with that of basic service.8
rates of mortality. Since 88% of these diseases are associated
O

with unsafe water, inadequate sanitation or insufficient hygiene,1 Over the period 1990–2015, access to piped water and other
the focus is on access to water services. While these diseases are improved sources increased from 66% to 81% of the rural population,
G

widely understood, there is less public awareness of the transmission signifying an increase of 15%.8 Targets for universal access to water
of viruses (such as hepatitis A and E, and influenza) through services were set by the post-apartheid government: all households
R

contaminated water or inadequate hygiene.2 In addition, non- were to receive piped water by 2008 and improved sanitation by
communicable diseases are associated with harmful environmental 2010;9 these target dates were later modified to 2014.
BA

pollutants found in water that can damage health, such as pesticides,

More detailed analysis of access is available from the 2013 General
nitrates and heavy metals.3
O

Household Survey,10 which indicates that 10 896 000 households,

This chapter also discusses questions of access to and functionality of or 72.1% of the total number surveyed, access water from taps
EM

water systems and drinking water quality, with particular emphasis either with direct connections to the house or yard connections.
on conditions in rural areas, including an assessment of the 2000– Table 1 shows that a further 2 290 000 households, or 15.2% of
2001 cholera epidemic and its impact on water services, and the the total surveyed, access public standpipes. Taken together, they
incidence of diarrhoea and other water-borne diseases. The current represent the proportion of the total survey households included in
2016 water crisis is reviewed in relation to increasingly varied the defined basic standard.
weather conditions and emerging health challenges. Findings and
conclusions are drawn on the issues of public health surveillance, Table 1: Levels of access to water services and facilities
prevention and promotion, water-quality reporting, and on the
Water source Households, Percent
health impacts of environmental toxicants.
000 of national total
House connection 6 845 45.3%
Access to safe drinking water and improved sanitation Site or yard access 4 051 26.8%
Public tap 2 290 15.2%
Increased access to piped water by the majority of the population
Other 1 921 12.7%
has been described as a “remarkable achievement”4 or even
Total 15 107 100.0
“one of the greatest feats in delivering on human rights”5 of the
post-apartheid government. Improved access to piped water and Source: Statistics South Africa, 2014.10
improved sanitation mark a considerable advance in public health,
particularly for those living in rural areas. Such access does more
than reduce water-related diseases, as improved hygiene also helps
to reduce vulnerability to other infections, such as influenza.

26 S A H R 20 1 6

These data further indicate that 1 921 000 households (or 12.7%
of all households) accessed water from a range of water sources
such as wells, dams, ponds, springs, rivers and streams, all of which
represent types of sources that fall below the basic standard in South
African water regulation.
There is a constitutional right to ‘sufficient’ water in South Africa;
however, there are questions about the volume and affordability
of the water and about water access when disconnections or flow
restrictors are enforced. Although DWS Regulations specify a basic
minimum standard of 25 litres per person per day, this has been
assessed as insufficient to meet basic needs. One calculation puts
the basic water requirement at 50 litres per person per day,11 but
access at this amount is regarded as unaffordable.12
Functionality of rural water systems
Government regulations describe functionality as the continuous
supply of piped water flowing at 10 litres/second.6 However,
surveys have found uneven levels of functionality. For example,
16 6
a review of 23 rural water systems in KwaZulu-Natal Province in
20 IL
200313 found that 78% were working (as water was flowing),
which implied a high level of functioning systems. However, 56% of
these systems either did not meet the standards of basic service or
Y T
did not work at all.
A N
The shortcomings included gaps in accessibility, ineffective
operation, incomplete construction and financial exclusion (some
M U
schemes did not provide for all sections of a community), water not
flowing from some taps, and several systems that were operational
4 ED
but incomplete. At that time free basic water was unevenly available,
thus excluding those who could not afford access to piped water. As
municipal management has been comprehensively extended and
O
has benefited from changes in the government allocation of revenue,
some of these unsatisfactory features have been resolved, but there
G
is evidence that issues of functionality and water quality remain.
R
A review of the data in national surveys14 found that the shortfalls in
functionality were predominantly in rural provinces, some of which
BA
had high levels of interrupted supply.
O
In 2009/10, a high proportion of households in two rural
provinces (78% in Mpumalanga Province and 69.5% in Limpopo
EM
Province) reported interrupted supply over the previous 12 months.
Interruptions were caused mainly by burst pipes, water leaks, poor
general maintenance and insufficient water, and were not always
speedily resolved; for example, in 2010, 68% of interruptions in
Mpumalanga lasted for more than 15 days.14
Water quality in rural systems
In addition to the problem of functionality, deficiencies have been
reported in the quality of drinking water in rural water systems,15
with a proportion of plants not achieving the South African National
Standard (SANS 241) for the quality of drinking water. On its own,
access to piped water may not signify access to safe drinking water.
In 2006, uneven water quality was recorded in a study of 55
rural water treatment plants, with only 18% complying with the
recommended limits in terms of microbiological quality specified in
national water standards. The authors reported the major factors
contributing to high bacterial readings as being due to ineffective
water treatment, resulting in “high turbidity and inefficient chemical
S A H R 20 1 6
Water, sanitation and health
(coagulant and chlorine) dosing, which led to low chlorine
residuals”15 Another study of rural groundwater systems found that
the majority of those tested did not meet national water standards
and that the groundwater systems were of inferior quality compared
to surface water systems.16 A study of groundwater quality in
Mpumalanga found similar conditions and concluded that some
water tested “pose[s] a serious threat to the health of consumers”.17
Such deficiencies in the qualitative aspects of water services indicate
that reports of high levels of access may have to be moderated, as
they may not signify access to continuous service or necessarily to
safe drinking water in line with national water standards.
Sanitation
Access to improved sanitation – defined in water Regulations6 as
PM
access to a ventilated toilet facility or better – has also improved
substantially during the post-apartheid period. The most recent
data illustrate that the insanitary conditions that typified the
apartheid era, during which most of the rural population had either
inadequate or no facility, have been partially redressed. Over the
period 1990–2015, access to improved sanitation (using JMP data
including ‘privy not ventilated’) changed from 52% to 77% of the
rural population – representing an increase of 29% over the past 25
years (Table 2).
Table 2: Levels of access to sanitation, 2013
Sanitation system Number of Percent of total
Households, 000
Flush toilets 9 418 62.3%
Ventilated privy 2 296 15.2%
Privy, not ventilated 2 456 16.3%
None 937 6.2%
15 107 100.0%
Source: Statistics South Africa, 2014.10
At the time of the General Household Survey conducted by Statistics
South Africa in 2013, the two levels of access (which met or
exceeded the basic standard of sanitation) amounted to 14 170 000
households, or 77.5% of all survey households. The remaining
households either had unimproved privies (2 456 000, or 16.3%) or
none (937 000, or 6.2% of all households). While 93.8% accessed
some type of toilet facility, the 16.3% with ‘unimproved’ privies and
the 6.2% with none represent the challenge in improving sanitation,
particularly in rural areas.
Although there has been progress in the post-apartheid period,
there has also been unevenness in the delivery of water services.
South Africa has for instance met the Millennium Development
Goal (MDG) target in water delivery but not in sanitation.7 Equally,
the government’s targets of universal access to piped water and
improved sanitation by 2014 have not been met and a section of
the population continues to experience uneven quality in terms of
sanitation facilities and water services.7
Water services and waterborne disease
This section looks at the incidence of waterborne-disease outbreaks to
determine whether advances in access to piped water and improved
sanitation have resolved the issue of functionality and water quality,
and thus succeeded in eliminating outbreaks of waterborne disease.
27
The cholera epidemic of 2000–2001 and outbreaks in waterborne
disease illustrate the health risks resulting from shortfalls in achieving
a health-sustaining environment. The cholera epidemic was
unexpected, spread widely and led to 114 000 cases resulting in
260 deaths, the majority of which were in KwaZulu-Natal Province
where the outbreak originated. Despite the high incidence, there
was (using various comparative standards) a comparatively low
level of mortality, estimated at 0.31% of those infected.18
The epidemic raised questions about access, functionality and water
quality – questions that had been identified earlier in scientific
studies and national surveys. The communities at the epicentre of the
epidemic were found to have access to infrastructure but since piped
water supply was at times irregular, and metered taps excluded
households that were unable to pay a monthly fee, continuous
proportion of households deprived of water services in all district
municipalities was examined and then compared with the under-five
year diarrhoea case fatality rate.
Figure 1 shows the number of households deprived of water
services, i.e. deprived of both piped water and improved sanitation,
in the six district municipalities surveyed. The majority of the district
municipalities with lower numbers of deprived households and
lower percentages of these as a proportion of total population are
reflected in the lower left quadrant, indicating that many of the
district municipalities are approaching universal access to water
services.
The district municipalities with the greatest numbers and the highest
percentages of vulnerable households are reflected in the upper right-
hand quadrant and appear as a smaller set of scattered outliers. In

PM
access was compromised.19 Households excluded from access by
these municipalities the number of households without water services
constant interruptions and cost-recovery measures reverted to using
ranged downwards from 100 000 to 40 000 as follows (with the
traditional water sources which were often contaminated.
percentage of the total population shown in brackets): OR Tambo

16 6
The rapid spread of cholera through northern KwaZulu-Natal to the (Eastern Cape) 34%, Alfred Nzo (Eastern Cape) 33%, Amathole
Eastern Cape and beyond, highlighted gaps and weaknesses across (Eastern Cape) (25%), Greater Sekhukhune (Limpopo)(22%),

20 IL
the rural water and sanitation landscape. Expansion of the disease Ehlanzeni (Mpumulanga) 16%, and Bojanala (Limpopo) 8%.
from ‘epidemic hotbeds’ to distant areas has been attributed to
Figure 2 shows the data for the child under-five-years diarrhoea
transport of the pathogen through hydrological networks along and
Y T case fatality rate in relation to data on water services for four
upstream from coastal areas, and to the mobility of people, possibly
district municipalities. The number (rather than the proportion) of
A N
without symptoms, across catchment areas who then transmit the
households without water services was used to highlight the extent
bacteria faecally.20 While the primary route for the disease appears
M U

of deprivation in areas of concern.

to have been along catchment areas, human mobility led to more
extensive transmission across catchment areas. In both cases, While it would have been preferable to use data on the incidence
4 ED

inadequate water services may not have impeded hydrological
transport or human transmission.
The Regulations published in April 2001 requiring a defined volume
O
of severe diarrhoea, there was greater confidence in the under-five
diarrhoea case fatality rate data. However, the graph is illustrative
rather than indicative of correlation, as the under-five case fatality
rate reflects not only the level of access to water services but also the

of free basic water6 were undoubtedly influenced by the cholera

accessibility and quality of health services in the district municipality.
epidemic and have led to improved access. Further, the incidence
G

For instance, a high fatality rate could be interpreted as indicating

of water-related diseases in subsequent years has not reached the
district municipalities with (a) sanitation conditions leading to high
same scale as in the early 2000s. However, there have been at
R

levels of dehydration from severe diarrhoea among under-five-year-

least two subsequent outbreaks of waterborne disease since the
old, or (b) poor accessibility and quality of care in local hospital
BA

cholera outbreak in 2000. The first was an outbreak of diarrhoea

N

services.
and typhoid in the town of Delmas in 2005,21 when the lack of
O

well-managed water treatment, particularly chlorination, was Again, most the municipalities are reflected in the lower left quadrant
identified as a significant causative factor. The second outbreak, of the graph, indicating lower numbers of deprived households and
EM

in uKhahlamba District in 2008, involved the contamination of
drinking water with E. coli following the breakdown of the local
waste-water treatment plant; the outbreak was reported to have led
to the death of 78 infants.22
The report of such outbreaks appears episodic. While the incidence
of diarrhoea in under-five-year-olds is recorded in the District
Health Barometer,23 reporting of the specific types of waterborne
diseases appears to be dependent on whether or not there is an
outbreak. Despite the reporting of a lower occurrence of outbreaks
in recent years, analysis of the data indicates ongoing high levels of
diarrhoeal infection in vulnerable rural areas (even if these infections
do not necessarily constitute an outbreak), with incidence spreading
across geographical areas.
lower under-five case fatality rates. In contrast, municipalities with
higher numbers of deprived households are reflected in the right-
hand quadrant of the scatterplot.
The trendline illustrates the relationship between deprivation (in
the poor quality of water and health services) and disease; district
municipalities with the highest number of deprived households
are generally (but not consistently) associated with higher child
under-five-year diarrhoea case fatality rates. Municipalities with
high concentrations of households without water services (in a
downwards range from 100 000 to 40 000 and with the under-five
case fatality rates for diarrhoea in brackets) include OR Tambo (173
per 1 000), Ehlanzeni (95 per 1 000), Mopani (86 per 1 000) and
Alfred Nzo (57 per 1 000).

Since the redistributive element in the division of revenue and local

Areas of high risk for waterborne disease
Given that access to water services has improved, an attempt
was made to determine the extent to which populations are still
vulnerable to waterborne disease; in this regard, the number and
government funding prioritises funds for water and sanitation and
other essential services (including funding for free basic services), it
seems that capacity issues are associated with continuing high levels
of deprivation. Rural councils often lack human resources and local

28 S A H R 20 1 6
 Water, sanitation and health

sources of revenue, and are more dependent on intergovernmental Such models utilising data on climate, living environment and
transfers.25 They are also found to lack experienced staff and well- incidence of waterborne disease should be updated if they are to
established procedures to access and manage these funds effectively. serve as tools for contemporary analysis and disease management.
The most useful output from renewed exercises of this kind would be
Surveillance and predictive analysis the development of maps of vulnerable areas so that national and
The broad association between patterns of disease and service local government officials can visualise the most vulnerable areas
levels in water and sanitation, plus the cholera epidemic of 2000– and prioritise interventions.
2001 and the concern to prepare adequately for such outbreaks,
stimulated two studies that systematically examine risk of waterborne Water crisis, climate change and health
disease in rural populations. The 2016 water crisis, precipitated by the worst drought since
The first study was undertaken in 2000, prior to the cholera 1933, has resulted in widespread water shortages that are
epidemic, by a unit in the Department of Water and Sanitation,26 increasing stress on an already challenged infrastructure. Although
and the second study was conducted after the cholera epidemic, by South Africa’s annual rainfall is below the world average, water
an independent group of researchers.20 The first study employed a consumption is above the world average. This has resulted in a water

PM
method of weighting risk factors (such as level of access to water demand–supply gap. Population growth and greater urbanisation
services and other indicators) to identify and prioritise areas of high will increase the demand for water supply in the future and require
risk for waterborne disease. The second study developed a model that greater attention be given to improving the overall quality of
of cholera transmission from available epidemiological records readily available water supply. Demand is therefore anticipated to

16 6
and a range of demographic, service-level and mobility data. The rise over the next 20 years, while the country’s water resources are
modelling of the pathways of a cholera epidemic was tested against considered to be almost fully allocated – leading to an ongoing

20 IL
the historic data to provide a predictive planning tool. critical period in water management.27

Y T Climate change is leading to rising temperatures, particularly in the

interior of the country, and is anticipated to bring changes in rainfall
A N
Figure 1: Households without access to safe water and improved patterns and increased droughts and floods. The net effect for water
sanitation in six municipal districts of South Africa, 2012
resources is likely to be greater water scarcity resulting from longer
M U

120 000
dry seasons and increased evaporation from dams.28 While these
effects will be uneven geographically and accompanied by larger
4 ED

OR Tambo
100 000
rainfall variances, there may be greater contamination of rivers and
other water sources because of a reduced dilution effect.27 A study
Number of households

80 000
Ehlanzeni of the ecological consequences of climate change finds that water
Amathole
O

60 000 Greater Sekhukhune quality is likely to be affected by the mobilisation of pollutants such
Alfred Nzo
as metals, as well as the increased transport of dissolved pollutants,
40 000 Bojanala
G

including pathogens.29
20 000
Under these conditions, greater care and improvement in the
R

0 management of hydrological flows, waste-water treatment and

BA

0% 5% 10% 15% 20% 25% 30% 35% 40%

drinking water purification are needed to achieve and maintain
N

No water services: percentage of total households in District Municipality

resilient water systems and sustain water services. At the municipal
O

Source: Statistics South Africa, 2012.a,24

level, a persistent issue is the reduction of water loss which requires
socio-political as well as technical management.
EM

Figure 2: Access to water services, and child under-five-years There is evidence of growing public concern about the quality of
diarrhoea case fatality rate (per 1 000) in four water, and increased sensitivity to service issues. General household
municipal districts in South Africa, 2011 surveys report lower levels of satisfaction over time; for example, less
200
than two-thirds of households rated their water services as ‘good’ in
180 OR Tambo 2013.10 Deterioration in levels of satisfaction is associated with a
decline in the percentage of households that feel that their water is
Under-5 case fatality per 1 000

160

140 clean, clear, tastes good and is free of unpleasant odours.

120

100 Alfred Nzo

Ehlanzeni
Waste-water treatment and acid mine drainage
80
There are many elements in the potential deterioration of water
60 Mopani
quality including salination, eutrophication, the presence of micro-
40
pollutants, microbiological pollutants and sedimentation. Some of
20
these factors are associated with the extensive re-use of water in
0
0 20 000 40 000 60 000 80 000 100 000 120 000 South Africa through the release of waste-water effluent of uneven
Households without access to water services
quality into rivers, which has implications for river health and
downstream water treatment.
Sources: Health Systems Trust, Statistics South Africa Census 2011.a,23,24

a Personal Communication, Michael Noble, South African Social Policy

Research Institute (SASPRI), March 2016.

S A H R 20 1 6 29
There has been considerable discussion about the types of
contamination that could pose the most immediate threats to health,
particularly eutrophication, and microbial pollution from poorly
managed waste-water treatment. Turton30 has persistently raised the
question of eutrophication, which leads to the growth of blue-green
algae (cyanobacteria) and results from the presence of nutrients
existing in sewage effluent. Cyanobacteria are difficult to treat
and eliminate, and threaten the health of humans and livestock, in
addition to damaging the ecosystem. The DWS acknowledges this
threat and has a monitoring system in place28 although the planned
regular reporting does not appear to be evident.
There is also ongoing concern about the direct health impact of the
presence of microbial pathogens in the effluent from water treatment
works. A study of pond systems in rural hospitals in northern
acid mine drainage (AMD), which is the outflow of acidic water
after mines are closed and tailing dams are decommissioned. AMD
is characterised by high salinity levels, elevated concentrations of
sulphate, iron, aluminium and manganese, and raised levels of toxic
heavy metals such as cadmium, cobalt, copper, molybdenum, zinc
and radionuclides.32 Specialised treatment has been researched and
developed but not yet generally applied; it appears that much of the
AMD leaches into rivers, resulting in the dilution of contaminants.27
There is a considerable range of potential impacts associated with
AMD, including on health. For instance, high levels of uranium
have been found in surface water at the Wonderfontein Spruit33
which if consumed untreated, can have serious health implications,
in particular kidney toxicity. It appears that the health impacts of
many environmental toxicants in water are internationally known but
should be grounded in the local context.

PM
KwaZulu-Natal, for instance, found that the effluent was being
used to water crops and even, indirectly, for domestic purposes.31
Anticipated trends in water and health
The researchers concluded that they “consistently found that such
effluents were either inadequately disinfected or not disinfected at Water-related health issues resulting from climate change may be

16 6
all”. These researchers traced the existence of Vibrio cholera in raw evidenced in the worsening of existing health outcomes rather than
sewage months before the cholera outbreak in October 2000. in unexpected diseases.34 The risk of adverse health impacts can be

20 IL
expected to follow the anticipated results of climate change; changes
Municipal waste-water treatment plants are discharging effluent
in temperature and precipitation, for example, may provide more
that has not been properly treated. South Africa has 986 municipal
Y T favourable conditions for the concentration of microbial pathogens.
water-treatment facilities currently in operation, which discharge
A N
2.1km3 (or 2 100 million kl) of treated water into river systems, Reviews of likely health impacts from climate change in South Africa
although the quality is uncertain,27 and inadequate treatment is conclude that enteric (intestinal) waterborne diseases will be more
M U

responsible for the existence of high levels of faecal coliforms in likely,35 and extreme events associated with changing climate
effluent entering rivers. Drawing from the Green Drop (waste-water) conditions may precipitate outbreaks of waterborne disease. E.coli,
4 ED

monitoring reports, Turton concludes that only 26% of sewage is
adequately treated before being discharged into rivers.30 Apart
from the additional cost of water treatment downstream, high levels
of contaminants in rivers and streams pose a direct health risk to
O
types of which are pathogenic, reproduce optimally in dark, warm,
moist environments found in warmer conditions in coastal areas.
Growth of the bacterium Vibrio cholera is affected by water salinity,

water temperature and changes in rainfall patterns. Studies of the

populations potentially drawing on these surface-water sources. impact of climate change on waterborne pathogen concentrations in
G

The Green Drop monitoring programme, which reports on the surface water indicate varying results, although extreme precipitation
quality of waste-water treatment, involves a complex assessment events (which will become more prevalent) are found to increase
R

of management practices and skills as well as effluent quality such concentrations.36

microbiological compliance. The reports provide the resulting risk
BA

Whether incidence develops into an epidemic may be determined as

profile, which for reasons of simplicity is selected for reference. much by the quality of governance (which can ensure quality water
O

Municipalities in the Eastern Cape that have been previously services) as by environmental and climate factors; the evidence27 is
that good access to water services can constitute an effective barrier
EM

identified as having deficits in water and sanitation delivery often

also have a high Green Drop risk profile: for instance, OR Tambo to incidence becoming a large-scale disease outbreak.
District Municipality has a risk profile of 98.4% and Alfred Nzo
Maintaining public health under these changing conditions will
District Municipality has a risk profile of 89.8%. None of the
demand improved management of waste-water facilities, closer
municipalities had more than 50% compliance for a single treatment
surveillance of water quality, and improved interventions to ensure
plant.
that water services are accessible and affordable to all. Effective
Ehlanzeni District Municipality (Mpumalanga) has a greater range primary health care services should also ensure safe drinking water.
of risk profile scores for the five component local municipalities than
OR Tambo and Alfred Nzo Municipalities in the Eastern Cape. The Sustainable Development Goals
The Ehlanzeni risk profiles ranged from Bushbuckridge with a high
The water-related Sustainable Development Goals (SDGs) adopted
of 83.3%, to Mbombela with a low of 42.5%. In comparison to
internationally in 2015 help to focus national and local government
the Eastern Cape municipalities mentioned, Mpumalanga had a
attention on key objectives to improve integrated water resource
generally lower risk profile, with Umjindi, Mbombela and Nkomazi
management and to strengthen adaptation strategies to climate
Local Municipalities recording some plants with more than 50%
change.37 These objectives include:
compliance.
➢➢ universal access to safe drinking water and improved
Those municipalities associated with high levels of under-five sanitation;
diarrhoea case fatality rates also tend to have high risk profiles
➢➢ improved water quality and wastewater management;
for the management of waste-water treatment. Other threats of
contamination to surface and underground water are posed by ➢➢ water-use efficiency;

30 S A H R 20 1 6
 Water, sanitation and health

➢➢ integrated water resources management on a wide scale; Conclusion

➢➢ public participation of local communities; and
➢➢ interventions to reduce the impact of water-related disasters.
While none of these objectives is unfamiliar in the South African
policy landscape, as a collective, they set a higher standard than
previous individual commitments and policies, and draw attention
to the central importance of sustainable management of water
resources to maintain public health. Table 1 sets out the water-related
SDGs and the necessary policy response.
Table 3: Water-related Sustainable Development Goals and
policy adjustments required to achieve these goals
Water-related Sustainable South African Policy
The relationship between water and health has been explored in
relation to the provision of water services, which serve to protect
populations from waterborne disease. Climate change will place
demands on the resilience of water systems, demands that go well
beyond the delivery and management of basic water services. The
following points are instructive in this context.
➢➢ Ongoing deficits in rural water services. Despite government
commitment to provide universal access to water and sanitation
by 2014, a proportion of the population, particularly in the
rural areas, remains unserved and vulnerable to waterborne
disease. Substantially incomplete water services, possibly
combined with inadequate health services in identified
rural areas, have left poor rural populations with under-five

Development Goals
Target 6.1: Universal access to
safe, affordable drinking water by
2030
Target 6.2: Universal access to
Framework
Existing government targets
predate this goal and should be
reviewed
Existing government targets
PM
diarrhoea case fatality rates that are much higher than that
of populations with virtually universal access to piped water.
➢➢ Health-risk modelling is possible. The two types of mapping

adequate and equitable sanitation
and hygiene by 2030
16 6
predate this goal and should be
of the potential vulnerability of populations to water-related
reviewed
diseases demonstrate that the areas for priority intervention

Target 6.3: Improved water quality,
better pollution control and
treatment of waste water, recycling
and re-use
Target 6.4: Increase water use
20 IL
Dealt with in Department of Water
and Sanitation (DWS) Water can be identified and that the likely pathways of cholera and
Quality frameworks;38 public
other water-related diseases can be tracked. Under conditions
oversight of sanctions for polluters
Y T
and public access to Green and of climate change, which will be associated with a greater
Blue Drop reports and other number of extreme events with potential for waterborne
A N
reviews must be enabled
epidemics, priority-setting for intervention should be guided by
Municipal and DWS guidelines and
M U

efficiency and sustainable use incentives needed; referred to in greater surveillance of the epidemiological and environmental
the National Development Plan39 data.
Target 6.5: Integrated water The National Water Act (NWA) 36
4 ED

resources management including
transboundary co-operation
Target 6.6: Protect water-related
ecosystems
of 199840 provides a framework ➢➢ Climate change impacts require improved management of
but some revision may be required water services. The current water crisis shows that the supply of
Dealt with in the Environment
water in sufficient quantity and quality is a challenge to water
Conservation Act 73 of 198941 and
governance; this focuses attention on the need for improved
O

National Water Act 36 of 199840 –

some revision is required management of infrastructure and water ecosystems. The
Target 6.a: Expand international Requires participation in and
G

deteriorating quality of available water requires diligent water

co-operation contribution to African, regional
and international organisations treatment. There appear to be two main areas for improved
R

Target 6.b: Participation of
local communities in water and
sanitation management
BA
Local Government: Municipal management of river water quality, firstly poorly treated
Structures Act 117 of 1998 42
effluent from waste-water plants, and secondly contamination
lays down basic provision for

participation in local government; from acid mine drainage, both of which are reducing the
however, this should be reinforced quantity of readily available water of reasonable quality and
O

Target 11.5: Reduce impact of Partially catered for in South

complicating treatment.
water-related disasters Africa’s disaster management
EM

framework
The wide range of the SDGs will place greater demands on integrated
governance, as they go well beyond the provision of basic services
to improve the quality and accessibility of services, and include the
environmentally associated issues of water re-use and ecological
commitments. Objectives such as the protection and restoration of
water-related ecosystems will require extensive interdepartmental
co-operation and co-ordination across multiple tiers of government.
The formal approach of the SDGs is intentionally top-down, but there
are other possibilities that could encourage bottom-up approaches.
Public participation, which has been formally instituted at the local
government planning level and in other ways, will be important
in achieving water efficiency as well as environmental and other
objectives. Such focus could be the positive basis for discussion with
municipalities and be part of a wider debate about efficiency in
water use and public concern about water quality.
➢➢ Environmental toxicants transported in water are linked to non-
communicable diseases. Environmental toxicants contamina-
ting drinking water can lead to early-life exposures that can
have developmental health impacts.43 Lapses in water-quality
monitoring for such contaminants can have wide-ranging
effects on child development and adult health.
Recommendations
➢➢ Improved public health surveillance in vulnerable communities
is needed. Mapped outputs from an appropriate model would
provide the information to focus attention on vulnerable
populations particularly at the district municipality level.
This will provide early warning of outbreaks, and serve
as an important planning tool for health and water service
interventions.

S A H R 20 1 6 31
➢➢ Disease prevention and health promotion should be focused
where they are most needed. The re-engineering of primary
health care through Ward-based Outreach Teams should
lead to improved disease prevention and health promotion in
vulnerable populations without water services. Environmental
Health Practitioners trained in water-related disease prevention
should be involved to support such interventions. In key areas
of identified need, interventions to achieve disease prevention
and health promotion should be substantially improved.

➢➢ The Department of Water and Sanitation and the Department

of Health should regularly review and publicly report on the
conditions of the unserved population. Despite the previous
government commitment to achieve universal access to piped
water by 2014, substantial numbers of the unserved population

PM
still have to access potentially contaminated natural water
sources and suffer higher rates of waterborne disease. The
modelling and mapping of public health should provide
an instrument to track water system delivery and provide

16 6
appropriate health system support. These interventions,
and hospital access and treatment in district municipalities

20 IL
with high under-five diarrhoea case fatality rates should be
reviewed and reported for further action.
Y T
➢➢ Make reporting of water quality management more readily
A N
and publicly accessible. The Green and Blue Drop monitoring
and reporting systems include a well-established annual review
M U

of changes in municipal water management. Despite this,

reports may be delayed and the reporting format is complex
4 ED

for ordinary citizens to review. For this form of incentive-based

regulation to function properly, reports should be publicly
available soon after completion to facilitate critical public
review in various ways, including through public meetings,
O

particularly at local level.

G

➢➢ Further research is needed into the development and

sustainability of sanitation services. Existing systems face
R

two challenges: the best-designed pit latrines will eventually

be filled to capacity and need replacement, and existing
BA

sewage systems are drawing large volumes of quality water

during a time of water constraint. More sustainable sanitation
O

technologies should be developed.

EM

Given the existing high burden of disease in South Africa, additional

water-related negative health impacts (exacerbated by climate
change) will strain public health systems. In order for water and
sanitation to have their full health impact, there is a need for capable
management of water resources, improved rural local government,
and a well-prepared primary health care system. Such an integrated
approach should be set within a programme to end the poverty of
large sections of the population.

Acknowledgments
The data analysis utilised datasets provided by Michael Noble from
the Southern African Social Policy Research Institute (SASPRI), and
Health Systems Trust.

32 S A H R 20 1 6

References
1 Prüss-Üstün A, Bos R, Gore F, Bartram J. Safer water, better
health: costs, benefits and sustainability of interventions
to protect and promote health. Geneva: World Health
Organization; 2008. [Internet]. [cited 22 March 2016].
URL: http://apps.who.int/iris/
bitstream/10665/43840/1/9789241596435_eng.pdf
2 World Health Organization. Review of latest available
evidence on potential transmission of avian influenza (H5N1)
through water and sewage and ways to reduce the risks to
human health. Geneva: World Health Organization; 2006.
[Internet]. [cited 22 March 2016].
URL: http://www.who.int/water_sanitation_health/emerging/
h5n1background.pdf
3 Schwarzenbach RP, Egli T, Hofstetter TB, Von Gunten U,
Wehrli B. Global water pollution and human health. Annual
Review of Environment and Resources. 2010;35:109–36.
4 Office of the Presidency, Republic of South Africa. Twenty
Year Review, South Africa, 1994–2014. 2015. [Internet].
[cited 22 March 2016].
16 6
URL: http://www.20yearsoffreedom.org.za/20YearReview.
5 South African National Department of Water Affairs and
20 IL
Forestry. A history of the first decade of Water Services
delivery in South Africa: 1994 to 2004. [Internet]. [cited 22
March 2016].
Y T
URL: https://www.dwa.gov.za/documents/Publications/
firstdecade.pdf
A N
6 South African National Department of Water Affairs and
M U
Forestry. Regulations relating to compulsory national
standards and measures to conserve water. 20 April 2001.
7 United Nations Children’s Fund/World Health Organization
4 ED
(UNICEF/WHO). Progress on Sanitation and Drinking Water
– 2015 update and MDG assessment. Geneva: WHO Press;
2015. p.43. [Internet]. [cited 25 March 2016].
URL:http://www.unicef.org/publications/files/Progress_on_
O
Sanitation_and_Drinking_Water_2015_Update_.pdf
G
8 Joint Monitoring Programme of the World Health
Organization and United Nations Children’s Fund. South
Africa: Estimates on the use of water sources and sanitation
R
facilities. June 2015. [Internet]. [cited 25 March 2016].
URL:http://www.wssinfo.org/documents/?tx_
BA
displaycontroller[type]=country_files&tx_
displaycontroller[search_word]=South%20Africa
O
9 Mbeki T. Address of the President of South Africa, Thabo
EM
Mbeki, at the Second Joint sitting of the third Democratic
Parliament, Cape Town, 11 February 2005. [Internet]. [cited
25 March 2016].
URL: http://www.sahistory.org.za/archive/2005-president-
mbeki-state-nation-address-11-february-2005
10 Statistics South Africa. General Household Survey 2013.
Statistical release P0318. Pretoria: Statistics South Africa;
2014.
11 Gleick PH. Basic water requirements for human activities:
Meeting basic needs. Water Int. 1996;21(2):83–92.
12 Bond P, Dugard J. Water, human rights and social conflict:
South African experiences. Law, Social Justice & Global
Development. 2008;1:1–21. [Internet]. [cited 22 March
2016].
URL: http://ccs.ukzn.ac.za/files/Bond%20Dugard%20LGD.
pdf
13 Hemson D. The sustainability of water projects in KwaZulu-
Natal. Parliamentary briefing, 23 September 2003.
S A H R 20 1 6
Water, sanitation and health
14 Statistics SA. Water and sanitation 2002–2010, GHS Series
Volume III. In-depth analysis of the General Household Survey
data. Report No. 03–18–02 (2002–2010). 2011. [Internet].
[cited 25 March 2016].
URL:http://www.statssa.gov.za/publications/
Report-03-18-02/Report-03-18-022010.pdf
15 Momba MNB, Tyafa Z, Makala N, Brouckaert BM, Obi
CL. Safe drinking water still a dream in rural areas of South
Africa – Case study: The Eastern Cape Province. Water SA.
2006;32(5):715–20.
16 Mackintosh G, Colvin N. Failure of rural schemes in South
Africa to provide potable water. Environmental Geology.
2003;44(1):101–5.
17 Mpenyana-Monyatsi L, Onyango MS, Momba MNB.
Groundwater Quality in a South African Rural Community:
PM
A Possible Threat to Public Health. Pol J Environ Stud.
2012;21(5):1349–58.
18 Hemson D, Dube B. Water services and public health: the
2000–01 cholera outbreak in KwaZulu-Natal, South Africa.
8th World Congress on Environmental Health, 22–27
February 2004, Durban, South Africa.
19 Cottle E, Deedat H. The Cholera Outbreak: A 2000–2002
case study of the source of the outbreak in the Madlebe Tribal
Authority areas, uThungulu Region, KwaZulu-Natal. Durban:
Health Systems Trust; 2002.
20 Mari L, Bertuzzo E, Righetto L, et al. Modelling cholera
epidemics: the role of waterways, human mobility and
sanitation. J R Soc Interface. 2012;9(67):376–88.
21 Momba MNB, Obi CL, Thompson P. Survey of disinfection
efficiency of small drinking water treatment plants: Challenges
facing small water treatment plants in South Africa. Water SA.
2009;35(4):485–93.
22 Lake L, Reynolds L. Addressing the social determinants of
health. In: Kibel M, Lake L, Pendlebury S, Smith C, editors.
The South African Child Health Gauge 2009/10. Cape
Town: Children’s Institute, University of Cape Town, 2010.
[Internet]. [22 March 2016].
URL: http://www.ci.org.za/depts/ci/pubs/pdf/general/
gauge2009-10/south_african_child_gauge_09-10.pdf
23 Health Systems Trust. Diarrhoea incidence under-5 years (per
1 000).[Internet]. [cited 3 April 2016].
URL: http://indicators.hst.org.za/healthstats/132/data
24 Statistics South Africa. Census 2011. Statistical release
P0301.4. Pretoria: Statistics South Africa; 2012.
25 Public Finance for WASH. Finance Brief 05. South Africa’s
Equitable Share Formula: a useful model for WASH
financing? August 2015. [Internet]. [cited 25 March 2016].
URL: http://www.publicfinanceforwash.com/sites/default/
files/uploads/Finance_Brief_5_-_South_Africa_Equitable_
Share_model.pdf
26 South African National Department of Water Affairs and
Sanitation. National Microbial Water Quality Monitoring
Programme. A First Report: On the Identification and
Prioritisation of Areas in South Africa with a Potentially High
Health Risk Due to Faecally Polluted Surface Water. Report
No: N /0000/00/RE/Q/4399, August 2000.
27 Hedden S, Cilliers J. Parched prospects: The emerging water
crisis in South Africa. African Futures Paper 11. Pretoria:
Institute for Security Studies; 2014. [Internet]. [cited 9 January
2016].
URL: https://www.issafrica.org/uploads/AF11_15Sep2014.
pdf
33
28 Department of Water Affairs. National Eutrophication 43 Barouki R, Gluckman PD, Grandjean P, Hanson M, Heindel
Monitoring Programme, Implementation Manual. 2002. JJ. Developmental origins of non-communicable diseases:
[Internet]. [cited 17 April 2016]. implications for research and public health. Environ Health.
URL: https://www.dwa.gov.za/iwqs/eutrophication/NEMP/ 2012;11:42.
EutrophicationMonitoringProgramme.pdf
29 Dallas HF, Rivers-Moore N. Ecological consequences of global
climate change for freshwater ecosystems in South Africa. S
Afr J Sci. 2014;110(5/6).
30 Turton A. Sitting on the Horns of a Dilemma: Water as a
Strategic Resource in South Africa. @Liberty No. 6, Issue 22.
Johannesburg: South African Institute of Race Relations; 2015.
31 Simpson E, Charles K. The health threat posed to surrounding
communities by effluent discharged from rural hospital sewage
treatment plants. Presented at the WISA 2000 Biennial
Conference, Sun City, South Africa, 28 May–1 June 2000.
32 South African National Department of Environmental Affairs

PM
and Tourism. Emerging Issues Paper: Mine Water Pollution.
2008. [Internet]. [cited 22 March 2016].
URL: http://soer.deat.gov.za/Mine_Water_Pollution_fPA1A.
pdfH.file

16 6
33 Winde F. Uranium pollution of the Wonderfontein Spruit,
1997–2008. Part 2: Uranium in water – concentrations, loads

20 IL
and associated risk. Water SA. 2010;36(3):257–78.
34 Myers J. The South African burden of disease and climate
change. Continuing Medical Education. 2012 Mar
Y T
13;30(3):72–5. [Internet]. [cited 9 January 2016].
URL: http://www.cmej.org.za/index.php/cmej/article/
A N
view/2351/2158
M U

35 Wright CY, Garland RM, Norval M, Vogel C. Human health

impacts in a changing South African climate. S Afr Med J.
2014;104(8). [Internet]. [cited 25 March 2016].
4 ED

URL:http://www.scielo.org.za/scielo.php?pid=S0256-
95742014000800029&script=sci_arttext
36 Hofstra N. Quantifying the impact of climate change on
O

enteric waterborne pathogen concentrations in surface water.

Curr Opin Environ Sustain. 2011 Dec 31;3(6):471–9.
G

37 United Nations Development Programme. Sustainable

Development Goals 2015 [Internet]. [cited 2016].
R

URL: http://www.undp.org/content/undp/en/home/
sdgoverview/post-2015-development-agenda.html
BA

38 Department of Water Affairs and Forestry. Republic of South

Africa. A Drinking Water Quality Framework for South Africa.
O

Department of Water Affairs and Forestry; 2005.

EM

39 National Planning Commission. National Development Plan

2030. Executive Summary, 2012. [Internet]. [cited 17 April
2016].
URL: http://www.gov.za/sites/www.gov.za/files/
Executive%20Summary-NDP%202030%20-%20Our%20
future%20-%20make%20it%20work.pdf
40 Republic of South Africa. National Water Act (36 of 1998).
Published for general information as Government Notice No.
1091, Government Gazette No. 19182, 26 August 1998.
[Internet]. [cited 17 April 2016].
URL: http://www.energy.gov.za/files/policies/
act_nationalwater36of1998.pdf
41 Republic of South Africa. Environment Conservation Act (73
of 1989). Published for general information as Government
Notice No. 1188, Government Gazette No. 11927, 9 June
1989.
42 Republic of South Africa. Local Government Municipal
Structures Act (117 of 1998). Published for general
information as Government Notice No. 19614, Government
Gazette No. 1650, dated 18 December 1998.

34 S A H R 20 1 6
Diet-related non-communicable diseases
in South Africa: determinants and policy
4
responses

Authors:
Mark Spires i Peter Delobelle i
David Sanders i Thandi Puoane i

PM
Philipp Hoelzel i Rina Swart ii

16 6
N 20 IL
on-communicable diseases (NCDs) are the leading cause of death globally Increasingly, international
and they are on the rise both in low- and middle-income countries, with South
Y T
Africa being no exception. Implicated in this upward trend in the country is an research links rapidly
A N
observed change in diet – a transition from traditional foods, to what has come to be changing food environment
known as the ‘western’ diet, i.e. more energy-dense, processed foods, more foods
with escalating chronic
M U

of animal origin, and more added sugar, salt and fat. Increasingly, international
research links rapidly changing food environment with escalating chronic disease, disease, i.e. it implicates
4 ED

i.e. it implicates population-level dietary change over individual factors such as population-level dietary
knowledge, attitudes and behaviours. Environmental and/or policy interventions can
be some of the most effective strategies for creating healthier food environments. change over individual
factors such as knowledge,
O

This chapter explores the link between the rise in diet-related NCDs, their proximal
determinants (specifically an observed change in diet patterns), contributing attitudes and behaviours.
G

environmental factors, what is currently being done or recommended to address this

R

internationally, and the most relevant national-level policies for South Africa.

The authors conclude that to improve dietary patterns and reduce chronic diseases in
BA

South Africa will require a sustained public health effort that addresses environmental
O

factors and the conditions in which people live and make choices. Overall, positive
policies have been made at national level; however, many initiatives have suffered
EM

from a lack of concerted action. Key actions will be to reduce the intake of unhealthy
foods and make healthy foods more available, affordable and acceptable in South
Africa.

i School of Public Health, Universit y of the Western Cape

ii Department of Dietetics and Nutrition, Universit y of the Western Cape

35
Introduction
Chronic non-communicable diseases (NCDs), mainly heart disease,
stroke, cancer, diabetes and chronic respiratory disease, account
for more than two-thirds of global deaths, at least half of which are
caused by common, modifiable risk factors such as unhealthy diet,
obesity, tobacco use and lack of physical activity.1
Currently, NCDs are the leading causes of death worldwide, resulting
in 16 million premature deaths each year;2 and this is projected
to worsen: in 1999, NCDs were estimated to have contributed
to just under 60% of worldwide deaths and around 43% of the
global burden of disease.3 Based on current trends forecast by the
World Health Organization (WHO), these diseases are predicted to
account for 73% of deaths and 60% of the disease burden by the
year 2020.1 Global projections indicate that the biggest increase
Proximal determinants
The leading behavioural risk factors for NCDs are tobacco use,
harmful alcohol consumption, unhealthy diets that include high
sugar, salt and fat intake, physical inactivity, and overweight and
obesity.15 More specifically, in terms of this chapter, the continuing
rise in prevalence of overweight and obesity in an increasing number
of LMICs has been associated with a dramatic change in diet. Poor
diet now generates more disease than physical inactivity, alcohol
and smoking combined,16 which is largely due to an observed
change in diet at the population level. This change, dubbed the
‘nutrition transition’, is characterised by a shift from traditional diets
based largely on staple grains or starchy roots, legumes, vegetables
and fruits but minimal animal foods, towards more energy-dense,
processed foods, more foods of animal origin and more added

PM
sugar, salt and fat.17–19 This new diet, commonly known as the
in NCD deaths will occur in low- and middle-income countries
‘western’ diet, is primarily made up of cheap, highly palatable,
(LMICs); currently already 80% of global NCD deaths occur in these
heavily promoted, energy-dense and nutrient-poor foods.18
regions.4,5

16 6
The transition is also evident in South Africa. The change in nutrient
The United Nations (UN) recently recognised NCDs as an increasing
intake among South Africans has been associated with change in

20 IL
threat and a major contributor to preventable disease and premature
population-level dietary patterns.20 Although dietary differences are
mortality. This has been a monumental step in placing NCDs on the
still evident among South Africans, increasing changes to the food
global health and development agenda. A UN High-Level Meeting
Y T
of Heads of State and Governments on the Prevention and Control
of Non-communicable Diseases was held in September, 2011. This
environment indicate that the ‘western’ diet will one day be common
fare across the country.21
A N
meeting classified NCDs not just as a health concern but as a major
M U

development issue. Participants adopted a political declaration to Environmental factors

increase global focus and attention to prevent and control NCDs,
Globally, communities that have low levels of access to affordable,
especially in LMICs.
4 ED

healthy food options generally have poorer diets and are at a higher
South Africa was a participant and signatory to this meeting and risk for certain diet-related diseases.22–27 Local food environments,
supported the final political declaration. NCDs impose a large defined here as “the physical presence of food that affects a person’s
O

and continuously growing burden on the health, economy and diet; a person’s proximity to food store locations; the distribution of
development of South Africa, and currently accounts for a staggering food stores, food service, and any physical entity by which food may
G

43% of recorded deaths. Rates of overweight and obesity (together be obtained; or a connected system that allows access to food”,28
the second-leading metabolic risk factor in NCD-attributable death play a key role in individual, family, and population-level health.
R

in South Africa6), have risen sharply over recent years,7–10 in International research increasingly implicates a rapidly changing
conjunction with ongoing high levels of underweight and nutritional food environment dominated by processed products high in sugar,
BA

deficiencies. In the year 2000, an estimated 7% of all nationally salt and fat, and demonstrates that these environments contribute
recorded deaths were attributed to excess body weight,11 while
O

to increasing levels of chronic disease, over and above individual

in 2004, NCDs linked to dietary intake, together with respiratory factors such as knowledge, attitudes, and behaviours.29–31 Simply
EM

diseases, contributed 12% to the overall disease burden.12 Currently,
more than 45% of men and women above the age of 35 are either
overweight or obese.13 While NCDs have historically affected the
more affluent and mainly White population, these conditions are
now affecting other population groups as well. It is believed that in
the coming decades, NCDs will further exacerbate wide inequalities
in longevity and quality of life in South Africa.14 Additionally, the
chronic nature of NCDs demands long-term care and imposes a
significant burden on an overstretched health system already
having to cope with the HIV and AIDS epidemic, a high burden of
tuberculosis (TB), maternal and child mortality, and high levels of
violence and injuries.
This chapter explores the link between the rise in diet-related NCDs,
their proximal determinants (specifically an observed change in diet
patterns), contributing environmental factors, what is currently being
done or recommended to address this internationally, and the most
relevant national-level policies for South Africa.
put: unhealthy food environments foster unhealthy diets. This has
been especially true for communities with predominantly low-
income, low socio-economic status residents.27–32
South Africa is rapidly catching up with high-income countries as the
‘western’ diet is becoming increasingly accessible to all segments
of society. This transition has accelerated dramatically since the
mid-90s when the post-apartheid government opened the borders to
trade and foreign direct investment.29 Since then ‘Big Food’ (a term
used to label large commercial entities that dominate the food and
beverage environment) has come to dominate the food supply by
making its products more available and affordable. Although there
are over 1 800 food manufacturing companies in South Africa, Big
Food manufacturers account for a disproportionately large number
of sales.30 According to a recent publication, Big Food is becoming
more widespread in South Africa and has been implicated in
unhealthy eating.31 Igumbor et al. report that there has been an
observed increase in the sale of almost all categories of packaged

36 S A H R 20 1 6

foods in the country from 2005 to 2010. for example: sales of
snack bars, prepared meals and noodles all rose by more than 40%;
and when compared with the worldwide average of 89 Coca-Cola
products per person per year, in 2010 “South Africans consumed
254 Coca-Cola products per person per year, an increase from
around 130 in 1992 and 175 in 1997”.32 Another study found that
in 2010, up to half of all young people were reported to consume
fast foods, cakes and biscuits, cold drinks and sweets on at least
four days a week.13 It is worth noting that of the top 10 companies
that dominate food processing/manufacturing in the country, five
(including the most dominant company) are South African. Igumbor
et al. conclude that:
various strategies adopted by Big Food to increase the
availability, affordability, and acceptability of their products
have contributed to … dietary changes in South Africa and to
the increased burden of obesity and NCDs.
Also accelerating the spread of the ‘western’ diet in South Africa
16 6
has been the rapid expansion of supermarkets, with chain outlets
now owning more than 50% of the retail food market,33 making
20 IL
supermarkets the primary place South Africans purchase their
foods.34 In general, supermarkets have made both staple and
packaged foods more affordable;35 however, healthier food options
Y T
typically cost between 10% and 60% more when compared with
A N
unhealthier options in these retail outlets.36 Availability of these
healthier options has also been observed as an issue, particularly for
M U
those living in low-income areas. One study noted that “supermarkets
in low-income areas typically stock less healthy foods than those in
4 ED
wealthier areas and, as a result, the supermarkets do not increase
access to healthy foods and may, in fact, accelerate the nutrition
transition”.37
O
These environmental factors are decreasing the diversity of food
stuffs consumed by South Africans. Dietary diversity plays a crucial
G
part in preventing undernutrition and overweight/obesity. With
healthier options usually being more expensive than their unhealthy
R
alternatives,38–40 and as a result out of reach for many South African
BA
families, dietary diversity has become less and less of a reality in
N
this country.41–44
O
EM
Policy approaches
International research has shown that “environmental and policy
interventions may be among the most effective strategies for
creating population-wide improvements in eating”.45 Based on
research and practice, consensus now exists regarding core policy
actions that can be taken to promote healthy diets.46,47 The policy
actions have been grouped into three domains in the NOURISHING
framework,48 including the food environment (e.g. nutrition labelling,
food taxation, restriction of food advertising); the food system (e.g.
supply-chain incentives); and behaviour-change communication (e.g.
mass-media campaigns, nutritional advice and education). Evidence
exists to support the benefits of focused mass-media campaigns,
food-pricing strategies, school-procurement policies and worksite
wellness programmes, but there is less conclusive evidence for food
and menu labelling and changes in the local built environment.49 In
addition, there is a dearth of research into how nutrition labels are
being received in the global South, especially among the urban and
rural poor, in order to assess the effectiveness of labelling policies.50
S A H R 20 1 6
Diet-related diseases
In the United States of America studies have shown greater effects
of food policies related to bans/restrictions on unhealthy foods,
mandates offering healthier foods, and altering purchase/payment
rules on foods purchased using low-income food vouchers compared
with other interventions such as menu labelling or the introduction of
new supermarkets.51 There is also consistent evidence that taxation
and subsidy intervention influence dietary behaviour.52 Mexico, for
example, implemented taxation of sugar-sweetened beverages and
other so-called junk foods, and many other countries have or are
actively pursuing taxes on sugar-sweetened beverages to combat
both obesity and dental disease.46 Early results from the sugar
taxation in Mexico indicate that in 2014 the purchase of soda and
other taxed drinks had dropped by 10% compared with the previous
year, whereas the purchase of bottled water rose by 13%, showing
that people were indeed changing to a healthier alternative.53
PM
Sugar taxes have been implemented in Denmark, Finland, France,
Hungary, Ireland and Norway, based on substantial scientific
evidence showning that decreased sugar-sweetened beverage
consumption reduces the prevalence of obesity and obesity-related
diseases and that a tax on sugar-sweetened beverages reduces
the obesity rate.54,55 However, in order for full health benefits to
be achieved, a tax on sugar-sweetened beverages would need to
be part of a wider approach to obesity that includes for example,
food labelling, advertising regulations, reformulation of foods and
drinks by industry and consumer-awareness programmes as well as
possible subsidies on healthy foods.
In order to monitor factors influencing the food environment
associated with obesity, the International Network for Food and
Obesity/non-communicable diseases Research, Monitoring and
Action Support (INFORMAS) has developed a set of modules.
It includes a framework to monitor, assess and provide input on
improving food environment-related policies. Known as the
Government Healthy Food Environment Policy Index (Food-EPI), this
approach puts forward seven policy domain areas, which “address
the key aspects of food environments that can be influenced by
governments to create readily accessible, available and affordable
healthy food choices”.56 These domains are food composition,
food labelling, food promotion, food provision, food retail, food
prices, and food trade and investment. ‘Good practice statements’
have been developed for each of these domains and are used as
benchmarks when assessing or rating existing policies in a given
jurisdiction. Currently, this rating process is taking place in South
Africa and results should be available soon.
Current national policy context
Poverty and food insecurity in South Africa have a unique and long
history that has been traced back and linked to colonialism and the
legacy of apartheid: “The former [colonialism] disrupted the African
production and indigenous knowledge on food security. The latter
[apartheid] designed a system that generally created unfavourable
conditions for black people in all aspects of livelihood”.57
Currently, under a rights-based system such as South Africa’s,
the government “must provide an enabling environment in which
people can adequately produce or procure food for themselves
and their families”.58 Section 27 of the South African Constitution
states that “everyone has the right to have access to sufficient food
and water”,59 and points out that “the state must take reasonable
37
legislative and other measures, within its available resources, to
achieve the progressive realisation of each of these rights”. As a
result, the South African government as ‘duty bearers’ is obliged to
respect peoples’ rights, protect these rights, and do all they can to
realise these rights, which means that decision-makers must generate
conditions in which everyone can be as healthy as possible, without
discrimination.60
Rapidly changing local food environments in South Africa have led
to the call for labelling and fiscal policy measures to address the
availability, acceptability and affordability of healthy versus less-
healthy foods, and for improved implementation of regulations for
the marketing of foods and beverages to children.31 Since 1994,
South Africa has taken some positive policy steps at national level
to address issues related to NCD prevention and/or healthy food
“Africans are eating more and more junk processed foods instead
of their traditional diet,” and [he] affirmed his desire to regulate junk
food starting with reducing salt in bread and eliminating trans-fats.67
In his 2016 budget speech, South African Finance Minister Pravin
Gordhan revealed plans to introduce a tax on sugar-sweetened
beverages, similar to the sin taxes on alcohol and tobacco.68 The
sugar tax will be implemented from 1 April 2017 and will be levied
on soft drinks, fruit juices, energy drinks and vitamin water. This
decision was informed by research indicating that a 20% tax on
sugary drinks could bring in an estimated R7-billion in additional
revenues each year and reduce obesity among 220 000 adults.69,70
Other relevant national level-policies, programmes and strategies
that shape provincial and community-level actions impacting food
environments are the Integrated Food Security Strategy,71 the

PM
access. In September 2011, the South African Minister and Deputy-
Integrated Nutrition Programme,72 the National School Nutrition
Minister of Health convened a summit on the Prevention and Control
Programme,73 the National Policy on Food and Nutrition Security,74
of Non-Communicable Diseases.61 The summit included various
and the National Development Plan.75 However, collectively,
governmental departments, researchers, private sector and civil

16 6
these policies frame food insecurity as primarily a rural and food-
society stakeholders, and resulted in a declaration that endorsed
production issue; few resources have been allocated to municipalities
action aimed at various risk factors (behavioural, environmental and

20 IL
to address urban concerns around this issue, which some argue is
structural). Subsequently, the national government has released its
where the focus is currently needed.76 On the whole, these policies
Strategic Plan for Non-Communicable Diseases, 2013–2017,62
Y T do not take environmental issues into account or spatial contexts
which provides a short-term framework to reduce the burden of
around access; rather, they focus on household-level issues such as
NCDs, including actions related to specific targets identified and
A N
income-generation, government safety nets, nutritional programmes,
agreed upon at the 2011 Summit. The plan outlines cost-effective
and on increasing production.77
M U

interventions/actions that address unhealthy diet, specifically

reduced salt intake in line with the WHO’s supported interventions
Policy coherence
on salt intake reduction in the sub-Saharan Africa region.66 It goes
4 ED

on to point out that dietary changes are needed in South Africa if All government departments and their respective policies have
NCDs are to be combatted effectively, and that food environments the potential to affect the health of the population/s they serve.
play a key role in this. The plan advocates for a legislative approach While health may not be the main aim of all these policies, their
O

to improve food environments, including legislation/regulations to implementation has the potential to have either a positive or a
reduce trans-fatty acids; regulations to reduce salt in processed food; negative effect on population health. Consequently, the World Health
G

consideration to be given to the ban of junk food advertisements Organization has said that policy coherence is vital across different
directed at children during key television programmes; the taxation of government sectors, and that when it comes to the promotion of
R

undesirable processed foods and the exemption of healthier choices health, various government department policies should complement
BA

from taxation; and better control of food and nutrient supplements. rather than contradict each other.78
N

A recent review of actions taken in South Africa to combat NCDs

In South Africa, a lack of policy coherence is apparent. One such
O

reveals that increased attention is being paid to NCDs in South

example is the contradiction between our national trade and
Africa, but that “this heightened focus has to be strengthened and
EM

sustained over the next decades to combat the current trend and
achieve a real reduction in the NCD-related burden”,14 and that
additional rigorous measures are required to continue to address the
common risk factors NCDs for South Africa.
With regard to reduced salt intake, voluntary measures have been
discussed with the appropriate consumer and industry groups and
a comprehensive salt-reduction plan, including legislative measures,
has been implemented.64 The Department of Health has approved
regulations which will come into effect in 2016.65 In addition, a new
advocacy group has been established, along with an educational
campaign launched by the Heart and Stroke Foundation to
communicate about the harms of high salt consumption. Similarly,
regulations relating to trans-fats in food already exist as of 2010,66
while new food labelling and advertising legislation came into being
in March 2012. It is encouraging that the current (February 2016)
South African Minister of Health, Dr Aaron Motsoaledi, stated that:
investment policy and our national health policy, with trade and
foreign direct investment promoting the influx of large amounts of
processed foods and sugary beverages, giving free rein to fast
food companies like McDonalds and Burger King. In more recent
documents, there has been an increasing call for an inter-sectoral
approach, which has yet to be realised in the South Africa Declaration
on the Prevention and Control of Non-Communicable Diseases,62
the National Strategy for Prevention and Control of Obesity79 and
the South Africa Strategic Plan for Non-Communicable Diseases,
2013–2017.62 These types of approaches have been successfully
used in initiatives such as the Health Promoting Schools Programme,
which was developed in response to a shared policy concern across
the health and education sector. The approach is obviously more
problematic when dealing with sectors with conflicting interests, e.g.
between health policy and trade and investment. As pointed out
in the Report of the Commission on Social Determinants of Health,
“trade policy that actively encourages unfettered production, trade,

38 S A H R 20 1 6
 Diet-related diseases

and consumption of foods high in fats and sugars to the detriment of
fruit and vegetable production is contradictory to health policy”.80
The reduction of obesity and promotion of health, including the
promotion of healthy food choices, will benefit directly from a
systems approach, including ‘upstream’ policy actions beyond the
traditional health sector.81 Health-in-All Policies (HiAP) is one such
approach. It has been described as a way that considers the impact
of policies on health outcomes, determinants and health systems,
with special emphasis on the distribution of these impacts.82 The
HiAP approach was adopted in South Australia, where the regional
government mapped the core business and policy directions of
local state departments against research showing what works in
combatting obesity. “Negotiations then developed high-level policy
commitments to address factors promoting healthy weight which
Acknowledgements
The writing of this chapter was made possible by generous support
from the DST-NRF Centre of Excellence in Food Security (University
of the Western Cape) and from the SMART2D project funded by
the European Commission’s Horizon 2020 Health Coordination
Activities (Grant Agreement No. 643692) under call “HCO-
05-2014: Global Alliance for Chronic Diseases:prevention and
treatment of type 2 diabetes”. The contents of this article are solely
the responsibility of the authors and do not reflect the views of the
EU.

PM
predominantly changed ways of working rather than requiring new
expenditure and also assisted departments in meeting their own
goals.”81 This initiative achieved buy-in from traditionally non-health
departments and an increased level of commitment to a broader

16 6
range of policy actions. In the South African context, HiAP could
be advocated and monitored through the establishment of an

20 IL
independent-of-government Health Promotion Foundation (HPF).83
HPFs work across sectors to support government and contribute
Y T
to the development of evidence-based policy in collaboration with
government, academia and civil society. HPFs have successfully
A N
influenced population health in countries such as Thailand
M U

and Australia, and in South Africa the Health Promotion and

Development Foundation Network has lobbied for the establishment
of an HPF, which has not materialised so far. Another approach
4 ED

to promote NCD prevention in South Africa would be guided by

the establishment of a multi-stakeholder national health commission
that actively engages other sectors including trade and industry,
O

agriculture, education, sports, and arts and culture.84 Whilst there

is strong national commitment and civil society support for this
G

initiative, provinces have been slow to prioritise and implement

action plans in this area over the last few years.85
R
BA

Conclusion
O

To improve dietary patterns and reduce chronic diseases will require

EM

a sustained public health effort. This must include consideration of

environmental factors and the conditions in which people live and
make choices. Overall, positive policy steps have been made at the
national level; however, most initiatives have been critiqued for lack
of action. Existing efforts that address initiatives NCD prevention,
their proximal determinants and contributing environmental factors
have to be strengthened and sustained in order to combat the current
trend and achieve a real reduction in the NCD-related burden.
Additional rigorous measures are also required to continue to
address the common risk factors for NCDs in South Africa. The South
African government should develop a co-ordinated, specific plan to
make healthy foods more available, affordable and acceptable, and
existing related policies should be implemented more effectively.

S A H R 20 1 6 39
References
1 Beaglehole R, Bonita R, Alleyne G, Horton R, Li L, Lincoln P, et
al. UN High-Level Meeting on Non-Communicable Diseases:
addressing four questions. Lancet. 2011;378(9789):449–55.
2 World Health Organization. Non-communicable Diseases
Progress Monitor Report, 2015. Geneva: World Health
Organization; 2015.
3 World Health Organization. WHO NCD Surveillance
strategy 2016. [Internet]. [cited 11 Feb 2016].
URL: http://www.who.int/ncd_surveillance/strategy/en/
4 World Health Organization. Global Burden of Disease. 2016.
[Internet]. [cited 11 Feb 2016].
URL: http://www.who.int/healthinfo/global_burden_disease/
5 World Health Organization. Global status report on
non-communicable diseases 2010. Geneva: World Health
Organization; 2011.
6 World Health Organization. Non-communicable Disease Fact
Sheet 2015. [Internet]. [cited 11 Feb 2016].
URL: http://www.who.int/mediacentre/factsheets/fs355/en/
16 6
7 Armstrong ME, Lambert MI, Lambert EV. Secular trends in
the prevalence of stunting, overweight and obesity among
20 IL
South African children (1994–2004). Eur J Clin Nutr.
2011;65(7):835–40.
8
Y T
South African National Department of Health, Medical
Research Council and OrcMacro. South Africa Demographic
A N
and Health Survey 2003. Pretoria: National Department of
Health; 2007.
M U
9 Reddy SP, James S, Sewpaul R, Koopman F, Funani NI, et
al. Umthente Uhlaba Usamila – The South African Youth Risk
4 ED
Behaviour Survey 2008. Cape Town: South African Medical
Research Council; 2010.
10 Kruger HS, Steyn NP, Swart EC, Maunder EMW, Nel JH,
et al. Overweight among children decreased, but obesity
O
prevalence remained high among women in South Africa,
1999–2005. Public Health Nutr. 2011;18:1–6.
G
11 Joubert J, Norman R, Lambert EV, Groenewald P, Schneider
M, et al. Estimating the burden of disease attributable to
R
physical inactivity in South Africa in 2000. S Afr Med J.
2007;97:725–31.
BA
12 Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM,
Bradshaw D. The burden of non-communicable diseases in
O
South Africa. Lancet. 2009;374:934–47.
EM
13 Bradshaw D, Steyn K, Levitt N, Nojilana B. Non-
communicable Diseases – A race against time. Parow:
Medical Research Council; 2010.
14 Puoane TR, Tsolekile LP, Caldbick S, Igumbor EU, Meghnath
K, Sanders D. Chronic non-communicable diseases in South
Africa: Progress and challenges: Social and environmental
determinants of health. In: Padarath A, English R, editors.
South African Health Review 2012–13. Durban: Health
Systems Trust; 2013; p.115–26.
15 World Health Organization. Global Health Risks. Mortality
and Burden of Disease Attributable to Selected Major Risks.
Geneva: World Health Organization; 2009.
16 Malhotra A, Noakes T, Phinney S. It is time to bust the myth of
physical inactivity and obesity: you cannot outrun a bad diet.
Br J Sports Med. 2015; 49(15):967–8.
17 Popkin BM. The nutrition transition in low-income countries: an
emerging crisis. Nutr. Rev. 1994;52(9):285–98.
18 Swinburn BA, Sacks G, Hall KD, et al. The global obesity
pandemic: shaped by global drivers and local environments.
Lancet. 2011;378:804–14.
40 S A H R 20 1 6
19 Kennedy G, Nantel G, Shetty P; Food and Agriculture
Organization of the United Nations. Globalization of food
systems in developing countries: impact on food security and
nutrition. FAO Food Nutr Pap. 2004;83:1–300.
20 MacIntyre UE, Kruger HS, Venter CS, Vorster HH. Dietary
intakes of an African population in different stages of
transition in the North West Province, South Africa: the
THUSA study. Nutrition Research. 2002;22:239–56.
21 Temple NJ, Steyn NP. Food prices and energy density as
barriers to healthy food patterns in Cape Town, South Africa.
J Hunger Environ Nutr. 2009;(4),203–13.
22 Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR.
Associations of the local food environment with diet
quality – a comparison of assessments based on surveys
and geographic information systems. Am J Epidemiol.
PM
2008;167(8):917–24.
23 Goldstein H, Harvey S, Banthia R, et al. Designed for
Disease: The Link Between Local Food Environments and
Obesity and Diabetes. California: Center for Public Health
Advocacy, PolicyLink, and the UCLA Center for Health Policy
Research; 2008.
24 Franco M, Diez Roux AV, Glass TA, Caballero B, Brancati
FL. Neighborhood characteristics and availability of healthy
foods in Baltimore. Am J Prev Med. 2008;35(6):561–7.
25 Morland K, Wing S, Diez Roux A. The contextual effect
of the local food environment on residents’ diets: the
atherosclerosis risk in communities study. Am J Public Health.
2002;92(11):1761–7.
26 Morland K, Diez Roux AV, Wing S. Supermarkets, other food
stores, and obesity: the atherosclerosis risk in communities
study. Am J Prev Med. 2006;30(4):333–9.
27 Morland KB, Evenson KR. Obesity prevalence and the local
food environment. Health Place. 2009;15(2):491–5.
28 Centers for Disease Control and Prevention. General Food
Environment Resources. [updated 6 Mar 2014]. [Internet].
[cited 11 February 2016].
URL: http://www.cdc.gov/healthyplaces/healthtopics/
healthyfood/general.htm
29 Thow A, Sanders D, Drury E, Puoane T, Chowdhury S,
Tsolekile L, Negin J. Importing obesity: Implications of regional
trade and investment for diet-related NCD prevention policy
in Southern Africa. Glob Health Action. 2015;(8):28338.
doi:10.3402/gha.v8.28338
30 USDA Foreign Agricultural Services. GAIN report South
Africa’s food processing sector offers opportunities for U.S.
exports. [Internet]. [cited 11 Feb 2016].
URL: http://static.globaltrade.net/files/
pdf/20120123003839246.pdf. 2011
31 Igumbor EU, Sanders D, Puoane TR, Tsolekile L, Schwarz C,
Purdy C, et al. “Big Food,” the Consumer Food Environment,
Health, and the Policy Response in South Africa. PLoS Med.
2012;9(7):e1001253.
32 Hawkes C. Marketing Activities of Global Soft Drink and
Fast Food Companies in Emerging Markets: A Review.
Globalization, diets, and non-communicable diseases.
Geneva: World Health Organization; 2002.
33 Greenberg S. Contesting the food system in South Africa:
Issues and Opportunities. Institute of Poverty, Land and
Agrarian Studies research report 42. Cape Town: University
of the Western Cape; 2010.

34 D’Haese M, Huylenbroeck GV. The rise of supermarkets and
changing expenditure patterns of poor rural households:
case study in the Transkei area, South Africa. Food Policy.
2005;30:97–113.
35 Weatherspoon D, Reardon T. The Rise of Supermarkets in
Africa: Implications for Agrifood Systems and the Rural Poor.
Dev Policy Rev. 2003;21:333–55.
36 Temple NJ, Steyn NP, Fourie J, De Villiers A. Price and
availability of healthy food: A study in rural South Africa.
Nutrition. 2011;27:55–8.
37 Battersby J, Peyton S. The Geography of Supermarkets in
Cape Town: Supermarket Expansion and Food Access. Urban
Forum. 2014;25(2):153–64.
38 Temple NJ, Steyn NP. Food prices and energy density as
barriers to healthy food patterns in Cape Town, South Africa.
J Hunger Environ Nutr. 2009;4:203–13.
39 Muzigaba M, Puoane T. Perceived and actual cost of healthier
foods versus their less healthy alternatives: A case study in a
predominantly black urban township in South Africa. East Afr
J Public Health. 2014;8(4):283–90.
16 6
40 Steyn NP, Mchiza Z, Abrahams Z, Temple N. Television
20 IL
advertising to children: Ethical considerations with regard
to advertising of unhealthy foods and drinks. Cape Town:
Human Sciences Research Council; 2014. [Internet] [cited
11 Feb 2016]. Y T
URL: http://www.hsrc.ac.za/uploads/
pageContent/4577/2014%20Television%20Advertising.pdf)
A N
41 Labadarios D, Steyn NP, Nel J. How diverse is the diet
M U
of adult South Africans? Nutr J. 2011;17:10:33. doi:
10.1186/1475–2891–10–33.
4 ED
42 Puoane TR, Tsolekile L, Sanders D. A Case Study of
Community-Level Intervention for Non-Communicable Diseases
in Khayelitsha, Cape Town. Brighton Institute of Development
Studies (IDS); 2013.
O
43 Tsolekile L, Lerebo W, Muzigaba M, Puoane T. Challenges
in combating childhood obesity in black township schools
G
of South Africa. Afr J Phys Health Educ Recreat Dance.
Supplement 2. 2014; p.442–56.
R
44 Stern R, Puoane T, Tsolekile L. An Exploration into the
Determinants of Noncommunicable Diseases Among Rural-to-
BA
Urban Migrants in Periurban South Africa. Prev Chronic Dis.
2010;7(6):1–7.
O
45 Morland KB, Evenson KR. Obesity prevalence and the local
EM
food environment. Health Place. 2009;15(2):491–5.
46 Roberto CA, Swinburn B, Hawkes C, Huang TTK, Costa
SA, Ashe M, et al. Patchy progress on obesity prevention:
emerging examples, entrenched barriers, and new thinking.
Lancet. 2015;385(9985):2400–9.
47 Roberto CA, Pomeranz JL. Public Health and Legal
Arguments in Favor of a Policy to Cap the Portion Sizes
of Sugar-Sweetened Beverages. Am J Public Health.
2015;105(11):2183–90.
48 Hawkes C, Smith TG, Jewell J, Wardle J, Hammond RA, Friel
S, et al. Smart food policies for obesity prevention. Lancet.
2015;385(9985):2410–21.
49 Afshin A, Penalvo J, Del Gobbo L, Kashaf M, Micha R,
Morrish K, et al. CVD Prevention Through Policy: a Review
of Mass Media, Food/Menu Labeling, Taxation/Subsidies,
Built Environment, School Procurement, Worksite Wellness,
and Marketing Standards to Improve Diet. Curr Cardiol Rep.
2015;17(11):1–12.
S A H R 20 1 6
Diet-related diseases
50 Mandle J, Tugendhaft A, Michalow J, Hofman K. Nutrition
labelling: a review of research on consumer and industry
response in the global South. Glob Health Action. 2015;8.
51 Mayne SL, Auchincloss AH, Michael YL. Impact of policy and
built environment changes on obesity-related outcomes: a
systematic review of naturally occurring experiments. Obes
Rev. 2015;16(5):362–75.
52 Niebylski ML, Redburn KA, Duhaney T, Campbell NR. Healthy
food subsidies and unhealthy food taxation: A systematic
review of the evidence. Nutrition. 2015;31(6):787–95.
53 Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage
purchases from stores in Mexico under the excise tax on sugar
sweetened beverages: observational study. 2016;352:h6704.
54 Hu FB. Resolved: there is sufficient scientific evidence that
decreasing sugar-sweetened beverage consumption will
reduce the prevalence of obesity and obesity-related diseases.
PM
Obes Rev. 2013;14(8):606–19.
55 Cabrera Escobar MA, Veerman JL, Tollman SM, Bertram
MY, Hofman KJ. Evidence that a tax on sugar sweetened
beverages reduces the obesity rate: a meta-analysis. BMC
Public Health. 2013;13(1):1–10.
56 Swinburn B, Vandevijvere S, Kraak V, Sacks G, Snowdon
W, Hawkes C, et al. Monitoring and benchmarking
government policies and actions to improve the healthiness
of food environments: a proposed Government Healthy
Food Environment Policy Index. Obes Rev. 2013;14(Suppl
1):24–37.
57 Empowerment for Food Security Programme. VVOB vzw
Formulation Report; 6 September 2015. Pretoria: Direct Aid
Project; 2015.
URL: http://www.kzndae.gov.za/Portals/0/Rural%20
Development/Food%20Security/FINAL%20formulation%20
report%20Food%20Security%20-%206%20sept.pdf
58 South African Human Rights Commission. The Right to Food
Campaign. 2014 [Internet]. [cited 8 August 2014].
URL: http://www.sahrc.org.za/home/index.php?ipkContentI
D=112&ipkMenuID=94
59 Republic of South Africa. The Constitution of the Republic of
South Africa, Act 108 of 1996. Pretoria: Government Printer;
1996.
60 World Health Organization. Fact Sheet No.323: The Right to
Health. 2015 [Internet] [cited 8 August 2014].
URL: http://www.who.int/mediacentre/factsheets/fs323/en/
61 South African National Department of Health. Summit on
Prevention and Control of Non-Communicable Diseases.
2011 [Internet]. [cited 1 November 2012].
URL: http://www.doh.gov.za/eventlist.php?eid=5
62 South African National Department of Health. Strategic
Plan for the Prevention and Control of Non-Communicable
Diseases, 2013–2017. Pretoria: National Department of
Health; 2012.
63 Sookram C, Munodawafa D, Phori PM, Varenne B, Alisalad
A. WHO’s supported interventions on salt intake reduction
in the sub-Saharan Africa region. Cardiovasc Diagn Ther.
2015;5(3):186–90.
64 Delobelle P, Sanders D, Puoane T, Freudenberg N. Reducing
the Role of the Food, Tobacco, and Alcohol Industries in
Noncommunicable Disease Risk in South Africa. Health Educ
Behav. 2016 (in press).
65 South African Government. Foodstuffs, Cosmetics and
Disinfectants Act 1972 (No. R. 214): Regulations relating
to the reduction of sodium in certain foodstuffs and related
matters, No. R. 214 (2013).
41
66 South African Government. Foodstuffs, Cosmetics and 84 Hofman K. Non-communicable diseases in South Africa:
Disinfectants Act 1972 (No. R. 249): Regulations Relating to A challenge to economic development. S Afr Med J.
Trans-Fat in Foodstuffs, No. R. 249 (2010). 2014;104(10):647.
67 The Guardian, Lawrence F. Alarm as corporate giants target 85 Pinkney-Atkinson V. Civil Society Status Report 2010–2015:
developing countries [Internet]. [updated 23 Nov 2011; cited Mapping South Africa’s Reponse to the Epidemic of Non-
1 May 2012]. Communicable Diseases. South African NCDs Alliance;
URL: http://www.guardian.co.uk/global-development/2011/ 2015.
nov/23/corporate-giants-target-developing-countries.
68 Mail and Guardian, Donnelly L. Gordhan announces sugar
tax [Internet]. [updated 24 Feb 2016].
URL: http://mg.co.za/article/2016-02-24-budget-speech-
2016-gordhan-introduces-sugar-tax
69 Tugendhaft A, Manyema M, Veerman LJ, Chola L, Labadarios
D, Hofman KJ. Cost of inaction on sugar-sweetened beverage
consumption: implications for obesity in South Africa. Public
Health Nutr. 2015;1–9.

PM
70 Manyema M, Veerman LJ, Chola L, Tugendhaft A, Sartorius
B, Labadarios D, et al. The potential impact of a 20% tax on
sugar-sweetened beverages on obesity in South African adults:
a mathematical model. PloS one. 2014;9(8):e105287.

16 6
71 South African National Department of Agriculture. The
integrated food security strategy for South Africa. Pretoria:

20 IL
Department of Agriculture; 2012.
72 South African National Department of Health. Integrated
Nutrition Programme Pretoria: Department of Health; 2002.
Y T
73 South African National Department of Education. National
A N
School Nutrition Programme. Pretoria: Department of
Education; 1994.
M U

74 Department of Social Development; Department of Agriculture,

Forestry and Fisheries. National Policy on Food and Nutrition
4 ED

Security. Pretoria: Department of Social Development,

Department of Agriculture, Forestry and Fisheries; 2014.
75 National Planning Commission. National Development Plan
2030: Our future – make it work. Pretoria: The Presidency,
O

Republic of South Africa; 2012.

76 The African Urban Food Security Network. Publications –
G

Urban Food Security Series 2016. [Internet]. [cited 3 Feb

2016].
R

URL: http://www.afsun.org/publications/
BA

77 Battersby J, Haysom G, Marshak M, Kroll F, Tawodzera G.

N

South African Cities Network Programme: A study on current

and future realities for urban food security in South Africa
O

(draft 3); 2015; doi: 10.13140/RG.2.1.4224.6487

EM

78 World Health Organization. Social determinants of health –

Key Concepts 2016. [cited 3 Feb 2016].
URL: http://www.who.int/social_determinants/
thecommission/finalreport/key_concepts/en/
79 South African National Department of Health. Strategy
for the Prevention and Control of Obesity in South Africa
2015–2020. Pretoria: National Department of Health; 2015.
80 Marmot M, Friel S, Bell R, Houweling TAJ, Taylor S.
Closing the gap in a generation: health equity through
action on the social determinants of health. Lancet.
2008;372(9650):1661–9.
81 Newman L, Ludford I, Williams C, Herriot M. Applying Health
in All Policies to obesity in South Australia. Health Promot
Int. 2016;31(1):44–58.
82 Ollila E. Health in All Policies: from rhetoric to action. Scand J
Public Health. 2011;39(6):11–8.
83 Perez AM, Ayo-Yusuf OA, Hofman K, Kalideen S, Maker
A, Mokonoto D, et al. Establishing a health promotion
and development foundation in South Africa. S Afr Med J.
2013;103(3):147–9.

42 S A H R 20 1 6
 EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM

43
Human Resources for Health
 Human Resources for Health

44
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
The contribution of specialist training
programmes to the development of a
5
public health workforce in South Africa

Authors:
Virginia Zweigenthal i
Leslie London i

PM
William Pick i

16 6
A 20 IL
population perspective on health underpins the 17 newly adopted Sustainable Public health is an inter-
Development Goals (SDGs) and South Africa’s recently promulgated White
Y T
Paper on National Health Insurance (NHI). Monitoring their progress, disciplinary field that aims to
A N
identifying health service priorities and implementing effective delivery strategies understand health problems,
requires a skilled public health (PH) workforce. Yet several key policies intended to
and to develop and evaluate
M U

transform the country’s health system radically make no mention of this workforce.
programmes to improve the
This chapter investigates the potential contribution of the Public Health Medicine
4 ED

(PHM) specialty to a public health workforce in South Africa. We describe the nature health status of populations.
of PH, the competencies anticipated of a PH workforce and the training programmes However, current South
for PHM specialists and the Master of Public Health (MPH). The discordance between
African health reform
O

the need for PH expertise generated by the current policy juncture in South Africa
and the current invisibility of graduates of PH programmes is explored. initiatives whilst flagging the
G

PH is an inter-disciplinary field that aims to understand health problems, and to importance of PH for the
R

develop and evaluate programmes to improve the health status of populations. The health service, give little
evolution of PH in South Africa reflects two trends: one focused on compliance with
BA

measures protecting human health, and the other focused on the development of detail on the role of
PH professionals.
O

innovative participatory models and policy emphasising comprehensive care.

EM

Both trends were led by doctors and historically, PH training was reserved for doctors.
After 1994, graduate PH programmes were opened to other health professionals
and social scientists. Legislation no longer reserved senior PH functions for doctors.
However, current South African health reform initiatives – the NHI, PHC re-engineering
and health workforce policies – whilst flagging the importance of PH for the health
service, give little detail on the role of PH professionals.

Understanding the history of PH in South Africa, the broadening of its inclusive

professional identity and the multi-disciplinarity of the PH workforce should facilitate
use of these skills to deliver on national and international development goals.

i School of Public Health and Family Medicine, Universit y of Cape Town

45
Introduction
Health is central to many global and national development agendas.
The recently adopted Sustainable Development Goals (SDGs) present
one explicit health goal: to “ensure healthy lives and promote well-
being”,1 and population health concerns underlie 13 other SDGs.2
The South African Constitution foregrounds access to health care as
a right, and population approaches to health underpin the National
Health Act of 20033 and other policies. Despite this philosophical
commitment to a public health (PH) approach in the health system,
the role of personnel trained in PH is not formally recognised, nor
are the institutions that train PH professionals accorded any special
responsibilities in human resource planning for health.
Resource allocation in the South African health system primarily
prioritises clinical services and focuses on individual ‘personal
health’ services, which are largely facility- and hospital-based.
Health services do not emphasise interventions addressing the
social determinants of health. This is evident in the recently released
16 6
National Health Insurance (NHI) White Paper,4 as well as other
recent national policy directives.5,6 These address system and
20 IL
workforce barriers to achieve health outcomes appropriate to South
Africa’s per capita spend on health. However, only with the 2015
Y T
Bill proposing a National Public Health Institute of South Africa
(NAPHISA)7 has there been any attempt to institutionalise South
A N
Africa’s PH capacity.
M U
In exploring the place of PH and reasons for its poor prominence in
South Africa’s health services, this chapter firstly reviews the function
of PH and competencies within health systems and the PH workforce,
4 ED
as well as the history and development of PH, its workforce and
selected training programmes in South Africa. Current South African
health reforms in the global context; the reasons for the effacement
O
of PH in the health services are discussed as well as its possible
future role.
G
R
Public health
BA
The term ‘public health’ is used in the literature in a number of ways:
an “activity, a discipline, a profession, an infrastructure, or even
O
a movement”.8 Some narrowly view PH as government-funded or
EM
public sector health services as opposed to private sector health
services,9 or as ‘community health’ in contrast to ‘personal health’
services rendered by clinical medicine.10
PH is most often defined as a field that focuses on the maintenance
and promotion of health at a population level,11 “assuring conditions
in which people can be healthy”.12 Winslow, an American PH
practitioner in the early 20th century, argued that PH was “the
science and art of preventing disease, prolonging life and promoting
physical and mental health and efficiency through organized
community efforts”.13 PH aims firstly to understand health problems
and systems before developing and managing programmes in
prevention and control to improve the health status of communities.
It is an inter-disciplinary field, encompassing a number of
disciplines including environmental health, occupational health,
epidemiology, biostatistics, demography, economics, and health
care organisation and management.11 Social science disciplines
such as geography, psychology, sociology and anthropology have
increasingly become integrated into PH practice.10 The perspectives
46 S A H R 20 1 6
and methods of these disciplines together provide information that
can inform health interventions. Information may come from lifestyle
risk factor analysis (epidemiology), economic cost-benefit analysis
of health policies (health economics), and organisational change
(management sciences). PH provides a mind-set that considers
different explanations for health phenomena which, in turn, inform
complex and multiple approaches, thus avoiding piecemeal insights
and interventions.14 PH practice is a multi-disciplinary enterprise.
‘Social determinants of health’ form a component of the PH
paradigm, and describe underlying conditions that interact with and
influence risks to health and well-being. These include the conditions
of everyday life and systems that help keep people healthy and
support them when they become sick.15 Most social factors lie
PM
outside the scope of health services,11 and require engagement
with stakeholders beyond the formal health sector. This intersectoral
nature of PH practice requires PH professionals to work with others
on factors determining human health and in systems to improve
health status, using levers for change such as the development of
social interventions, policy change and advocacy.16 The World
Health Organization (WHO) has framed this mandate as the ‘health
in all policies’ approach, which asserts that PH professionals need
to ensure that a health agenda is part of all government initiatives
and policies – in, for example, housing, education and energy,17
which is a recognised challenge in South Africa.18 Following
this perspective, the SDGs prioritise the ‘fight against poverty’
and recognise that determinants of health include environmental,
economic and social factors.19
Ideals of social justice are implicit to PH, which also holds the
fair distribution of society’s benefits and responsibilities as a core
value.16,20
Public health in healthcare systems
Before the 20th century, coercive PH measures – such as health
inspection, isolation of cases and quarantine – protected populations
against infectious diseases. The decrease of epidemics due to
effective control measures and the rise of effective diagnostics and
therapeutics resulted in health care becoming synonymous with
clinical medicine.9 ‘Personal’ health care, focusing on preventive
and curative services at an individual level, became the domain of
health services and health professionals.
Modern health systems comprise organisations and people who act
to “promote, restore or maintain health”.21 Indicators measure the
success of service delivery, and include inputs; processes – access,
coverage, quality and safety; outputs; outcomes; and impact – equity,
risk protection and efficiency and improved health.22 PH expertise is
needed for the effective implementation of these approaches.
At a global level, health is seen to underpin social development.
Health was central to the Millennium Development Goals (MDGs)
and is key to the successive goals, the SDGs. The notion of ‘universal
health coverage’ (UHC),23 adopted by the UN General Assembly in
2012,24 promotes equity and access to health care which underpins
the NHI White Paper and the SDGs.19,25 As articulated in the NHI
White Paper, UHC requires strengthened health systems as critical to
the achievement of major health goals. PH skills and competencies

are core to the production of robust health research, evidence-
based policy and services management to support health systems
strengthening.26
Globally there is agreement that PH functions centre on identifying
the health status and needs of populations and their surveillance;
developing policy; implementing and evaluating promotive,
preventive and disease control programmes; ensuring the delivery
and quality of services; and developing a competent workforce that
is able to lead and develop partnerships.27–30
In many countries, PH institutes31 lead and co-ordinate PH functions
with capacity for surveillance, response to PH emergencies, and
the development of national diagnostic and reference laboratory
systems with transnational links. Key disease control programmes
are required (including those for chronic disease addressing
behavioural risk factors), as are solution- and action-orientated
research to identify new and improve existing health interventions.26
The US Centers for Disease Control and Prevention (CDC) proposed
16 6
a set of core functions, competencies and organisations that require
strengthening to maximise impact on health systems and population
20 IL
health.26 As valid epidemiological data are the foundation for
policy, decision-making and interventions, skilled personnel are
Y T
needed who can work on surveillance, track vital statistics, estimate
disease burden, and evaluate determinants of health and impacts
A N
of interventions. Personnel in health ministries who collect, interpret
M U
and translate data into policies, guidelines and recommendations
also need competencies in leadership and management.
4 ED
Investment in PH strategies to prevent and therefore reduce ill-health,
decrease health inequalities, and increase life expectancy, is ethical
and reflective of the right to health32,33 However, these goals are
difficult to achieve due to the complexity of PH challenges such as
O
social and economic inequalities, an underdeveloped evidence
G
base for PH interventions, and the demands of curative care which
overshadow longer-term investment in population health.34
R
The public health workforce
BA
PH professionals are people educated in PH and employed to
O
improve health through a population focus.35 They work in technical
EM
and line functions within health services, and in research and
specialist institutions, as managers, leaders, planners, implementers
or researchers. They work at all levels of health services – national,
provincial/state, district or municipal levels – and in defined spheres
Figure 1: Public health practitioners in South Africa
Other professionals
Others involved with postgraduate PH
with public health training involved with
public health
S A H R 20 1 6
Public health workforce
such as environmental health, health promotion or surveillance.
Professionals come from a range of occupational backgrounds –
doctors, nurses, health managers, health economists, environmental
health specialists, health promotion specialists and community
development workers.8 The range of PH workers in South Africa is
depicted in Figure 1.
A barrier to improved health outcomes is widespread health service
personnel shortages, which are the result of inadequate numbers
of trainees, geographical maldistributions, and losses due to
death, retirement, migration or career change.36 Poor knowledge
about the health workforce, its size, function, and optimal skill
mix, compounds this crisis.37 Globally, PH personnel are also both
insufficient in numbers8,38 and maldistributed. They have been
largely overlooked in national human resources health plans, and
PM
allocated a meagre budget. The reasons for this neglect may be due
to resource allocation prioritising curative health care39 in the face
of imperatives to reduce health costs. These shortages are profound
in resource-poor countries, as reported for the Democratic Republic
of the Congo, Ethiopia, India, Nigeria, Sri-Lanka and the Sudan.40
Competencies for PH professionals are in disciplinary domains
such as PH sciences, management, policy-making and assessment,
and skills are needed to manage complex work contexts such as
cultural competence, leadership and communication. A review of
competencies for low- and middle-income countries (LMICs) using
a Delphi technique identified the following PH competencies: the
ability to identify population health status, assemble evidence for
decision-making and generate performance improvement strategies;
management skills to implement decisions; report and research
proposal-writing skills, and intersectoral skills.41 In a commentary
on PH training and its relationship with health systems development
in sub-Saharan Africa, Fonn identified leadership in health and the
understanding of disease burden and the social determinants of
health as key competencies.42
development of public health in South Africa
A brief historical analysis accounts for the place of PH in the South
African health system. PH in South Africa developed along two,
often conflicting paths. The first entrenched the ‘status quo’ and
the other innovated models of health care responsive to social
determinants of health and was a precursor to the primary health
care (PHC) approach.
Health professionals
with postgraduate PH
training
Public Health Medicine
specialists
Doctors with
postgraduate PH
training
47
Colonial and early post-colonial period : 1652—1920
Due to colonial influences, South Africa’s early health system was
doctor- and hospi-centric, and by the end of the 19th century there
were hospitals in most major towns and in some rural areas built
by missionaries and mining companies for their employees.43 Most
hospitals and clinics were taken over by national, provincial and
local government departments of health under apartheid during the
third quarter of the 20th century.
In 1807, the first PH legislation was introduced due to the epidemics
of the 18th and 19th centuries that had decimated the population
of the Cape Colony. It provided for the registration of medical
practitioners, and for PH measures controlling infectious diseases
through disease notification and inoculation against smallpox.44
notable progressive exceptions), was laid in this early period of PH
development.
Pre-apartheid period
Health challenges in the 1920s and 1930s were due to the
development of urban slums and the growing TB epidemic affecting
mineworkers. Widespread migration of black people to cities
resulted in diseases caused by “overcrowding, poor sanitation, diets
and social disintegration”.54 During this period, the divide between
‘personal’ and ‘public health’ services in South Africa’s emerging
health system persisted, and ‘personal’ health services were mostly
delivered in racially segregated hospitals which were curatively
orientated. Services were inequitable along race, and urban and
rural lines.

PM
There are some examples of innovative health care in this era. One
A key initiative to transform the fragmented and inequitable nature
of the first hospitals for local indigenous people, Grey Hospital in
of South Africa’s health services – the National Health Services
King William’s Town, used trained orderlies before nurses were
Commission – led by Dr Henry Gluckman, was established by
appointed, and in 1858, the hospital started a three-year general

16 6
the South African Party in 1942. Its brief was to advise on the
practitioners’ training programme.45 In 1891, the Cape Colony
establishment of a National Health Service (NHS) for South Africa’s
introduced registration for nurses and midwives – the first legislature

20 IL
population. The impetus for its establishment was government’s
in the world to do so – due to the work of Henrietta Stockdale, an
recognition of the health problems of ‘poor Whites’, who had little
English nun and nurse who helped establish hospitals and maternity
Y T access to health care, a phenomenon that had grown during the
services in Kimberley.46 She developed the first nursing training
war.55
schools in South Africa, took nursing outside of hospitals into
A N
community and mining settings, and is credited with establishing Gluckman identified four major problems in the organisation of
M U

nursing as a profession in South Africa.47
As in Britain, South Africa’s early 20th century PH services were
4 ED
health care: poor co-ordination due to the three-tier health system;
maldistribution and shortages of human resources and facilities; an
inappropriate emphasis on curative and institutional care; and a

a response to epidemics that accompanied the development of

profit-orientated private practice focused on curative care in urban
emerging urban centres. The 1919 Public Health Act, the first robust
White areas.56 The Commission’s proposals extended beyond the
national initiative, modelled on the British system, and drafted and
Health Department to sectors such as town planning, housing and
O

adopted in response to the high mortality of the 1918 influenza

education. It recommended the establishment of a Ministry of Health
epidemic.48 The Act provided for a separate Department of Public
with a more “comprehensive scope”, and a reorganised health
G

Health and Minister at national level, and created administrative

service with policy-making and programming at all levels, within
functions at provincial and local government levels. It provided for
a NHS.57 Community health centres were proposed as the basic
R

‘basic measures’ in PH, which remained intact for nearly 60 years.

unit for service delivery, providing integrated health education and
BA

The Act established a fragmented health service – a three-tiered preventative care with curative services.58 A Department of Health
N

national, provincial and municipal system – which, with some was established in 1945, with Gluckman as its first Minister.57
O

modifications, persisted into the apartheid era. Resources and

The proposed service model was based on the work of a group of
authority for hospital services were given to provinces, a political
EM

concession to persuade the Boer republics to accept the Union.49
Hospitals were segregated racially with separate facilities or wards
for different racial designations. PH functions were focused at local-
authority level and, as in the UK, powers were given to municipal
Medical Officers of Health (MOHs) to control infectious diseases.
MOH appointments were subject to ministerial approval, with
preference given to doctors qualified in PH.
PH legislation in Europe enabled the provision of potable water,
and the protection of air and food from pollutants and contaminants.
Many commentators argue that these measures were introduced for
utilitarian reasons – the creation of healthy workers for commercial
purposes and fitter soldiers for military purposes.50–52 This social
engineering function is echoed in South Africa’s history, with PH
measures often being invoked to clear urban settlements, enabling
the development of segregated and apartheid cities.53
The basis for a more authoritarian and state-supportive role for
PH, which persisted through to the end of the apartheid era and
promoted the interests of the dominant social classes (despite
health workers led by Drs Sydney and Emily Kark who pioneered an
integrated model of clinical medicine and PH services – including
education, agriculture and income generation – in rural Natal, the
most notable example being the Pholela Clinic. Government did not
share their vision, and in 1939 the Secretary of Health, Eustace
Cluver, initiated centres to provide inexpensive services for African
people who had a high burden of tuberculosis (TB), venereal diseases
and malnutrition, who filled urban hospitals and were considered
a burden on the economy.49 The ‘Kark’ model, an example of
social epidemiology,59 was named Community-Orientated Primary
Care (COPC), and over 40 clinics were established in Natal and
elsewhere in South Africa during the 1940s and 50s. Teams of
trained lay health workers and professionals assessed, monitored
and delivered health care, focusing on individuals and communities
in defined populations.60 This model combined PH functions such
as prevention, promotion, surveillance, intersectoral work and
community participation with primary clinical care.
Resistance from district surgeons who saw the centres as a threat to
their practices – the care of the indigent49 – together with the hostile

48 S A H R 20 1 6
 Public health workforce

policy environment following the 1948 National Party ascendance
to power, resulted in the emigration of many professionals and the
end of the social medicine/COPC movement in South Africa.49
Health centres reverted to being “inexpensive clinics for the early
treatment of disease amongst Natives”.49
Nonetheless, the COPC legacy, together with China’s ‘barefoot
doctor’61 movement (later called ‘village doctors’), contributed to the
PHC approach, adopted by the WHO and reflected in the Alma Ata
Declaration,53 a 20th century milestone in PH. The PHC approach is
based on health being a human right, requiring the action of social
and economic sectors in addition to the health sector.62
Apartheid period : 1948—1994
In 1948, the National Party came to political power on an
In 1987, CHWs and community health projects coalesced into the
National Progressive Primary Health Care Network (NPPHCN), a
civil society advocacy group that included PH professionals, and
called for the implementation of a PHC-oriented service based on four
principles: “socio-economic development, community accountability,
concerned health worker practice and comprehensive care”.74
Member organisations had spearheaded earlier CHW projects.
The network became a space wherein government policies could be
challenged and a future national health system debated, but it did
not advocate epidemiological approaches to evaluate the impact of
health services.75
Some health projects were forerunners of functioning district health
systems. Services in ‘health wards’ were linked to rural district
hospital services, with hospital outreach services supporting clinic

PM
and community health services. Community participation in health
election platform that promised intensified racial segregation, and
care and community health committees developed in some areas,76,77
consolidated a racially segregated social system. Fragmentation of
pre-dating post-apartheid legislation mandating the establishment of
a hospicentric health service into 14 health departments resulted
formal structures to facilitate community participation.

16 6
in massive duplication of service delivery, waste and inequity.
There were marked differences in disease prevalence and mortality
The post-apartheid period

20 IL
between races, with Africans faring the worst and Whites the best.63
These outcomes reflected differences in living conditions, work, In 1994, South Africa transitioned to a non-racial democracy. The
nutrition and access to services. Y T extraordinary processes of health transformation after apartheid
are documented in detail elsewhere.25,66,78–80 This section focuses
Interestingly, even in this ideologically driven era, there was
A N
on the main features of post-apartheid transformation of the health
government recognition of a disorganised health service that was
system relevant to human resources in PH.
“bewildering in complexity and diversity … and fragmentation”,64 a
M U

comment made by the Secretary of Health in 1976. A new Health Act Major obstacles tackled were the unbundling of homeland
was introduced in 1977 to “provide measures for the promotion of and ‘own/general affairs’ health administrations, and building
4 ED

the health of the inhabitants of the Republic… and define the duties, management capacity for the new district health system. Inadequate
powers and responsibilities of authorities which render services”.65 numbers and inequitably distributed health professionals particularly
Local authorities were responsible for maintaining environmental affected rural areas and provinces. Restructuring involved merging
O

health, preventing communicable diseases, and health promotion the myriad health authorities and resolving disparities in salaries
and rehabilitation, and the head of these – a Medical Officer of and conditions of service. Incongruence of geographical boundaries
G

Health – was to be “a medical practitioner who possesses a degree with local government, as well protracted discussions about which
or diploma in community health registerable with the Medical, level of government (provincial or local) would be responsible for
R

Dental and Supplementary Health Professions Act of 1974”.65 “comprehensive service provision”, consumed energy and delayed
BA

implementation.79
N

In contrast, PHC, human rights and PH approaches, fuelled by political

opposition to apartheid, were central to civil society’s progressive Efforts to develop accessible services again focused on ‘personal’
O

health initiatives during the later apartheid era. In the 1980s, health services. New clinics were built, hospitals ‘revitalised’ and
EM

initiatives developed based on a commitment to socio-economic systems developed: management, human resources, pharmacy and
development, community accountability and comprehensive care. information systems, and tracking service performance. Progress
These included the establishment of community clinics by health was made in redistributing resources geographically and between
workers, including doctors, humanitarian and political activists, levels of care.54
e.g. Black Consciousness students;66,67 the formation of activist
Two initiatives, the Reconstruction and Development Programme
healthworker organisations such as the National Medical and Dental
(RDP) and the White Paper on the Transformation of the Health Care
Association (NAMDA),68 the Organisation of Appropriate Social
System in South Africa (1997), provided the policy and strategic
Services in South Africa (OASSSA)69 and the Health Workers Society
framework for the reform of the health system.78 These built on the
(HWS).70 Later, the policy frameworks for the new African National
ferment of policy development for a new South Africa during the
Congress (ANC)-led government were produced by progressive
last five to 10 years of apartheid rule. Earlier initiatives included the
academics, activists and PH professionals.71 Lay healthworker
ANC’s National Health Plan, which envisaged the restructuring of
involvement in health service delivery through community health
the health system based on the PHC approach, drawing inspiration
worker (CHW) programmes re-emerged in the 1970s along the lines
from the country’s earlier COPC experience and the Alma Ata
of the COPC initiative.72 Programmes focused on the training and
Declaration, and proposed decentralised services with health
deployment of lay health workers to understand communities’ health
centres being the foundation of service delivery.81
issues, enskilling them to undertake promotive, preventive, curative
as well as rehabilitative and palliative health care. Initiatives were The RDP emphasised the provision of housing, sanitation, water,
prominent in rural and poor peri-urban settlements and positively nutrition and health services as central to people’s needs. It provided
impacted on PH indicators and outcomes such as child and infant for free health care to children under six and to pregnant and breast-
mortality and health knowledge.73

S A H R 20 1 6 49
feeding women, and a primary school nutrition scheme.82 These
initiatives echoed the PH measures introduced in the UK in the 19th
Century where environmental changes such as housing, sanitation
and later, school meals, were prioritised by MOHs.83
The 1997 White Paper proposed the establishment of a unified
health system,84 emphasising the delivery of decentralised health
services closest to people, based on the principles of comprehensive
PHC, and laying the basis for the concept of a district health
system. The new National Health Act (61 of 2003) embodied this
commitment to develop a unified, district-based health system and
accessible health services,3 and made provision for community
involvement in health care.
The Act, whilst valuing population health perspectives, did not create
PH institutions or discuss explicit roles for a PH-trained workforce.
human resources for health and ‘vested interests’. Competing
interests between the Departments of Health and Higher Education
and Training, nursing bodies, and the Health Professions Council of
South Africa (HPCSA), have resulted in ineffective implementation of
health workforce strategies.85
Despite the establishment of the district health system in South Africa
and high levels of inputs, health outcomes in South Africa remain
below expectation.80,85 In 2012, men had a life expectancy at birth
of 56 years, and women, 62.93 HIV denialism during the Mbeki
presidency (1999–2008) undermined programmes for prevention
and treatment of the HIV and TB epidemics, which were the main
causes of premature death, and exacerbated the crisis in healthcare
delivery.94

With the abolition of the 1977 Health Act, MOH positions in local
authorities fell away, signalling a final end to positions in the health
system linked directly to PH training.
PM
Public health professionals in South Africa a
Historically in South Africa, positions were earmarked for doctors
with PH diplomas (DPH) in MOH posts. In the 1980s, PHM

16 6
specialists replaced the diploma doctors. After the end of apartheid,
The South African health workforce health service posts requiring PHM specialists fell away until

20 IL
recently, when a few provinces created provincial or district posts
By the end of the 20th century, South Africa was facing a serious
for PHM specialists. In addition, academic PH specialist positions
health workforce crisis.85,86 The 1997 White Paper84 highlighted
Y T were created and remain. These are ‘joint’ posts – provincial service
staff shortages and geographical inequities, and prioritised
posts linked to academic institutions reserved for registered PHM
training for clinical professions and skills development in health
A N
specialists. There are also few posts in the public sector for which an
management. It also proposed the establishment of a National
MPH degree is mandated.
School of Public Health. The 2001 Pick Report,87 the first post-
M U

apartheid government-commissioned human resources report for International experience is varied. The USA licenses medical
a PHC-oriented health service, proposed a restructured clinical specialists in ‘preventive medicine’, and in Australia, New Zealand
4 ED

workforce. It argued for expanding numbers and broader scopes of and Ghana there is licensing for medical specialists in PH, but with
practice for lower levels of nursing and pharmacy staff.88 Its terms few posts linked to specialist qualifications. In Canada, public health
of reference did not include the PH workforce per se and, besides physicians are the ‘gold standard’ for MOHs, who play a critical
O

training programmes and employment for a range of mid-level role in national and local health systems.96 On the other hand, in the
workers, many recommendations were not implemented. UK, PH specialists are appointed to posts with titles such as ‘public
G

health consultant’ or ‘specialist’.97 Over the past 15 years, PH

Important factors aggravating the workforce crisis were the decision
specialty in the UK has opened up to all health professionals exiting
R

to close many nursing colleges, resulting in decreasing nurse

specialist exams, not only medical doctors. However, in Europe, the
outputs,89 voluntary severance packages offered to senior staff,
BA

title of ‘public health specialist’ is reserved for doctors.98

N

freezing of posts resulting in declining number of public sector health

personnel,85 and the closure of many NGOs that were training and
O

Postgraduate public health training

employing lay health workers.79
EM

Historically in South Africa, PH training was largely provided for

Relatively few policies addressing the workforce crisis were
doctors through university medical or health sciences faculties,
implemented. Numbers of nurses registered, however, increased
training them to be managers in the health service. Although
between 1997 and 2007.85 Mid-level worker training was instituted
statutory responsibilities fell away, postgraduate training continued
after 2008, with slow integration into health services and minimal
and postgraduate training programmes were established, some
career-pathing.85,90,91 To improve the supply and retention of
with a focus on specific PH disciplines such as epidemiology,
doctors, community service for graduates was made compulsory
demography and implementation science. Currently, there are two
and is now recognised as a measure to redress health workforce
main routes for postgraduate PH training. One route, reserved
maldistribution, although with many weaknesses.91 Cuban doctors
for medical graduates, is through training offered by approved
were recruited as part of a binational programme and students
universities leading to a Master of Medicine (MMed) degree – a
were sent to Cuba for medical training. Scarce skills and rural
specialist qualification, enabling registration with the HPCSA as a
allowances78 and later, improved salaries for nurses and doctors
PHM specialist. The other route is through Master of Public Health
– Occupation Specific Dispensations (OSD) – were introduced.80
(MPH) programmes, which in addition to medical graduates, admits
Notwithstanding these initiatives, government recognised that students from a range of undergraduate health and social sciences
South Africa still had an inadequate and inequitable distribution degrees.b For the most part, these programmes were developed by
of health professionals, with insufficient numbers of pharmacists,
nurses, general and specialist doctors.5 Inadequate production was a This section on the PH workforce draws heavily on the doctoral work
of an author (VZ) who focused on PH-trained doctors, particularly PHM
exacerbated by emigration of health personnel and an internal specialists.95 There is less detail provided on other PH professionals (a
limitation) which requires further research.
drain to a growing private health sector.92 A health workforce crisis
b There are other PH qualifications, such as MScs and PhDs, but the main ones
persists and is in part due to ineffective structures for managing are MPH and MMed.

50 S A H R 20 1 6
 Public health workforce

Community Health departments previously offering PH training for
doctor managers.
There is confusion as to what exactly constitutes a ‘public health
specialist’ in South Africa. In practice, the term is no longer reserved
for doctors on the PHM specialist register. ‘Specialist’ designations
in PH have become broad and include a range of health and non-
health trained PH graduates. PH graduates are often referred to
as PH ‘professionals’ or ‘specialists’,99–101 and ‘specialist’ positions
in constituent disciplines of PH are advertised in the South African
media.c
on PHM specialists’ career paths, reasons given for not registering
were that: it was not a requirement for a job; it incurred cost but no
benefit; ignorance that registration was not effected automatically;
difficulty encountered in the process of registration; or emigration.95
Currently, registrar programmes are offered at all universities offering
medical training except Walter Sisulu University, and there are an
estimated 20 PHM specialists in training with an annual output of
six to eight graduates.105 Although the HPCSA register is notoriously
inaccurate,95 by the end of January 2016, there were 146 doctors
registered as either Community Health or PHM specialists.106

Public Health Medicine training
Specialist training posts in PHM for doctors are funded by provincial
health departments. Undergraduate university training qualifies
At the end of PHM training, some graduates are unable to find
employment utilising their skills, and there are few public sector
positions earmarked specifically for graduates with this training.95

PM
doctors to register as medical practitioners with the HPCSA. While Master of Public Health training
PH forms part of undergraduate medical training, postgraduate
Over the last 20 years, the scope and number of postgraduate
in-depth training facilitates expertise. Specialist training is through
PH training courses in South Africa have grown. Historically, non-
four-year full-time programmes in an apprenticeship model in

16 6
medical postgraduate PH training focused on epidemiology through
service settings. Most programmes include theoretical training.
Honours and later, Masters degrees. Adding in management and
This is a regulated process with HPCSA-designated training posts

20 IL
social sciences59 resulted in a range of MPH ‘specialisms’. Courses
linked to approved training programmes at universities. Graduates
are offered by universities through schools of public health within
are assessed by the College of Public Health Medicine (CPHM)
Y T faculties of Health Sciences.g These are one- to two-year course-
examinations according to a defined curriculum,d and are required
work degrees with a minor dissertation component, and are open to
to demonstrate competency in a range of skills,102 qualifying them
A N
health science, social science and science graduates.
to register as specialists with the HPCSA.
M U

The range of MPH ‘specialisms’ varies by university and includes

The PHM specialty was set up in 1975 to create a cadre of doctors
epidemiology, health economics, health promotion, monitoring
who could hold senior management and leadership positions in the
and evaluation, environmental and occupational health, social
4 ED

health sector in national, regional and metropolitan areas,103 with

and behavioural health sciences, and health services management.
broader competencies than were required by the MOHs. Modelled
Degrees can be undertaken on a full- or part-time basis and are
on the British specialty,104 the service role was expanded to include
residential or distance-based.
O

academia, research, health policy and leadership that aimed to

improve the health status of populations. By 2007, eight universities had produced 603 MPH graduates,
G

with 34% emanating from the Medical University of South Africa

Registration as a PHM specialist was either through the route
(MEDUNSA) and 13% from the University of Cape Town (UCT).107
of either a Master in Medicine degree (MMed) conferred by
R

By the end of 2010, 301 had completed or were completing MPHs

universities, or through a CPHM fellowship qualification. The CPHM
at UCT.95 International students, particularly from Africa, form a high
BA

was set up in 1975 and initially called the Faculty of Community

proportion of MPH graduates and by 2007, 32% of MEDUNSA
Health, but became the CPHM in 1998. The College started
graduates were international students.107 No recent collated data
O

examining in 1982, but a few doctors with MMed degrees qualified

on this demographic are available.
and registered before this.e Titles of the qualification included
EM

‘Community Medicine’ and ‘Community Health’, but in 1998 the
fellowship nomenclature changed to Public Health Medicine. Whilst
CPHM or MMed qualifications enable specialist registration with
statutory councils – the HPCSA from 1983f or its predecessor the
South African Medical and Dental Council (SAMDC) – not all those
qualifying are registered as specialists.
As of 2010, 177 doctors had successfully completed training
entitling them to register as specialists with the HPCSA. However,
only 60% had registered. From the doctoral work of an author (VZ)
c For example, see http://www.indeed.co.za/Public-Health-Specialist-jobs [9
December 2014] for adverts for 1) specialists in Monitoring and Evaluation
and 2) Prevention; [13 February 2016].
d Learning domains are: Health measurement and informatics; Behavioural
and social sciences; Occupational health; Infectious diseases, their
prevention and control; Environmental health; Non-infectious diseases and
their prevention; Health services management; Health economics. This
curriculum, developed over a decade ago, is currently being reviewed in the
light of competencies required in South Africa.
e Correspondence with Prof John Matjila, past Head of the Department of
Community Health, University of Pretoria, 4 June 2014.
f This is the first year that specialists with fellowships or MMeds were
registered on the HPCSA register.
While it is a requirement for some government posts, this hetero-
geneous degree is not a professional qualification with core
competencies that are standardised, nationally accredited and
monitored. It is not linked to a career track in either the public or
the private sector, and graduates’ career trajectories are unknown.
In summary, there are a range of PH professionals in South Africa.
These include personnel with defined skills such as environmental
health officers (EHOs); clinically trained professionals with
postgraduate PH training; social scientists with skills in health
promotion; health economists; health systems researchers; managers
who are able to identify and address systems failure; and doctors
who have undergone specialist training in PH.105 This is represented
in Figure 1.
g Unlike the American model where courses are typically run by autonomous
schools of public health, the standard model in South Africa is a School
within a Health Science Faculty.

S A H R 20 1 6 51
The Motsoaledi era reforms
Dr Aaron Motsoaledi recognised the poor performance of the health
system and soon after his 2009 appointment as the Minister of Health,
drew up a 10-point plan108 to improve health system performance
towards achieving the MDGs within a PHC approach.109 The
plan focused on a range of health services challenges that set
the stage for the introduction of NHI services: leadership; facility
and health workforce management; improving quality of care and
health infrastructure; the prevention and management of infectious
diseases, maternal and child health; and health promotion.109 These
challenges have been addressed by a range of National Department
of Health policy papers and interventions discussed in this section.
Health system reforms
Specific interventions and policies have been articulated to address
inadequacies and, through a PH lens, these are outlined in Table 1.
The earliest was the ‘re-engineering of PHC’ which consisted of
16 6
three streams that have been piloted and implemented since 2010.
These are the establishment of Ward-based PHC Outreach Teams
20 IL
(WBOTs), along the lines of the Brazilian Family Health Programme
(PSF); the establishment of District Clinical Specialist Teams (DCSTs);
establishment of School Health Teams.80,110
Y T
and a focus on comprehensive school health services through the
A N
The WBOTs deliver services beyond the boundaries of professions
M U
and facilities. They comprise nurses and community health workers
serving a geographic population.80 Their broad scope of practice
– household health assessments identifying risks, promoting health,
4 ED
screening, adherence support, and referrals85 – encompasses both
PH and individual care functions, and is reminiscent of the earlier
COPC model.
O
The DCSTs, focusing on maternal and child health outcomes, consist
G
of medical specialists and nurses who ensure that management
protocols are followed, provide in-service training and improve
R
health system functioning.111 Notably, PH professionals are omitted
from these teams, and are not mentioned in the PHC re-engineering
BA
strategy.
O
Other notable reforms are the establishment of the Office for Health
Standards Compliance (OHSC), a statutory body mandated to
EM
ensure compliance of the physical and operational environment
of PH facilities to provide quality care,112 and the ‘Ideal Clinic’
initiative,113 set up to ensure administrative, information, clinical and
oversight mechanisms for clinics in response to doctors’ reluctance to
work in PHC settings.114
Health workforce policies
Motsoaledi inherited a health system which in 2009, commentators
argued, had insufficient political leadership and “weak manage-
ment... [which] led to inadequate implementation of … good
policies… There [was] a substantial human resources crisis facing
the health sector”.54 The extent of this crisis is detailed elsewhere,85
and the implications for the PH workforce are discussed in this
section.
In efforts to redress past race-based exclusion from employment
opportunities, inexperienced managers had been appointed
to manage service transformation and human resources. Poor
leadership with little emphasis on implementation, monitoring and
52 S A H R 20 1 6
assessment of policies led to differences in provincial expenditure
and health outcomes.54
A recognition of the need for health workforce planning,
management, training and employment was articulated in the
2011 Human Resources for Health (HRH) policy document.5 This
echoes calls from the international health educational community
to train health professionals to be “systems-based, to improve
the performance of health systems by adapting core professional
competencies to specific contexts”.115
The HRH document noted that PH personnel were not institution-
alised and that personnel performing PH functions were “not
appropriately trained in epidemiology, planning and statistical
analysis”.5 It recognised the importance of health system reform and
acknowledged the skills-set needed to support this.
PM
The HRH policy document also echoed the memorandum of the
Heads of Public Health Medicine105 to the National Department
of Health that called for clarity about career paths for medical
and other PH professionals, and the establishment of PH units at
provincial and district levels. PH responsibilities outlined in the HRH
document were to develop provincial and district health strategies,
and monitoring and evaluation frameworks to evaluate the outcomes
of the re-engineered PHC model. The document quantified the
shortage of PHM specialists, citing 97 professionals employed
in 2011, which was half the required 0.04/10 000 population,
and estimated that it will take 14 years to achieve this target. It
is striking that Schools of Public Health that graduate hundreds of
MPH and other higher-degreed graduates annually have not lobbied
government vigorously about appropriate positions for them.
Other policy initiatives include the re-opening of nursing colleges,
incorporation of lay health workers through the PHC health teams,
and health manager training.111 Numerous management courses
and programmes have been implemented and task teams have been
appointed to address management and leadership training.91
The need for competent health managers, however, continues to be
voiced,116 and is mentioned in the NHI White paper, discussed in
this section.4 Research among stakeholders has explored the skills
for hospital managers,117 as well as the importance of a range of
both management and PH competencies for clinic managers and
district team leaders.118 Managers require context-related skills for
planning, controlling, organising and leading, and PH skills focused
on identifying health problems facing communities, conducting
community needs assessments, and managing and analysing data.
Some commentators have called for district-level managers to have
Masters-level training in PH skills, particularly in epidemiology.119
2015 health policy initiatives
As can be extrapolated from Table 1, the 2015 NHI White Paper,4
as the most recent initiative to overhaul the South African PH care
system, is premised on the district health system and gains made
from health system reforms such as PHC re-engineering.6 While
the White Paper emphasises the financing options for a national
health service, it also highlights the health system changes required
for introduction of an equitable, cost-effective needs-based health
service for South Africa. However, the White Paper is weak on
identifying concrete strategies to make PHC the ‘heartbeat’ of the
NHI with its concomitant emphasis on prevention.
 Public health workforce

The 2015 NAPHISA Bill proposes the establishment of an institution Public health units
for surveillance and ‘public health services’.7 Based on the CDC
Expertise to strengthen the health services is reflected in some
model to institutionalise PH core functions and competencies,26
provincial health plans. For example, the Western Cape Department
it partially addresses the gap for PH leadership to reduce the
of Health’s 2020 Health Plan121 aims to strengthen PH capacity. A
underlying risks to health in South Africa, given the lack of capacity
Health Impact Assessment directorate was established and mandated
to collect, analyse and use population health data to identify
to assess the impact of prevention initiatives and clinical services
appropriate interventions and to model possible gains including
on the population’s health status. This unit monitors outputs against
their cost-effectiveness.120 The proposed national PH institute,
annual performance plans and implementation, and provides “PH
NAPHISA, is to focus on surveillance, training and research on
intelligence, guidance based on national and international research
major threats to health – communicable and non-communicable
to demonstrate which interventions are most cost-effective”.121
diseases, cancers, and violence and injury. Its scope excludes
key drivers of ill-health such as the social determinants of health, This initiative echoes health sector PH functions which had been
occupational health and environmental health. The Bill intends to highlighted in 1994 by UCT’s incoming professor of Public Health,
assimilate staff from the National Institute of Virology (NIV) and the Jonathan Myers. His inaugural speech highlighted PH skills shortages,
National Health Laboratory Service (NHLS). Apart from the mention particularly at senior levels in the health services.122 He argued

PM
of these institutions and outlining the management of NAPHISA, the that PH functions in health plans and provincial organograms were
Bill is silent about the PH human resources required for the range dispersed in clinical services or in planning and human resources
of PH functions listed. In addition, its PH research and training departments, and called for the establishment of PH units to play a

16 6
mandates overlap with those of existing universities and national “critical intelligence function in a context of shifting health priorities
research institutes. and needs with appropriate health interventions”.122 In Myers’

20 IL
Whilst skills to transform systems are emphasised in these documents
and attention is given to the competencies of managers, insufficient
Y T
notice is taken of the need for a cadre of skilled health professionals
to develop and evaluate reforms. Policies are focused on clinical staff
A N
supporting or providing ‘personal’ health services, with scarcely any
M U

explanation of preventive health functions and the roles of the range

of PH trained personnel given in Figure 1.
4 ED

Table 1: Comparison of public health competencies and specialist roles in key 2011 and 2015 health policy documents

Component Re-engineering NHI White Paper4 Human Resources for NAPHISA Bill7
O

monograph1 Health policy5

Focus (year) Primary care reform (2010) Health financing to achieve National workforce policy Establishment of PH
G

universal health coverage (2011) institute (2015)

(2015)
Notion of ‘public health’ Public sector health Public sector health service; public sector health service, technical skills informing
R

service; an approach, skills, preventative health scheme technical skills – prevention, policy and implementation
prevention surveillance
BA

Public Health presence

Level in health system National (Silent) National National
O

Provincial Provincial work with provinces

EM

District work with local authorities

Structure Public Health Units (Silent) Senior managers National PH institute
Public Health Units
Adequate personnel? Lack of capacity (Silent) Inadequate numbers and (Silent)
distribution
Posts for personnel (Silent) (Silent) Limited numbers of posts Yes
Public Health Medicine (Silent) (Silent) Yes. For prevention, (Silent)
specialists? promotion, strategic
planning, monitoring &
evaluation
MPH graduates? (Silent) (Silent) (Silent) (Silent)
Gaps outlined and Capacity (Silent) Make role of PHM and other Leadership, surveillance
strategies Use Universities/MRC PH graduates more explicit and co-ordination
in management and strategy Provide training for public
health; co-operate with
other institutions
Public health professional (Silent) (Silent) Work with universities and Training and workforce
training College of Medicines of development for
South Africa to develop surveillance and in public
job-frameworks and agreed health
competencies
Increase output.

S A H R 20 1 6 53
Component Re-engineering NHI White Paper4 Human Resources for NAPHISA Bill7
monograph1 Health policy5
Stewardship for public health
Elements Interpretation of information Demographics Surveillance Co-ordination of
surveillance;

Epidemiology Evidence for interventions Conduct surveillance

Technology Strategic prioritisation Training

Health systems research
Whose responsibility? Family Physicians
National health department
PHM & professionals
Use data to inform policy/
priorities
Research for policy making;
‘basic’ research; operational
research
NAPHISA

Health Reform

a. District Clinical Specialist Teams
Composition Family physician, mental
health, oral health and
rehabilitation
PM
Principal specialists: Principal specialists: N/A
Obstetrics, Paediatrics, Obstetrics, Paediatrics,
Family Medicine, Family Medicine,
Anaesthetics; Midwife & Anaesthetics

16 6
PHC nurse
Deliverables District teams impacting Mentorship, clinical (Silent) N/A

20 IL
on social determinants of governance, data usage for
health planning
b. Ward-based PHC Outreach Teams
Composition
Y T
Nurses, CHWs reporting to
facility manager
Nurses, CHWs reporting to
facility manager
(Silent) N/A
A N
Deliverables Health promotion and Data on population health (Silent) N/A
prevention; Improved child status; health promotion,
M U

health outcomes adherence support, referrals

c. School Health Teams
Composition Nurses Mobiles with nurses N/A N/A
4 ED

Activities Screen, vaccinate, health Screen, refer, vaccinate N/A N/A

education
d. Management and Governance of Health Facilities
O

Strategy Produce and use district Delegate to hospitals, Institute of Leadership and Training and information
health plans district offices and PHC Management in Health Care
G

facilities
Information system for Upgrade information
monitoring
R

systems
Deliverables Strengthened district and Functional health system for Competency and (Silent)
facility management personal and non-personal management qualification
BA

health services framework for positions

Health Promotion
O

Strategy PHC outreach teams Multi-sectoral National Ward based outreach teams (Silent)
EM

Deliverables Health promotion & illness
prevention for health
communities
Quality Assurance
Health Commission
Health promotion to reduce Improved population health (Silent)
burden of disease

a. Office of Health Standards Compliance

Target institution (Silent) Health institutions Accreditation of tertiary N/A
hospitals
Deliverables (Silent) Certification and accredited Co-ordinating Council for N/A
to provide quality care Clinical Excellence.
b. Ideal Clinic
Target institution Pre-dates this intervention PHC facility N/A N/A

Deliverables N/A Quality clinical care Pre-dates this intervention N/A

responsive to communities
Other
General health personnel (Silent) (Silent) Integrate PH approaches Technical training and
training into training health workers information to health
professionals

54 S A H R 20 1 6
 Public health workforce

view, such units could house permanent PH staff – PHM specialists
or post-doctoral employees, together with registrars and Master’s
graduates. Academic PH specialists would have service roles and
co-supervise registrars who would rotate through district level units.
He warned that PH should play a critical role through advocacy and
research so that it did not merely prop up a failing health system.
Conclusion
Over 70 years later, in post-apartheid South Africa, the four health
system challenges identified by the 1942 Gluckman Commission
persist. Poor health service co-ordination also prevails – between
national, provincial and local health departments, and between
government departments with responsibilities relating to the social
marked to confirm competency. The competencies and career-paths
of these and other PH graduates, however, need further research.
Recent health service reform initiatives provide an opportunity
to redefine the role of PH professionals in South Africa. Roles
intimated in policy documents are chiefly technical – in surveillance,
information gathering and are advisory. They provide demographic
and epidemiological information to inform strategic planning and
prioritisation of services, monitoring and evaluation of services,
as well as health promotion and prevention. The policy, quality
assurance, research, training and implementation mandates are
mentioned without elaboration.
Minor attention is given to roles within health service structures at
national, provincial and district levels. We have noted, however, that
health managers require management and PH competencies to lead

determinants of health. Policies, particularly those affecting the
health workforce, are also often not congruent. Maldistribution and
shortages of human resources and facilities remain, together with
inappropriate emphases on curative and institutional care, as well
PM
health system reform and structures. In time, the entry requirement
for district managers could be a postgraduate PH qualification.
The advent of the NHI White paper and the NAPHISA Bill at the

16 6
as a profit-orientated private practice focused on curative care. The close of 2015 provides an opportunity for PH-trained professionals
solution to these challenges in 1942 was a national health service to advocate for and demonstrate their value. Their wide and

20 IL
– so too in 2016. versatile skills-base allows them to work in district, provincial and
national units, in technical and service roles. Their functions would
We have aimed to show that PH approaches, competencies and
Y T include population health needs assessments, support for planning,
trained personnel are essential for the success of development and
implementation, service evaluation and the control of health
A N
health systems agendas, and of universal health care globally and
threats. PH units at national, provincial and district levels should
nationally. Human resources for health, including PH in South Africa,
be established, and their design could build on the experience of
M U

are inadequate. Whilst PH skills are identified in key health policies,

existing units in the Western Cape and Gauteng. Their staff would
the range of PH professionals and roles is largely overlooked.
include multi-disciplinary teams with PH professionals, including
4 ED

There are some positions for PHM specialists but few for other PH
PHM specialists and other PH professionals, and where possible
professionals. Dedicated PH units are rare and their establishment
have strong relationships to academic institutions. They are a
remains ill-defined in current health policy.
potential resource providing ‘intelligence’ to inform the process of
O

The reasons for their poor prominence may be a combination of health system development and restructuring as part of the creation
factors. Firstly, historically, PH professionals in South Africa enforced of a NHI system for South Africa.
G

the ‘status quo’. After apartheid, earmarked PH doctor posts were

abolished, senior management was no longer the domain of doctors
R

or health professionals, and generic management skills were seen

as sufficient. Due to an insufficient evidence base and the long-term
BA

impact of PH strategies, ‘personal’ health services received priority.

O

The post-apartheid public sector health system was faced with

demands of managing clinical and curative services and resources
EM

were allocated to infrastructure, clinical personnel and managerial

systems. In addition, there were few credible practitioners with a
range of PH skills, other than in academia or in advocacy NGOs.
Some contributed to post-apartheid health policy and senior
management, but they were few in number and not recognised as
public health professionals for the work they did. As a result, the
discipline remained largely unknown and poorly understood.

However, the terrain of available and skilled PH professionals

has shifted. PHM specialists are still being produced, and have a
unique combination of clinical training and experience coupled with
theoretical and experiential training. They form part of the ‘family’
of public health practitioners in Figure 1. In addition, postgraduate
PH training, mainly through MPH degrees, has produced numerous
graduates over the past 15 years.

Is there a critical mass able to contribute, are they ‘fit for purpose’
and, together, have they shown their worth? Uneven competencies
among MPH graduates may be the consequence of burgeoning
‘specialisms’. These heterogeneous courses may need to be bench-

S A H R 20 1 6 55
References
1 United Nations Development Programme. Sustainable
Development Goals 2015 [cited 2016].
URL: http://www.undp.org/content/undp/en/home/
sdgoverview/post-2015-development-agenda.html
2 International Council for Science. Review of the Sustainable
Development Goals: The Science Perspective. Paris:
International Council for Science (ICSU); 2015.
3 Republic of South Africa. National Health Act 61 of 2003.
Government Gazette Vol. 469, No. 26595. Cape Town:
Government Printer; 2004.
4 South African National Department of Health. National Health
Insurance for South Africa: Towards universal health coverage.
Pretoria: National Department of Health; 2015.
5 South African National Department of Health. Human
Resources for Health South Africa: HRH Strategy for the Health
Sector: 2012/13–2016/17. Pretoria: National Department
of Health; 2011.
6 Barron P, Shasha W, Schneider H et al. Re-engineering
16 6
Primary Health Care in South Africa: discussion document
[unpublished report]. November 2010.
20 IL
7 National Public Health Institute of South Africa Bill.
Government Gazette, Notice No. 1092 of 11 November
2015. Cape Town: Government Printer; 2015.
Y T
8 Beaglehole R, Dal Poz MR. Public health workforce:
A N
challenges and policy issues. Hum Resour Health.
2003;1(1):4.
M U
9 Slomka J. Professionalism in public health education. In: Cuff
PA, editor. Establishing transdiscriplinary professionalism
4 ED
for improving health outcomes. Washington DC: National
Academies Press; 2013.
10 Turshen M. The politics of public health. London: Rutgers
University Press; 1989.
O
11 Beaglehole R, Bonita R. Public Health themes: historical and
contemporary. Public health at the crossroads: achievements
G
and prospects. 2nd ed. Cambridge: Cambridge University
Press; 2004. p.173–89.
R
12 Institute of Medicine. The future of public health. Washington,
DC: National Academy Press; 1988.
BA
13 Winslow CE. The untilled fields of public health. Science.
O
1920;51(1306):23–33.
EM
14 El Ansari W, Russell J, Wills J. Education for health: case
studies of two multidisciplinary MPH/MSc public health
programmes in the UK. Public Health. 2003;117(5):366–76.
15 National Collaborating Centres for Public Health. What are
the social determinants of health? [Internet]. [cited 20 May
2014].
URL: http://www.nccph.ca/docs/NCCPHSDOHFactsheet_
EN_May2012.pdf.
16 Edwards NC, MacLean Davison C. Social justice and core
competencies for public health: improving the fit. Can J Public
Health. 2008;99(2):130–2.
17 World Health Organization. The Helsinki Statement on
Health in All Policies. The 8th Global Conference on Health
Promotion, Helsinki, Finland, 10–14 June 2013 Helsinki:
World Health Organization; 2013 [cited 30 December
2014].
URL: http://www.healthpromotion2013.org/health-
promotion/health-in-all-policies
18 Andrews G, Wolmarans M. Demographic and health trends.
In: Matsotso MP, Fryatt RJ, Andrews G, editors. The South
African Health Reforms: 2009–2014. Cape Town: Juta and
Company Ltd; 2015.
56 S A H R 20 1 6
19 World Health Organization. Health in 2015: from MDGs,
Millennium Development Goals to SDGs, Sustainable
Development Goals. Geneva: World health Organization;
2015.
20 Rawls J. Justice as fairness: Political not metaphysical.
Philosophy of Public Affairs. 1985;14:223–51.
21 World Health Organization Western Pacific Region. Health
services development: The WHO health systems framework
2014. [Internet]. [cited 2 April 2014].
URL: http://www.wpro.who.int/health_services/
health_systems_framework/en/
22 World Health Organization. Everybody business:
strengthening health systems to improve health outcomes :
WHO’s framework for action 2007. [Internet]. [cited 15 April
2014].
PM
URL: http://www.who.int/healthsystems/strategy/
everybodys_business.pdf
23 Ooms G, Marten R, Waris A, Hammonds R, Mulumba M,
Friedman EA. Great expectations for the World Health
Organization: a Framework Convention on Global Health
to achieve universal health coverage. Public Health.
2014;128(2):173–8.
24 Dye C, Reeder JC, Terry RF. Research for universal
health coverage. Science Translational Medicine.
2013;5(199):1999e13.
25 Freeman M, Hunter J, Rispel L. Primary Health Care and
universal health coverage in South Africa. In: Matsotso MP,
Fryatt RJ, Andrews G, editors. The South African Health
Reforms: 2009–2014. Cape Town: Juta and Company Ltd;
2015.
26 Bloland P, Simone P, Burkholder B, Slutsker L, De Cock KM.
The role of public health institutions in global health system
strengthening efforts: the US CDC’s perspective. PLoS Med.
2012;9(4):e1001199.
27 Pan American Health Organization. Public health in the
Americas: Conceptual renewal, performance assessment,
and bases for action. Washington, DC: Pan American Health
Organization; 2002.
28 Office for State, Tribal, Local and Territorial Support Centers
for Disease Control and Prevention. The 10 essential public
health services: an overview 2014. [Internet]. [cited 5 April
2014].
URL: http://www.cdc.gov/nphpsp/documents/essential-phs.
pdf
29 Public Health Agency of Canada 2007–2008. Report on
plans and priorities. [Internet]. [cited 20 May 2014].
URL: http://www.tbs-sct.gc.ca/rpp/2007-2008/phac-aspc/
phac-aspc-eng.pdf
30 White F. The imperative of public health education: A global
perspective. Med Princ Pract. 2013;22:515–529.
31 Binder S, Adigun L, Dusenbury C, Greenspan A, Tanhuanpää
P. National Public Health Institutes: Contributing to the Public
Good. J Public Health Policy. 2008;29(1):3–21.
32 United Nations General Assembly. International covenant on
economic, social and cultural rights, 16 December 1966,
United Nations, Treaty Series, Vol. 993, p.3. [Internet]. [cited
16 April 2014].
URL: http://www.unhcr.org/refworld/docid/3ae6b36c0.html
33 Toebes B. Towards an improved understanding of the
international human right to health. Human Rights Quarterly.
1999:661–79.
34 Marks L, Weatherly H, Mason A. Prioritizing investment in
public health and health equity: what can commissioners do?
Public Health. 2013;127(5):410–8.

35 Gebbie K, Rosenstock L, Hernandez LM. Who will keep
the public healthy? Educating public health professionals
in the 21st century. 1st ed. Washington, DC: The National
Academies Press; 2003.
36 World Health Organization. Human Resources for Health :
Toolkit on monitoring health systems strengthening. 2009.
[Internet]. [cited 18 March 2016].
URL: http://www.who.int/healthinfo/statistics/toolkit_hss/
EN_PDF_Toolkit_HSS_HumanResources_oct08.pdf
37 Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury
M, et al. Human Resources for Health : overcoming the crisis.
Lancet. 2004;364(9449):1984–90.
38 Beaglehole R, Bonita R. Global public health: a scorecard.
Lancet. 2008;372(9654):1988–96.
39 Smith R, Beaglehole R, Woodward D, Drager N. Global
Public Goods for Health: health economics and public health
perspectives. Oxford: Oxford University Press; 2003.
40 Heller RF, Chongsuvivatwong V, Hailegeorgios S, Dada J,
Torun P, Madhok R, et al. Capacity-building for public health.
Bull World Health Organ. 2007;85(12):930–4.
16 6
41 Alexander L, Igumbor EH, Sanders D. Building capacity
20 IL
without disrupting health services: public health education
for Africa through distance learning. Human Resources for
Health. 2009;7(28).
Y T
42 Fonn S. Linking public health training and health systems
development in sub-Saharan Africa: opportunities for
A N
improvement and collaboration. J Public Health Policy.
2011:S44–S51.
M U
43 Jaques PH, Fehrsen GS. A history of health care in South
Africa until 1997. Adler Mus Bull. 2007;33(1):4–18.
4 ED
44 Fee E, Porter D. Public health, preventive medicine, and
professionalization: Britain and the United States in the
nineteenth century In: Fee E AR, editor. A history of education
in public health: Health that mocks the doctors’ rules. Oxford:
O
Oxford University Press; 1991.
45 Hofmeyr GS. Grey Hospital, King William’s Town. Its
G
formative years. S Afr Med J. 1986;70(10):615–7.
R
46 Loch DL, Stockdale M. Sister Henrietta, Community of St.
Michael and All Angels. London: Longmans; 1914. [Internet].
BA
[cited19 April 2014].
N
URL: http://anglicanhistory.org/africa/henrietta/home.html.
O
47 Marks S. Divided sisterhood: Race, class and gender in the
South African nursing profession. London: Macmillan; 1994.
EM
48 Phillips H. The origin of the Public Health Act of 1919. S Afr
Med J. 1990;77(10):531–2.
49 Marks S. South Africa’s early experiment in social
medicine: its pioneers and politics. Am J Public Health.
1997;87(3):452–9.
50 Leeder S. The scope, mission and method of contemporary
public health. Aust N Z J Public Health. 2007;31(6):505–8.
51 Watson P. Ideas: a history of thought and invention, from fire
to Freud. New York: HarperCollins; 2005.
52 Foucault M. The Birth of the Clinic: An Archaeology of
Medical Perception. London: Tavistock; 1973.
53 Phillips H. Plague, Pox and Pandemics: A Jacana Pocket
History of Epidemics in South Africa. Johannesburg: Jacana
Media; 2012.
54 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D.
The health and health system of South Africa: historical
roots of current public health challenges. Lancet.
2009;374(9692):817–34.
S A H R 20 1 6
Public health workforce
55 Carnegie Commission. Carnegie Commission Investigation on
the Poor White Question in South Africa. New York: Carnegie
Corporation; 1932.
56 Burrows EH. The Leyden tradition in South African medicine. S
Afr Med J. 1956;30(11):257–8.
57 Gluckman H. Acceptance Speech. Admission to Honorary
Fellowship of the College of Medicine of South Africa on 21
October 1983. Transactions of the College of Medicine of
South Africa. 1984;(Jan–June):12–5.
58 Phillips HT. The 1945 Gluckman Report and the establishment
of South Africa’s health centers. Am J Public Health.
1993;83(7):1037–9.
59 Yach D, Tollman SM. Public health initiatives in South Africa in
the 1940s and 1950s: lessons for a post-apartheid era. Am J
Public Health. 1993;83(7):1043–50.
PM
60 Longlett SK, Kruse JE, Wesley RM. Community-oriented
primary care: historical perspective. J Am Board Fam Pract.
2001;14(1):54–63.
61 Zhang D, Unschuld PU. China’s barefoot doctor: past,
present, and future. Lancet. 2008;372(9653):1865–7.
62 World Health Organization. Social determinants of health:
WHO called to return to the Declaration of Alma-Ata 2014.
[Internet]. [cited 28 February 2014].
URL: http://www.who.int/social_determinants/tools/
multimedia/alma_ata/en/
63 De Beer C. The South African disease: Apartheid health and
health services. Nottingham: Africa World Press; 1986.
64 De Beer J. A forward view of health services in South Africa.
S Afr Med J. 1976;50(11):431–40.
65 Republic of South Africa. Health Act 63 of 1977. [Internet].
[cited 24 April 2014].
URL: http://www.ehrn.co.za/download/act_health.pdf
66 Baldwin-Ragaven L, London L, De Gruchy J. An ambulance
of the wrong colour: Health professionals, human rights and
ethics in South Africa. Cape Town: Juta and Company Ltd;
1999.
67 Mzamane MV, Maaba B, Biko N. The Black Consciousness
Movement. In: The South African Democracy Trust, editor. The
road to democracy in South Africa (1970–1980). 2. Pretoria:
Unisa Press; 2006.
68 Abdool Karim SS, editor. NAMDA Conference Proceedings:
health and human rights. 25/26 January 1986, Medical
School, Durban, South Africa. Durban: National Medical and
Dental Association; 1986.
69 Hayes G. The struggle for mental health in South Africa:
Psychologists, apartheid and the story of Durban OASSSA. J
Community Appl Soc Psychol. 2000;10(4):327–42.
70 Pick W, Claassen J, Le Grange C, Hussey G. Health activism
in Cape Town: A case study of the Health Workers Society. S
Afr Med J. 2012;102(6):403–5.
71 London L. Health and Human Rights: What Can Ten Years
of Democracy in South Africa Tell Us? Health Hum Rights.
2004;8(1):1–25.
72 van Ginneken N, Lewin S, Berridge V. The emergence of
community health worker programmes in the late apartheid
era in South Africa: An historical analysis. Soc Sci Med.
2010;71(6):1110–8.
73 Makan B, Bachman M. Community health worker
programmes in the Western Cape province. Durban: Health
Systems Trust; 1997.
74 National Progressive Primary Health Care Network
(NPPHCN). National Progressive Primary Health Care
Network.Braamfontein1995. p.1–22.
57
75 Tollman SM, Pick WM. Roots, shoots, but too little fruit:
assessing the contribution of COPC in South Africa. Am J
Public Health. 2002;92(11):1725–8.
76 Ferrinho P, Robb D, Corneljie H, Rex G, editors. Community
Participation. Primary health care in support of community
development. World Health Forum; April 1993.
77 Liversage H. Prospects for Community Participation in
Development: A Critical Evaluation of the Valley Trust. Durban:
University of Natal; 1990.
78 Schneider H, Barron P, Fonn S. The promise and the practice
of transformation in South Africa’s health system. In: Buhlungu
S, Daniel J, Southall R, Lutchman J, editors. State of the
Nation: South Africa 2007. Pretoria: HSRC Press; 2007.
79 Kautzky K, Tollman S. Primary Health Care in South Africa. In:
Barron P, editor South African Health Review Durban: Health
Systems Trust, 2008; Ch 2. p.17–30.
92 Padarath A, Ntuli A, Berthiaume L. Human resources. In:
Ijumba P, Day C, Ntuli A, editors. South African Health
Review 2003/04. Durban: Health Systems Trust; 2003.
p.299–318.
93 World Health Organization. South Africa life expectancy at
birth 2013. [Internet]. [cited 10 June 2014].
URL: http://www.who.int/countries/zaf/en/
94 Nattrass N. Mortal combat: AIDS denialism and the struggle
for antiretrovirals in South Africa. Durban: University of
KwaZulu-Natal Press; 2007.
95 Zweigenthal V. The contribution of public health medicine
specialists to South Africa’s health system. Cape Town: 2015.
96 Medical Officers of Health Competencies Working Group. A
set of mimimum competencies for Medical Officers of Health
in Canada; final report. 2009. [Internet]. [cited 18 February
2016].

80 Naledi T, Barron P, Schneider H. Primary health care in SA
since 1994 and implications of the new vision for PHC re-
engineering. In: Padarath A, English R. South African Health
Review. Durban: Health Systems Trust, 2011; p.17–28.
PM
URL: http://nsscm.ca/Resources/Documents/Minimum%20
MOH%20Competencies%20-%20FINAL%20-%20Clean-%20
post-v5.pdf
97 Rahman E, Wills J. An evaluation of a public health

16 6
practitioner registration programme: lessons learned for
81 African National Congress. A national health plan for South
workforce development. Perspectives in Public Health.

20 IL
Africa. Johannesburg: African National Congress; 1994.
2014;134(5):259–67.
P.1–5.
98 Paccaud F, Weihofen A, Nocera S. Public health education
82 Ministry in the Office of the President. White paper on
Y T in Europe: old and new challenges. Public Health Rev.
reconstruction and development. Pretoria: Government
2011;33(1):66–86.
Gazette; 1994. [Internet]. [cited 23 November 2014].
A N
URL: http://www.gov.za/documents/index.php?term=&dfrom 99 McCoy D, Bennett S, Witter S, Pond B, Baker B, Gow J, et al.
=&dto=&tps[0]=5&subjs[0]=0&p=2 Salaries and incomes of health workers in sub-Saharan Africa.
M U

Lancet. 2008;371(9613):675-81.
83 Gillam S, Yates J, Badrinath P. Essential public health theory
and practice. Cambridge: Cambridge University Press; 2007. 100 Coulson N. Developments in the Use of the Mass Media at
4 ED

the National Level for HIV/AIDS Prevention in South Africa

84 South African National Department of Health. White paper
Victoria, British Columbia: Communication Intitiative; 2002.
for the transformation of the health system in South Africa,
[Internet]. [cited 2015 6 January 2015].
1997. [Internet]. [cited 28 February 2012].
URL: http://www.comminit.com/global/content/
URL: http://www.gov.za/documents/index.php?term=&dfrom
O

developments-use-mass-media-national-level-hivaids-prevention-
=&dto=&tps%5B0%5D=5&subjs%5B0%5D=0&p=2
south-africa
85 Pick W, Jacobs M, Buthelezi G. Human Resources for
G

101 Keikelame MJ, Murphy CK, Ringheim KE, Woldehanna

Universal Health Coverage. In: Matsotso MP, Fryatt RJ,
S. Perceptions of HIV/AIDS leaders about faith-based
Andrews G, editors. The South African Health Reforms:
R

organisations’ influence on HIV/AIDS stigma in South Africa.

2009–2014. Cape Town: Juta and Company Ltd; 2015. p.
Afr J AIDS Res. 2010;9(1):63–70.
160–80.
BA

102 Regulations for admission to the fellowship of the College of

86 Matsotso MP, Strachan B. Human Resources for Health
Public Health Medicine of South Africa, 2013.
for South Africa: HRH Strategy for the Health Sector
O

URL: http://www.collegemedsa.ac.za/view_exam.
2012/13–2016/17. In: Padarath A, English R, editors. South
aspx?examid=42
African Health Review 2011. Durban: Health Systems Trust;
EM

2011; p.49–58. 103 Archives of the Colleges of Medicine of South Africa.

Establishment of the College of Public Health Medicine. [14
87 Pick W, Khanyisa N, Cornwall J, Masuku M. Human
April 2014].
Resources for Health : A National Strategy. Pretoria: South
African National Department of Health; 2001. 104 Spencer IW. Postgraduate training and qualification
in community medicine in South Africa. S Afr Med J.
88 Hugo J. Mid-level health workers in South Africa: not an easy
1975;49(2):35–43.
option: human resources. In: Ijumba P, Barron P, editors. South
African Health Review 2005. Durban: Health Systems Trust; 105 Zweigenthal V, London L. Public Health Professionals in the
2005. p.148–58. re-engineered Primary Health Care model for South Africa.
[unpublished report]. Submitted to the National Department of
89 Breier M, Wildshut A, Mgqolozana T. Nursing in a new era:
Health for the Heads of Public Health Medicine: University of
The profession and education of nurses in South Africa. Cape
Cape Town; May 2011.
Town: HSRC Press; 2009.
106 Health Professions Council of South Africa. i-Register Pretoria
90 Cooke R, Couper I, Versteeg M. Human Resources for Rural
2016. [Internet]. [cited 13 February 2016].
Health. In: Padarath A, English R, editors. South African
URL: http://isystems.hpcsa.co.za/iregister/
Health Review 2011. Durban: Health Systems Trust; 2011;
p107–18. 107 Mokwena K, Mokgatle-Nthabu M, Madiba S, Lewis H,
Ntuli-Ngcobo B. Training of public health workforce at the
91 Lloyd B, Sanders D, Lehrman U. Human Resource
National School of Public Health: meeting Africa’s needs. Bull
Requirements for National Health Insurance. In: Padarath A,
World Health Organ. 2007;85(12):949–54.
Fonn s, editors. South African Health Review 2010. Durban:
Health Systems Trust; 2010; p.71–8.

58 S A H R 20 1 6
 Public health workforce

108 South African National Department of Health. National

Department of Health Strategic Plan 2010/11–2012/13
2010. [Internet]. [cited 24 April 2014].
URL: http://www.nationalplanningcycles.org/sites/default/
files/country_docs/South%20Africa/south_africa_strategic_
health_plan_2010-2013.pdf
109 Health Systems Trust. The 10-Point Pplan. Kwik Skwiz
[Internet]. 2010 [cited 24 April 2014].
URL: http://www.hst.org.za/sites/default/files/
ks_1V2_10pointplan.pdf
110 Pillay Y. PHC re-engineering in South Africa: are we making
progress? [Internet]. [cited 10 June 2014].
URL: http://www.phasa.org.za/phc-re-engineering-in-south-
africa-are-we-making-progress/.
111 Pillay Y. The implementation of PHC re-engineering in South
Africa. [Internet]. [cited 19 March 2012].

PM
URL: http://www.phasa.org.za/wp-content/
uploads/2011/11/Pillay-The-implementation-of-PHC.pdf
112 Office of Health Standards Compliance 2014. [Internet].
[cited 18 March 2016].

16 6
URL: http://www.ohsc.org.za/
113 South African National Department of Health. Ideal Clinic

20 IL
components and definition. Pretoria: National Department of
Health; 2015.
114 Freeman M HJ, Rispel L. Primary Health Care and Universal
Y T
Health Coverage in South Africa. In: Matsotso MP, Fryatt
RJ, Andrews G, editors. The South African Health Reforms:
A N
2009–2014. Cape Town: Juta and Company Ltd; 2015.
p.63–84.
M U

115 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et

al. Health professionals for a new century: transforming
4 ED

education to strengthen health systems in an interdependent

world. Lancet. 2010;376(9756):1923–58.
116 Pillay R. Managerial competencies of hospital managers in
O

South Africa: a survey of managers in the public and private

sectors. Human Resources for Health . 2008;6(4):1–7.
G

117 Pillay R. Defining competencies for hospital management.

Leadersh Health Serv. 2008;21(2):99–110.
R

118 Moyo S, Madale C, Ogunmefun C, English R. Research

Snapshot: Public health and management competency
BA

requirements for Primary Health Care facility managers at

sub-district level in the District Health System in South Africa.
O

Durban: Health Systems Trust; 2013.

EM

119 Nachega JB, Uthman OA, Ho YS, Lo M, Anude C, Kayembe

P, et al. Current status and future prospects of epidemiology
and public health training and research in the WHO African
region. Int J Epidemiol. 2012;41(6):1829–46.
120 Bradshaw D, Norman R, Lewin S, Joubert J, Schneider M,
Nannan N, et al. Strengthening public health in South Africa:
building a stronger evidence base for improving the health of
the nation. S Afr Med J. 2007;97(8 Pt 2):643–9.
121 Western Cape Government. 2020: The future of health
care in the Western Cape. A draft framework for dialogue.
November 2011. [Internet]. [cited 20 April 2014].
URL: http://www.westerncape.gov.za/other/2011/12/
healthcare_2020_-_9_december_2020.pdf
122 Myers J. Public health in the new South Africa: Will Cinderella
become queen? Inaugural lecture for Chair of Public Health.
University of Cape Town. Cape Town; 1994.

S A H R 20 1 6 59
60
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Disabling health: the challenge of incapacity
leave and sickness absence management in
6
the public health sector in KwaZulu-Natal
Province
Authors:
Rajen N . Naidoo i
Saloshni Naidoo ii

PM
Sujatha Hariparsad i

16 6
S 20 IL
ickness absence and long-term incapacity leave contribute substantially to the Management of ill-health
national service delivery challenges that are particularly evident in the public
Y T
health sector. The Auditor-General’s reports, and the Department of Public among healthcare workers
A N
Service and Administration, have highlighted these challenges. is not addressed at the
workplace, resulting in poor
M U

Recognising this as an area requiring intervention, the Department of Public Service

Administration developed the ‘Policy and Procedure on Incapacity leave and Ill- decision-making about fitness-
health Retirement’ and outsourced the management of sickness absence to private
4 ED

agencies. Management of ill-health among health-care workers is not addressed at to-work and work incapacity
the workplace; this has resulted in poor decision-making about fitness to work, and contributing to levels of
to work incapacity contributing to levels of absenteeism that exceed international
absenteeism that exceed
O

benchmarks for the healthcare sector.

international benchmarks for
G

This chapter reviews and critiques current approaches in the management of ill-
health among healthcare workers and assessment of their ability to work. A review the healthcare sector.
R

was done of the literature on current benchmarks and approaches to managing

sickness absence; secondary data from national and provincial Department of Health
BA

reports were also reviewed. A description is given of a small sample of short-term

O

sickness-absence cases (n=151) at a hospital in KwaZulu-Natal. Two of the cases are

highlighted.
EM

Healthcare workers experience a significant burden of disease caused by a range

of workplace hazards. This, together with inadequate institutional management
of sickness absence, results in a high number of lost work-days. In 2004–2006
and 2007–2009, the national cost of sickness absence was R7.3m and R8.8m
respectively, while the provincial costs were R208m and R303m respectively. In 2014,
sickness absence resulted in an average of seven days (senior management), eight
days (skilled supervisors) and eight days (lower categories), among all those workers
taking sick leave.

The authors propose an approach that ensures institutional responsibility for sickness
absence, involvement of the Employee Health Service in the case of five days of
absence, and involvement of the Occupational Medical Practitioner in cases of
repeated short-term absence and assessment of fitness to work.

i Discipline of Occupational and Environmental Health, School of Nursing and Public Health, Universit y of KwaZulu- Natal
ii Discipline of Public Health Medicine, School of Nursing and Public Health, Universit y of KwaZulu- Natal

61
Introduction
Healthcare workers (HCWs) form a substantial percentage of the
South African public sector workforce. The Human Resources for
Health (HRH) Strategy for the Health Sector 2012/13–2016/17
forms part of the State’s 10 Point Plan, and focuses on the
improvement, planning, development and management of human
resources within the National Department of Health (NDoH).1 From
2004 to 2010, the health sector has seen an estimated 37% increase
in the number of health professionals within the public sector.1
The health of HCWs, particularly those in the public sector,
persistently occupies a low priority in the broader South African
health agenda. The strategic plans and policy statements of the
NDoH reflect minimal attention to the need to ensure a healthy
workforce in the public health sector, or to how the health of the
HCW impacts on the delivery of the NDoH’s mandates. While this
is symptomatic of the approach for workers in the public sector in
general, the greatest impact of a lack of such focus is felt in key
16 6
service delivery arenas such as health and education.2
20 IL
One of the nine priorities of the National Development Plan 2030
is to “Improve Human Resources in the health sector” to achieve
an effective health system. While this focus centres on training
Y T
and accountability, it fails to take cognisance of the inadequate
management of the health of the ‘health workforce’, either in
A N
identifying work-related ill-health or managing the impacts of ill-
M U
health on the ability of workers to provide the services they have
been employed to deliver.
4 ED
Over the last few years medical surveillance of HCWs has increased;
however, this is largely to identify workers with tuberculosis (TB). As
such, the surveillance is not representative of a systematic approach
O
to determine the capacity of workers to perform their work functions
or to identify those at risk for developing occupational diseases.3
G
The current burden of occupational and non-occupational disease
being reported among HCWs in South Africa covers the spectrum
R
of communicable and non-communicable diseases.4–9 These health
BA
outcomes also vary across the different categories of HCWs, from
clinical (doctors, nurses, clinical assistants) to laboratory staff,
O
general assistants, and administrators in the healthcare sector. The
EM
growing burden of these diseases and their natural progression in
the presence of modern medical interventions can result in HCWs
developing related chronic health disabilities. These disabilities
can impact on the individual’s work performance in the healthcare
setting and impacts negatively on service delivery.
Inadequate management of chronic illnesses results in increased
sickness absence in the workplace. This takes the form of short-term
absences or long-term sick leave, and is a global phenomenon,
prompting much research and review in the private and public
sectors worldwide. In the United Kingdom (UK), the average
number of days of absence per employee per annum in the private
sector is approximately 5.5, compared with eight days for those
in the public sector.10 Approximately 140 million work-days have
been reported as lost each year to sickness absence in the UK.11
While in the majority of instances, these are short-term absences,
approximately 300 000 employees annually failed to return to work
following long-term absences. According to this 2011 report, the
total cost of sickness absence to the UK public sector was estimated
at £4.5 billion.
62 S A H R 20 1 6
Within the UK’s National Health Service (NHS), long-term absence
accounts for 56% of working days lost, and 70% of the costs of
absence.12 According to a 2009 report, staff absenteeism in the
NHS was 10.7 days a year, compared with 9.7 days per year in the
public sector, and 6.4 days in the private sector. This translates into a
loss of 10.3 million working days each year, costing the NHS £1.7
billion each year.13 Although the NHS is not directly comparable to
the South African context, the extent of the problem in the UK, with
its established management system, would suggest that this issue is
likely to be substantially greater in South Africa.
In other developing countries, the problem is considerably more
severe. In a district in Kenya, it was estimated that the average
health staff absenteeism (sickness and general absenteeism) rate
PM
was 25%, resulting in a loss of US$51 000 per month to each
health facility.14 In India, the estimated average absenteeism rate is
40%.13 In a study of several developing countries, including India,
Bangladesh, Uganda, Peru and Indonesia, health staff absenteeism
rates ranged from 25% to 40%, with higher-skilled staff (doctors) as
compared to general assistants being more likely to be absent.15
The need for appropriate disease management of HCWs in public
health facilities in South Africa is of growing concern. In this chapter,
we present the current legislative context and practices for disability
management of HCWs in public sector healthcare facilities in South
Africa. Using our experiences in public sector hospitals in KwaZulu-
Natal Province (KZN) and through a review of the literature, we
propose a model for managing HCW disability and sickness
absence in South African public healthcare facilities. We focus our
critique on data available for KZN, and compare these with national
data where available.
Methodology
We reviewed documents addressing the problem of sickness absence
in other countries, particularly the UK, with a special focus on the
NHS. Several government-level investigations have been conducted
by the NHS and they have made recommendations and proposed
solutions. These documents were identified using Google Scholar
and PubMed, using the keywords ‘sickness absence’ and ‘health
care’, and by means of a targeted search through the UK NHS
and UK government websites. The key documents identified were
“Health at work – an independent review of sickness absence”,11
“Guidelines on prevention and management of sickness absence”,12
and the “NHS Health and Well-being Review”.13
Reports were also reviewed from the Public Services Commission of
South Africa, the Department of Public Services and Administration,
and the national and KZN Departments of Health, accessed through
a Google search using the keywords ‘sickness absence’, ‘health
care’ and ‘South Africa’. A search was also done on the websites of
these government agencies. This approach provided the following
documents: “Report of the Auditor-General on a Performance Audit
of the Management of Sick Leave Benefits at certain National and
Provincial Departments”;2 “Evaluation of the Impact of the Policy
and procedure on Incapacity Leave and Ill-health Retirement (PILIR)
on Sick Leave Trends in the Public Service”;16 “Incapacity leave
and ill-health retirement: briefing by Departments of Public Service
and Administration, Health, Correctional Services. Committee

minutes”;17 “KwaZulu-Natal Department of Health Annual Report
– 2014/2015”;18 and “South African National Department of
Health Annual Report 2013/2014.”19 The latter two documents are
produced biennially by the national and provincial Departments of
Health and only the most recent reports were reviewed.
The authors also reviewed a small sample of employees from a single
department within a healthcare institution. All employees who had
made an application to the Human Resource Management (HRM) in
the previous cycle (January 2013 – December 2015) were reviewed.
Eighteen of 303 employees submitted 151 short-term incapacity
leave applications for short-term leave during the 2013/2015 leave
cycle. The authors reviewed all 151 applications.
The purpose of the document and patient review was to describe
and identify challenges with current disability management of
HCWs in the public health system with a view to proposing a model
for managing sickness absence at an institutional level.
In the subsequent section based on a review of the existing literature,
16 6
information is presented on the burden of disease among HCWs,
the legislative and policy framework for managing illness, and the
20 IL
process for incapacity management of HCWs. Further information
is presented on secondary data analysis of clinical assessments of
disability in HCWs.
Y T
A N
Burden of disease among healthcare workers
M U
The common communicable diseases reported among HCWs include
TB8,20 and HIV.5 The HIV prevalence rate among HCWs in two
4 ED
public sector hospitals in Gauteng was reported as being 11.5%,
with the prevalence rate among nurses being 13.7%.5 A systematic
review of the epidemiology of and programmatic response to TB
O
among HCWs in South Africa showed that the incidence of TB
among HCWs ranged from 138 per 100 000 population to 1 133
G
per 100 000 population. The reported prevalence rate for active TB
ranged from 1.4% to 5%, and that of latent TB infection from 26.6%
R
to 84%.21 There was no consistent association between age and risk
BA
category among the studies reviewed.
The availability of antiretroviral treatment (ART) for persons living
O
with HIV has resulted in an increased life expectancy,22 placing
EM
them at risk of complications associated with chronic diseases of
lifestyle. The presence of HIV infection has been shown to increase
the incidence of TB infection among HCWs,8 while complicated
and uncomplicated TB among HCWs has resulted in considerable
morbidity within this population.20,23 Complications associated with
TB have resulted in HCWs experiencing pneumonectomies, hearing
loss and neurological disorders,23 resulting in incapacity.
Obesity, diabetes, hypertension, non-infective respiratory diseases,
musculoskeletal disorders (MSDs), and dermatological diseases are
non-communicable disease presentations typically found among
HCWs.6,7,9,24 In a survey of 200 HCWs in a tertiary hospital in
Pretoria, the prevalence rates for obesity, diabetes and hypertension
were reported as 37%, 10.5% and 19% respectively.9 The
prevalence rate of lower-back pain in South African HCWs has been
reported to range from 25% to 58%,4,7 and a high number of HCWs
seek medical help for their musculoskeletal-related pain.7 The natural
complications associated with chronic diseases of lifestyle and
musculoskeletal disorders are likely to present within this population
as HCWs age. Asthma and allergic dermatitis due to latex exposure
S A H R 20 1 6
Incapacity leave and sickness
in the workplace is a well-recorded presentation among South
African HCWs leading to disability.4,6,25 The estimated prevalence
rate for latex allergy among HCWs is reported at 3%–12%.7,26–28
The actual prevalence of blood-borne pathogens among HCWs is
unknown but mimics that of the general population, with the risk
of occupational infection being the highest for hepatitis B (30%)
and lowest for HIV (0.3%).29 Data for occupation-related infectious
disease prevalence among HCWs in Limpopo Province submitted
to the Compensation Commissioner between 2007 and 2009
included TB (83.9%), cholera (10.7%) and chicken-pox (5.4%).30
Lack of organisational support, job demands and nursing of patients
lead to stress and burnout among HCWs.31–33 In the process of
caring for patients, HCWs are often victims of physical violence,
which is an added stressor in the work environment.34 The burden of
PM
caring for terminally ill patients and those living with HIV and AIDS
is also a source of stress among HCWs.35 These workplace factors
lead to psychosocial stress among HCWs, with the potential to
increase absenteeism in healthcare facilities.27 Absenteeism triggers
a vicious cycle as it leads to staff shortages, which contribute to
increased organisational stress resulting in further absenteeism.
Despite the extensive body of literature on the relationship between
working conditions and ill-health, neither the NDoH’s Human
Resources of Health strategy document,1 nor the country’s National
Development Plan 2030,37 nor the Lancet Special Issue on “Health
Challenges for South Africa”,38,39 provide any indication of the
need to address the health of the health workforce, or how the health
of the HCW impacts on the ability to address the health challenges
facing the country. Furthermore, despite our knowledge about the
prevalence of these diseases, our understanding of the disabling
chronicity among HCWs and its impact on their capacity to work is
largely unknown.
Legislative and policy framework for managing
illness in the Department of Health
The primary reason for HCW health status being obscured is the
approach of the NDoH and the healthcare institutions, in that ill
workers generally seek private health care, and no system exists
to monitor the health of the ill worker at the workplace. A national
guideline on medical surveillance is available,40 providing a
detailed approach to the pre-placement of workers, ongoing medical
surveillance, and sickness absence management. However, these
guidelines have not been translated into actual policy at provincial
or institutional level. In some KZN institutions, medical surveillance
programmes are managed by sessional doctors, mostly without
any specific training in occupational health, and in others there
is no medical doctor. Approximately four KZN hospitals employ
full-time doctors to manage their Employee Health Services (EHS).
This under-resourcing of EHS implies that the health of HCWs is
inadequately monitored by health professionals with the appropriate
skills. Doctors without the necessary training are not able to assess
hazards and the risks posed by such hazards, nor are they able to
recommend interventions to control these hazards or to implement
risk-based medical surveillance to detect workers who are likely to
acquire work-related diseases.
The World Health Organization/International Labour Organization
Guidance Note on improving HCW access to TB and HIV
63
management at their workplaces emphasises the need for employee
health services for HCWs to be instituted at both national and
workplace level.41 The NDoH’s 2014 National TB Management
Guidelines specify that medical surveillance programmes for HCWs
should be established and maintained.42 However, while these
policy documents are crucial for the detection of those likely to
develop occupationally acquired diseases, and are important in the
management of those with acute illness, they make no reference to
those HCWs whose ailments develop into disability.
To address work-caused health outcomes, most institutions implement
the legal requirements as set out in the Compensation for Occupational
Injuries and Diseases Amendment Act (130 of 1993) (COIDA).
Obtaining statistics at provincial or national level for HCW cases
submitted to the Compensation Commissioner for compensation is
difficult, as this process occurs at institutional level and no official
reports are published at provincial or national level. Based on limited
research, approximately 18.35% of 583 known cases of TB among
HCWs were reported to the Compensation Commissioner between
16 6
1999 and 2004 in hospitals in eThekwini, KwaZulu-Natal.43 In
Limpopo Province, only 56 cases of occupational disease among
20 IL
HCWs were reported to the Compensation Commissioner between
2007 and 2009.30
Y T
These findings are in the context of generally low reporting of
A N
occupational diseases to the Compensation Commissioner in South
Africa.44 In addition, the failure of COIDA to effectively address
M U
the rehabilitation of injured and diseased workers, either back
into the working environment or into alternative jobs, is a notable
4 ED
shortcoming.
Legislative context for incapacity management
O
of HCWs in the public sector
G
The employment, retirement and termination of services among
HCWs in public sector facilities is governed by the Public Service
R
Act (103 of 1994) (PSA).45 As determined by the Minister of
Public Service and Administration in terms of the PSA, incapacity
BA
leave is defined as additional sick leave granted at the discretion
of the employer. This leave allocation is guided by the Policy and
O
Procedure on Incapacity Leave for ill-health Retirement (PILIR).46 The
EM
PSA makes provision for the dismissal of an employee on the basis of
ill-health or incapacity, with due observance of the Labour Relations
Act (66 of 1995) (LRA).47 The Basic Conditions of Employment Act
(75 of 1997) (BCEA),48 the Employment Equity Act (55 of 1998)
(EEA),49 and the LRA47 provide a supporting framework to the
PSA. The Public Service Co-ordinating Bargaining Council (PSCBC)
Resolutions 7 of 200050 and 5 of 200151 provide further guidance
on the management of incapacity among HCWs in the public sector.
In terms of the BCEA, all employees are entitled to 36 days of paid
sick leave in a three-year cycle. The EEA allows for medical testing of
employees where needed,49 while the LRA47 allows for termination
of services on the basis of ill-health after full investigation of the case
and all potential alternatives have been considered.
COIDA makes provision for compensation of injuries and diseases
“arising out of and in the course of an employee’s employment”.
The procedures for compensation applicable to HCWs (and public
sector workers in general) differ somewhat from those workers in the
private sector. Government departments, including the NDoH, are
considered ‘employers individually liable’. As such, the Department
64 S A H R 20 1 6
does not pay annual levies to the Compensation Fund (exempted
employer status), and becomes responsible for all expenses arising
from occupational injuries and diseases, including medical aid,
compensation for temporary and permanent disability, as well as
funeral expenses, as defined by the law. In terms of the law, it is the
provincial Department of Health (DoH) that is directly registered as an
‘employer individually liable’ – and not the provincial administration
(Office of the Premier) or the NDoH. Thus, individual healthcare
institutions are not classified as ‘employers’ in their own capacity.
All institutional submissions must therefore be made through the
provincial head office of the DoH. The latter is then responsible for
onward submission of claims to the Compensation Commissioner.
The Commissioner will determine liability for the injury or disease,
and inform the DoH accordingly. If liability is accepted, the DoH
is then expected to cover the necessary costs (for medical aid,
PM
compensation for temporary disability and funeral expenses).
Pension, lump-sum compensation and dependents’ payments are
paid through the National Treasury (Pensions Administration).52
This ‘internalised’ liability in the compensation process leads to
further complexities in the management of HCWs with chronic
incapacitating illnesses. During the period of temporary disability as
defined by COIDA, an injured or diseased worker is either provided
with alternative work (generally without consultation of the EHS or
a doctor with occupational health training) or is placed on leave if
no alternative work is available. In the case of the latter, this leave
is generally incorrectly deducted from the employee’s standard sick
leave allocation. Once this temporary disability period is over,
and a decision on permanent disability is made, the employee is
rarely informed of this decision by the Commissioner. The employee
either continues with the alternative work indefinitely or remains
on sick leave, without the option of challenging the decision of the
Commissioner, as is provided for in law. It is unclear whether the
employee receives full pay throughout this period, or a portion as
stipulated by the Act.
Process for incapacity leave management in
public sector hospitals
In terms of the PILIR46 policy in public sector hospitals, HCWs
who have exhausted their 36-day sick-leave cycle may apply for
temporary incapacity leave, which may be short-term (≤ 29 days)
or long-term (≥ 30 days) incapacity leave. Up to the 36th day, the
leave process is based on sick notes submitted by the employee to
the line manager who then submits the documentation to the Human
Resources Department. There is no discussion about the absence
from work between any member of the institution’s management and
the employee up to this critical point, nor are any referrals to the
EHS activated.
The application to the Health Risk Manager (HRM) must be made
within five working days of the first day of absence (Figure 1). The
HCW submits the requisite documentation together with all medical
reports and certificates to the Human Resource Department of the
facility. Within five days, the employer must verify all documentation
and submit it together with a departmental report to the HRM while
granting the employee conditional temporary incapacity sick leave
for a maximum of 30 days. The HRM must acknowledge receipt of
the documentation within two working days and confirm in writing
that a response will be generated within 12 working days. The
 Incapacity leave and sickness

HRM reviews the application (primary assessment) and determines
whether (1) the application is invalid and hence no incapacity leave
will be granted, (2) the application is valid and incapacity leave
must be granted, (3) the application is valid but the applicant must
undergo specified treatment, or (4) the application is valid but the
applicant must undergo a secondary assessment. The employer
must, within 30 days, make a decision on granting or refusing
the employee’s application and inform the HCW in writing of
the decision. If incapacity leave is granted, the conditional leave
is converted to incapacity leave. However, if the application is
rejected, the employer must indicate whether the conditional leave
should be considered as annual leave or unpaid leave.
In the case of long-term incapacity leave, the HRM may request
that the HCW be subjected to a full assessment, which entails a
In terms of this process, the HRM essentially makes the decision
based on third-party medical reports. The HCW is not seen in
person by the HRM prior to the HRM making this decision; hence if
the documentation is incomplete or does not reflect the actual extent
of the HCW’s incapacity, inappropriate decisions can be made.
Sickness absence among healthcare workers in
the public sector
According to a report by the Auditor-General, in the three-year
period from 1 January 2001 to 31 December 2003, government
employees accounted for 12.6 million days of sick leave, at a cost of
R3 527 million.2 HCWs in the Western Cape Province and KZN took
approximately 600 000 and 1.8 million days of sickness absence

secondary or further medical assessment to determine functional
capacity. Based on this assessment, a decision is made as to whether
the HCW should continue with temporary incapacity leave and if so,
the duration of the leave period.
PM
respectively from January 2001 to December 2003, amounting
to R127 million and R461 million in each province respectively.2
It may be argued that this occurred before the introduction of the
PILIR strategy. The absence of data since implementation of the

16 6
PILIR in 2006 does not permit proper evaluation of this system.
If the HCW’s condition is determined to be a permanent incapacity, The Department of Public Service and Administration (DPSA)

20 IL
the employer may grant permanent incapacity leave for a maximum
of 30 days. During this period, the employer, based on the advice of
the HRM, determines the feasibility of either alternative employment
Y T
or duties or workplace adaptation to accommodate the HCW. If the
A N
permanent incapacity is such that the HCW cannot be effective at
his/her rank, then a process to terminate the employee’s services on
M U
presents data showing that in the period immediately following
implementation of the PILIR, the NDoH experienced a decrease of
just 846 sick days from a total of approximately 18 000 sick leave
days.16 Of all the workers taking sick leave during these two periods,
each worker took an average of 2.3 and 2.2 days respectively.
Clearly, the PILIR did not result in any meaningful improvement

the basis of ill-health is commenced. in the early days of its implementation.17 The latter report states
4 ED

Figure 1: Process flow for temporary/permanent incapacity leave and/or ill-health retirement application when an employee has exhausted
36 days in a three-year leave cycle
O

Employee submits temporary/permanent

G

incapacity leave and/or ill-health retirement

forms to employer within 5 days of absence.
R
BA

N
O
EM

The employer must inform the employee of the

outcome of his/her application within 30 days Employer verifies sick leave credits on PERSAL
from date of application. and the completion of relevant documentation
and refers to the health risk manager (HRM) for
assessment within 5 days.

Based on the advice from the HRM, the

employer must make a decision whether to
approve or refuse temporary/permanent leave The HRM acknowledges receipt of the
and/or ill-health retirement application. documentation and confirms in writing to
respond with decision within 12 days (primary
assessment).

Source: Adapted from the Public Service Commission, 2010. 53

S A H R 20 1 6 65
that for the NDoH, the cost of sickness absence during these two
periods (2004–2006 and 2007–2009) was R7.3m and R8.8m
respectively.16 At provincial level, the situation was substantially
worse: KZN as the leading province recorded 786 934 and 871
227 days of sick leave in these periods, at a cost of R208m and
R303m respectively (Tables 1 and 2).16 According to the recent KZN
DoH Annual Report, sick and disability leave cost approximately
R452m in 2014,18 compared with the NDoH’s bill of R15m in 2014
(Table 3).19 In 2014, the average length of sick leave taken at a
national level had substantially increased to 42 days19 compared to
the 2010 DPSA Report.16
Table 1: Total number of sick leave days taken in government
health and education departments per province,
2004–2009
The trends emerging from this data across the two periods suggest
that the rate of absenteeism among senior levels of staff may be
a cause for concern, with an almost 44% increase among senior
management and a 47% increase among skilled supervisors,
compared to only a 7.6% increase among the lower categories of
staff (Table 2). However, in terms of cost, it is the latter category that
contributes the greatest (89%) loss to the Department.
However, by 2014, these numbers had dramatically changed (data
not shown):18 in a single year, senior management had utilised 2 763
days of sick leave, while skilled supervisors had taken 84 060 days
and the lower categories had taken 341 403 days. This resulted
in an average of seven days (among senior management), eight
days (among skilled supervisors) and eight days (among lower staff
categories), of all those workers taking sick leave.

January 2004 to January 2007
December 2006 to June 2009
Total number of Total number
PM
Approximately 8.6% (n=16 234) of employees in the KZN public
sector applied for temporary incapacity leave to the HRM during
the period November 2006 to December 2012, having exhausted

16 6
Province Departments days taken of days taken their allocated 36 days over the three-year cycles. It is reported
Eastern Cape Education 550 819 585 217 that within the same period, 11.8% (n= 8 138) of the KZN DoH

20 IL
Health 463 793 446 633 employees had utilised all their allocated 36 leave days and had to
Free State Education 380 191 328 350 apply for temporary incapacity leave through the HRM.54
Health 231 323 218 513
Gauteng Education
Health
Y T
679 734
631 144
675 642
607 378
Apart from the 2010 DPSA evaluation,16 no further recent evaluations
of the PILIR have been conducted, despite HRM’s concerns about
A N
KwaZulu-Natal Education 741 733 708 935 the delivery of services as expressed to Parliamentary oversight
M U

Health 786 934 871 227 structures.17 According to statements provided to Parliament, various
government departments indicated that there were delays on the
Source: Adapted from Public Service Commission; 2010.16
part of the HRM in responding to the submissions.17
4 ED

Table 2: Total number of sick leave days taken per level and cost for the period from January 2004 to June 2009, KwaZulu-Natal
Department of Health
O

January 2004 to December

January 2007 to June 2009
G

2006
Department of Health level No of days Cost in Rand No of days Cost in Rand
R

Senior management (level 13–16) 808 891 634 1 468 1 918 008
Highly skilled supervisor (level 9–12) 23 648 15 903 822 44 755 38 697 036
BA

Lower – highly skilled production

(level 1–8) 762 433 191 239 911 824 976 262 589 297
O

Other 45 13 356 28 16 573

Totals 786 934 208 048 724 871 227 303 220 915
EM

Source: Adapted from Public Service Commission, 2010.16

Table 3: Leave utilisation in the South African National Department of Health54 and the KwaZulu-Natal Department of Health,53 2014

Percentage
Percentage Number of of total Average Total number
Total of days with employees employees number of of days with
Government number of medical using sick/ using sick/ days per medical
sector days certification1 disability leave disability leave employee Estimated cost certification
National2
Sick leave 11 153 96 1 543 100 42 14 261 044 10 704
Disability leave4 1 054 100 62 100 17 1 295 844 1 054
Province3
Sick leave 438 812 86 55 117 100 8 399 457 000 378 562
Disability leave 57 151 100 1 933 100 30 52 135 000 56 982

1 Total number of days in excess of two days

2 National leave utilisation from 1 January 2014 to 31 December 2014
3 Provincial leave utilisation from 1 January 2014 to 31 December 2014
4 Disability leave (includes temporary and permanent disability)

Source: The South African National Department of Health19 and KwaZulu-Natal Department of Health.18

66 S A H R 20 1 6

The 2014 data represent the second year of the last leave cycle
(2013–2015). It can be expected that the patterns of leave will vary
across the three-year cycle, with a greater number of employees
utilising allocated sick leave in the final year of the cycle.
Case study
The authors reviewed 151 submissions for short-term leave
applications, of which 58% had been decided upon by the HRM.
These employees accounted for almost 1 200 days of leave. None
of these employees was assessed by the institutional EHS prior to
submission to the HRM, despite having already taken 36 days of
sick leave in the previous three years. From this point forward,
despite the policy requiring a 30-day turnaround time, the average
turnaround time within our sample was 110 days, with 29 days’
delay from the date on which the employee had submitted the sick
note (range of days: 1–170 days), and 28 days (range of days:
1–136 days) in the Human Resources Department submitting to the
16 6
HRM. For the cases on which the HRM had reached a decision,
this was done in an average of 53 days (range: 9–124 days). Our
20 IL
estimates of the cost in lost productivity, based exclusively on income
(assuming Grade 1 levels) was approximately R613 000.
Y T
In the event of the HRM rejecting the application, the management
at the institution is faced with the dilemma of insisting that an ill
A N
employee continue working. Should the employee accept this
M U
position, the employee either returns to his/her usual area of work
or is arguably given ‘light duty’. In the first instance, the return to
work against the wishes of the employee creates much resentment,
4 ED
resulting in further poor work performance. The poor performance
and reduced productivity (possibly with increased frequency of
short-term leave) impacts on patient care and on fellow workers
O
in the Department. Should the employee be placed on light duty
(generally a decision made by line or senior managers, without
G
consultation of an occupational medical practitioner), the post held
by the employee is retained, resulting in a compromised workforce
R
in the employee’s original work area. In many instances, placing
BA
an individual on light duty results in that individual remaining in this
position until retirement, because there is no internal mechanism for
O
ill-health review.
EM
Two scenarios of sickness management
The scenarios presented in Box 1 and Box 2 reflect the presentation
and management of two HCWs on short- and long-term sickness
absence in the public health sector. These cases are representative
of the current situation in the sector.
S A H R 20 1 6
Incapacity leave and sickness
Box 1: Short-term sickness absence case study: Sick leave not
approved and employee to return earnings for non-
sanctioned days off
In the last three-year leave cycle (1 January 2013–31 December 2015), a
HCW from a healthcare institution had exhausted the 36-day allocation
within the first year. Despite this extreme usage, the HCW was not referred
to the EHS. In the following year (2014), the HCW took a further 36 days,
once again with no review by an occupational medical practitioner. In line
with the relevant policy, the HCW submitted sick notes on return to work
for each of the six spells of absence. On each occasion, applications were
submitted to the HRM. Following review by the HRM, each of these six
periods was declined. The HCW was informed that R13 669 was owed
for these non-sanctioned days off. Thus, an employee who is likely to have
some form of chronic ailment resulting in these above-average days of sick
leave, is now facing economic stress, still with no appropriate management
of the underlying ill-health.
PM
Box 2: Long-term sickness absence case study: Application still
under review and employee not at work
As in the previous case, a HCW had exhausted the 36-day sick leave
allocation early in the cycle. Subsequent submissions to the HRM for
short-term absences were approved. The HCW was not assessed by
the EHS at the institution at any point. Subsequently, due to the chronic
ailment diagnosis by and related advice from her private doctors, the
HCW applied for long-term sickness absence. Three periods of long-term
absence accounted for 185 days of sick leave. The HCW’s applications
are still under review by the HRM. Even during this period of long-term
absence applications, the HCW has not been assessed by the institution’s
EHS. It is likely that during the period of repeated short-term absences, a
proper clinical evaluation could have resulted in an earlier diagnosis of
the chronic ailment, appropriate medical intervention, and thus efficient
workplace management. To date, despite her chronic ailment and
long terms of sickness absence, no assessment has been undertaken to
determine the level of disability or impairment for the HCW to function
in her post. The HCW is currently not at work, and has submitted another
application for long-term sickness absence.
Discussion
Review and critique of the existing institutional processes for
managing the health of the health workforce
The current management of ill HCWs at health institutions is almost
non-existent and lacks a systematic approach. While workers will
report to the EHS for follow-up of their chronic illnesses or to collect
medication for chronic ailments, workers who fall ill or are chronically
ill are usually managed by private healthcare providers, with little or
no involvement of the EHS, until their prescribed sick leave (36 days)
usage over the three-year cycle is exhausted. Currently, a HCW
returning to work within two days has no obligation to present a
medical certificate, while those taking more than two days leave
and taking leave on more than two occasions during an eight-week
period are required to present a medical certificate to their line
manager, who submits this to the Human Resources Department for
placement in the employee’s personal file.
Line managers receive no guidance on how to manage HCWs
taking short-term sick leave, until the number of sick days taken over
the three-year cycle exceeds 36 days.
The PILIR policies of the DPSA entrench this ‘externalised’ approach
(directed by the employee’s private healthcare providers), largely
because the DPSA is focused on the control of lost productivity days
rather than on managing the health of the health workforce. This
outsourcing continues after the 36th day through management by
67
the HRM. In terms of appropriate service management, the ‘lost
productivity’ paradigm is not inherently flawed. However, it enables
management of the problem only after an extended period of ill-
health (36 days), and seeks redress from an external agent (the HRM)
thereafter. This persistent externalisation of ill-health management is
certainly flawed, and in attempting to manage sickness absenteeism
effectively, certain key assumptions are made. The current approach
assumes that:
➢➢ The private healthcare provider assessing a HCW has
adequate training in occupational health.
➢➢ When declaring a HCW unfit to work, the private healthcare
provider understands the nature of the healthcare working
environment and the work demands, and is able to determine
the level of incapacity of the worker in this context.
illness and determination of capacity to work, a one-third reduction
in sickness absence is possible, and would result in a saving of
approximately £555 million per year.13
The EHS-driven approach has been recognised in the UK, where an
assessment of sickness absence concluded that “where occupational
health was provided, 39% of companies recorded a decline in
short-term absence, whilst 28% experienced a reduction in long-term
absence”.10
As the roll-out of National Health Insurance (NHI) gathers pace, and
a renewed vigour in the Human Resource for Health Strategy takes
shape, the ‘health of the health workforce’ has to assume a central
position in the debate on restructuring our healthcare system. Failure
to recognise the impact of ill-health on the productivity of HCWs and
failure to adopt an internalised, systematic approach will continue to

➢➢ The line manager is able to determine the HCW’s level of
fitness to return to work, and place him or her appropriately
within the working environment.
PM
result in inadequate service delivery.
In developing the model proposed by the authors, the NDoH in
collaboration with the DPSA should adopt a multi-pronged strategy

16 6
➢➢ The human resources officer monitors and intervenes relating to the health of the health workforce. A comprehensive
appropriately when there are long or repeated periods of systematic evaluation must be undertaken, and the full extent of

20 IL
absence. the problem of absence from work (and ‘under-work’ in the ‘light-
duty’ approach) should be documented, along with the impact on
➢➢ When making a decision on an application, the HRM,
Y T employees, service delivery and patient care, and the resulting
understands the nature of the working environment of the
costs. This requires multi-stakeholder participation undertaken by
A N
specific worker and the associated work demands.
appropriate experts. We suggest that consideration be given to the
Rather than adopting a systematic approach to the ill-health of
M U

fact that use of external disability managers creates major pitfalls in

workers, the management of the institution (and the Department) managing ill-health in HCWs, and that this should be addressed.
engages the EHS when the HRM rejects an employee’s application.
4 ED

Developed in consultation with stakeholders and taking cognisance

Managers either accept the HRM recommendation and insist that
of local and institutional-level circumstances, specific strategies
the worker return to work, or believe that the recommendation was
should be implemented. The UK NHS response, along which South
incorrect and request the medical doctor at the EHS to intervene. In
Africa’s NHI is modelled, provides useful insights and some ideas
O

most instances, when insisting that the worker returns to work, the
for confronting the problem. It argues for a work-focused approach
employee believes otherwise and seeks out the assistance of the
G

that respects the right to sick leave, recognises that work is generally
EHS doctor. In both scenarios, the EHS doctor (who has not been
good for physical and mental health, and encourages management
involved in the prior management of the HCW, nor in making the
R

to develop temporary workplace adaptations to enable the HCW

decision on the HCW’s ability to work) is now expected either to
to work despite his/her adverse health status. The approach also
challenge the HRM decision or convince an ill employee that he or
BA

recognises that being ‘100% fit’ is not always the requirement

she should return to work. Clearly, this results in human resource
for work. The NHI argues that this work-focused approach is
O

mismanagement and frustration for the employer and the employee.

substantially different from their previous approaches to managing
EM

In summary, these data support the concerns that sickness absence
in itself compromises healthcare service delivery through the
numbers of days lost – in excess of 500 000 days in KZN at a
cost of about R452m in 2014 alone. This provides strong evidence
that the strategies employed by the DPSA (the PILIR model) are not
effective. Ensuring the health of the health workforce requires a more
focused, institutional intervention, driven by the appropriate experts
in occupational medicine.
Strategies for change
In the UK, the NHS recognised the challenges resulting from sickness
absence at its hospitals; it conducted a systematic analysis of the
problem13 and proposed institutional ‘evidence-based strategies’
to address these. The philosophy adopted was not framed around
control of sickness absence, but rather around employee wellness
and health.12 The Boorman Review estimated that the NHS loses
approximately 10 million working days each year due to sickness
absence.13 The Review estimated that through appropriate
intervention, early detection of ill-health, proper management of the
employee ill-health because “it focuses on what the employee can
do or might be capable of doing with reasonable help, rather than
what they cannot do due to illness or injury”.12
In the interim, a short-term strategy for managing ill employees at
healthcare institutions is essential. The management of these workers
must be internalised at the institutional level, such that appropriate
intervention can be implemented for individual workers well before
the 36th day in a three-year cycle is reached. The externalised
approach currently in use in the public sector serves to exacerbate
the problem, and undermines or even negates the health care of ill
workers.
Our proposal (Figure 2), while both simple and cost-effective,
does require the investment of resources. However, based on the
anticipated savings from lost productivity and improved patient
care, we argue that the return on investment may be substantial.
It is proposed that workers who are absent from work for more than
five days in a single sick-leave period or for 10 days collectively
over a two-month period, or those who are declared unfit to work

68 S A H R 20 1 6
 Incapacity leave and sickness

by a medical practitioner outside the institution for similar periods by the required evidence. If the disease is aggravated by work, the
of time, must be referred to the institution’s EHS for an evaluation. occupational medical practitioner, together with the line manager,
Line managers and human resource practitioners should be trained must determine whether alternative placement is necessary or job
to recognise this requirement, and to make appropriate and timeous modification is possible.
referrals to the EHS. These workers must be assessed by a doctor
If the worker is assessed as being totally unfit for work, and job
with training in occupational health. The responsibility of the EHS
modification or alternative work are not feasible, the worker should
doctor is to determine whether the worker is fit for usual duties, fit for
be processed for medical boarding. Again, this should be an
alternative or adapted duties, or completely unfit to work. In the latter
internal process, without the involvement of the HRM. However, the
two cases, the doctor must determine the duration of the modified
Department and its stakeholders should define ‘total incapacity’ by
work duties. The period of review must also be specified. If the ill
stipulating whether this would pertain to ‘own’ or ‘any’ occupation,
worker is still at work, the line manager assumes responsibility for
and providing guidance to the medical doctors involved in the
ensuring review of the HCW by the EHS. If the worker is totally unfit
individual assessments. For example, in the case of a HCW employed
and no longer at the institution, the Human Resources Department
as an Intensive Care Unit nurse, who is no longer able to work in
assumes responsibility for maintaining contact with the employee.
such an environment but is able to perform basic nursing duties – i.e.

In assessing the ill HCW, the EHS doctor is also expected to determine
whether any work-related factors can be shown to have caused or
exacerbated the illness. If so, the doctor must refer the worker to an
occupational medicine specialist for further decision-making on the
PM
total incapacity for ‘own’ occupation, but capable of working in any
other occupation – it should be determined whether this HCW should
be medically boarded or placed in another healthcare occupation in
keeping with his/her capacity, but vacating the original post, such

16 6
HCW’s ability to work. If, in the opinion of the specialist, the disease that service delivery is not compromised.
is caused by the HCW’s work environment, the procedure for

20 IL
reporting an occupational disease to COIDA must apply, supported

Y T
A N
Figure 2: Proposed institutional management of workers with ill-health and sickness absence
M U
4 ED

Employee absent for five days in a single leave period or

more than 10 days collectively over two months
O

On return to work, referred by Line If not at work, communication by HR, and

Manager to EHS prior to commencing work referal of employee to EHS
G
R

Occupational Medicine doctor reviews

report by employee’s personal physician
BA

and conducts assessment

O
EM

If work-related, compensation process commenced,

removal from work environment or workplace modification
implemented

Employee declared fit for Employee declared

Employee assessed fit to work
alternative duties unfit to work

Occupational Medicine doctor consults Period of removal from work together

with employee’s personal physician with medical review periods specified

By consensus, the employee If period of disability persists, then

to be returned to normal duties process of medical boarding initiated

S A H R 20 1 6 69
Clearly, institutional-level interventions that internalise the manage-
ment of ill HCWs require additional human resources – particularly
in strengthening the EHS at hospitals and clinics in the public
sector. We propose that a network of health professionals with
varying levels of skills in occupational health be established. Ideally,
there should be at least one occupational medicine specialist for
3 000 HCWs. While this may not be immediately achievable, a
decentralised approach integrated into the district health system
model is more practical. At regional hospital level, an occupational
medical specialist should be appointed to lead the EHS and to
provide outreach to district hospitals. As is the practice in any other
clinical service at healthcare institutions, this specialist should be
assisted by one to four occupational medicine registrars, depending
on the numbers of HCWs within the catchment of district hospitals
and clinics served by the regional hospital. These registrars,
Most of the available information from these agencies focuses on
cost savings rather than on the effectiveness of promoting the health
of HCWs. Generally, there is a lack of a systematic critique of the
current PILIR system and the functioning of the HRM. We trust that this
chapter opens the debate on this system, with a view to fundamental
policy change.
In presenting the information from these various government
agencies, we focused on KZN, and to some extent on the national
level. Although several of the national DPSA and PSC reports
contained information on the other provinces, we purposely chose
to describe only KZN scenarios because of the size of the provincial
public health sector, and because the impacts in costs and average
days lost were substantial in this province.
Another key limitation is the use of a small sample size from the KZN

PM
under the supervision of the specialist, would provide the required institution, largely for illustrative reasons, and therefore the results
specialist support at district level. In addition, depending on the are likely to be biased in various ways. However, this research
employee population at the district hospital, the appointment of was not intended as an analytic investigation, but rather as an

16 6
either a full-time or a sessional doctor with postgraduate training in exploration of the challenges. For reasons of confidentiality, we are
occupational health is required. unable to provide further descriptions of this sample.

20 IL
Currently, no healthcare institutions in the country have employed
occupational medicine specialists to manage their EHS. This limits Conclusion
Y T
the availability of evidence in support of our proposed model being
successful. However, anecdotal evidence from KZN shows where The ill-health of South Africa’s health workforce is having a disabling
A N
occupational medicine registrars, working under the supervision effect on the health of the nation. Substantial numbers of HCWs are
either incapable of performing the tasks for which they have been
M U

of the occupational medicine specialist, have been able to make

decisions on cases of long-term incapacity leave, resulting in either employed because of their health status, or have been inadequately
a return to work, job modification or alternative job descriptions. assessed and inappropriately managed through the existing systems
4 ED

of ill-health management. The State has attempted to improve control

Training of the occupational medicine specialist focuses on
of sickness absence through externalised management; instead, it
understanding and assessing the working environment, assessing
is necessary to improve the management of ill-health among the
the risk to health, performing a clinical evaluation of an employee,
O

health workforce, and to adopt a work-focused approach. Through

and determining the best placement of the employee within the
a concerted effort to support the health of the health workforce, it is
G

working environment, or modification of the working environment

possible to reduce the number of sick leave and disability leave days
to protect the health of employees. This can only be done at local
taken. Institutional-level approaches can simultaneously address the
R

or institutional level.
health of HCWs, ensure that more workers are at work, and improve
BA

Management of the EHS by an occupational medicine specialist productivity and patient care.
N

is further strengthened by the ability of the specialist to perform

O

monitoring and evaluation of the various programmes implemented

by the EHS, and to conduct trends analysis to identify at-risk
EM

environments or tasks. The latter allows for early intervention to

protect the health of employees.

Limitations
Apart from our generic description of the HRM process described,
we lacked access to information on the tendering process for the
issue of these contracts to the various HRMs. We also have no
information on the approaches adopted by the HRM in arriving at
various decisions on each case, the extent to which independent
specialists are used, and whether these specialists are trained in
occupational medicine. We submit that these gaps in information do
have an influence on the proposed model.

We relied substantially on the reports developed by the government

agencies in South Africa, including the Public Services Commission,
the Department of Public Service Administration and the national and
KZN Departments of Health and there are no means of validating
this information. We are, however, confident of the veracity of the
data, as these were extracted from national databases such as the
PERSAL system and from the HRM sources.

70 S A H R 20 1 6

References
1 South African National Department of Health. Human
Resources For Health South Africa: HRH Strategy for the
Health Sector 2012/13–2016/17. Pretoria: National
Department of Health; 2011.
2 Republic of South Africa. Report of the Auditor-General on a
Performance Audit of the Management of Sick Leave Benefits
at certain National and Provincial Departments. December
2005. [Internet]. [cited 16 February 2016].
URL: https://www.agsa.co.za/
Documents/Valueaddingauditreports/
PerformanceAuditreportsandmediarelease/
Performancearchives2005/tabid/256/id/559/Default.aspx
3 Adams S, Ehrlich R, Ismail N, Quail Z, Jeebhay M.
Occupational health challenges facing the Department of
Health: protecting employees against tuberculosis and caring
for former mineworkers with occupational health disease. In:
Padarath A, English R, editors. South African Health Review
2012/2013. Durban: Health Systems Trust; 2013.
4 Naidoo R, Coopoo Y. The health and fitness profiles of nurses
16 6
in KwaZulu-Natal. Curantionis. 2007;30(2):66–73.
5 Connelly D, Veriava Y, Roberts S, Tsotetsi J, Jordan A, DeSilva
20 IL
E, et al. Prevalence of HIV infection and median CD4 counts
among health care workers in South Africa. S Afr Med J.
2007;97(2):115–20. Y T
6 Phaswana SM, Naidoo S. The prevalence of latex
A N
sensitisation and allergy and associated risk factors among
healthcare workers using hypoallergenic latex gloves at
M U
King Edward VIII Hospital, KwaZulu-Natal, South Africa: a
cross-sectional study. BMJ Open. 2013;3(12):e002900.
7 Madiba S, Hoque ME, Rakgase R. Musculoskeletal disorders
4 ED
among nurses in high acuity areas in a tertiary hospital
in South Africa. Occupational Health Southern Africa.
2013;19(1):20–3.
O
8 Tudor C, Van der Walt M, Margot B, Dorman SE, Pan WK,
Yenokyan G, et al. Tuberculosis among health care workers in
G
KwaZulu-Natal, South Africa: a retrospective cohort analysis.
BMC Public Health. 2014;14:891.
R
9 Skaal L, Pengpid S. Obesity and Health problems among
South African healthcare workers: do healthcare workers take
BA
care of themselves? S Afr Fam Pract. 2011;53(6):563–7.
10 Chartered Institute of Personnel and Development. Absence
O
Management. 2014. [Internet]. [cited 12 February 2016].
URL: https://www.cipd.co.uk/binaries/absence-
EM
management_2014.pdf
11 Black C, Frost D. Health at work – an independent review of
sickness absence. Her Majesty’s Stationary Office. London.
Department of Work and Pensions; November 2011.
[Internet]. [cited 12 February 2016].
URL: https://www.gov.uk/government/uploads/system/
uploads/attachment_data/file/181060/health-at-work.pdf
12 National Health Service Employers. Guidelines on prevention
and management of sickness absence. London, 2013.
[Internet]. [cited 12 February 2016].
URL: http://www.nhsemployers.org/~/media/Employers/
Documents/Retain%20and%20improve/Guidelines%20
on%20prevention%20and%20management%20of%20
sickness%20absence%205%20November%202013.pdf
13 Boorman S and the Health and Wellbeing Review Team. NHS
Health and Well-being Review. UK Department of Health,
London. 2009. [Internet]. [cited 12 February 2016].
URL: http://webarchive.nationalarchives.gov.
uk/20130107105354/http:/www.dh.gov.
uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_108799
S A H R 20 1 6
Incapacity leave and sickness
14 Deussom R, Jaskiewicz W, Dwyer S, Tulenko K. Holding
Health Workers Accountable: Governance Approaches to
Reducing Absenteeism, IntraHealth International. [Internet].
[cited 29 March 2016].
URL: http://www.intrahealth.org/files/media/holding-health-
workers-accountable-governance-approaches-to-reducing-
absenteeism/holding-health-workers-accountable-governance-
approaches-reducing-absenteeism.pdf
15 Chaudhury N, Hammer J, Kremer M, Muralidharan K,
Halsey Rogers F. Missing in action: Teacher and health
worker absence in developing countries. Journal of Economic
Perspectives 2006;20(1):91–116. [Internet]. [cited 29 March
2016].
URL: http://siteresources.worldbank.org/
INTPUBSERV/Resources/477250-1187034401048/
ChaudhuryandothersMIA.pdf
PM
16 South African Public Service Commission. Evaluation of the
impact of the Policy and procedure on Incapacity Leave and
Ill-health Retirement (PILIR) on Sick Leave Trends in the Public
Service. Pretoria: The Public Service Commission; 2010.
17 Public Service and Administration Parliamentary Committee.
Incapacity leave and ill-health retirement: briefing by
Departments of Public Service and Administration, Health,
Correctional Services. Committee minutes. 11 March 2015.
[Internet]. [cited 12 February 2016].
URL: https://pmg.org.za/committee-meeting/20484/
18 KwaZulu-Natal Department of Health. Annual Report –
2014/2015. [Internet]. [cited 29 March 2016].
URL: http://www.kznhealth.gov.za/2014-2015-Annual-
Report.pdf
19 South African National Department of Health. Annual Report
2013/2014. [Internet]. [cited 12 February 2016].
URL: http://www.gov.za/documents/department-health-
annual-report-20132014
20 Von Delf A, Dramowski A, Khosa C, Kotze K, Lederer P,
Mosidi T, et al. Why healthcare workers are sick of TB. Int J
Infec Dis. 2015;32:147–51.
21 Nicol L, Mehtar S, Dheda K, Adams S, van der Walt M,
Osman M. A systematic review of the epidemiology of a
programmatic response to TB in health care workers in South
Africa. Evidence to Inform South African Tuberculosis policies
(EVISAT) Project. Western Cape Province, South Africa: 2014.
[Internet]. [cited 12 February 2016].
URL: http://www.afro.who.int/index.php?option=com_
docman&task=doc_download&gid=9448&Itemid=2593
22 Johnson LF, Mossong J, Dorrington RE, Schomaker
M, Hoffmann CJ, Keiser O, et al. Life expectancies of
South African adults starting antiretroviral treatment:
collaborative analysis of cohort studies. PLoS Med. 2013;
10(4):e1001418.
23 Padayatchi N, Daftary A, Moodley T, Madansein R, Ramjee
A. Case series of the long term psychological impact of drug
resistant tuberculosis in HIV-negative medical doctors. Int J
Tuberc Lung Dis. 2010;14(8):960–6.
24 Phiri LP, Draper CE, Lambert EV, Kolbe-Alexander TL. Nurses’
lifestyle behaviours, health priorities and barriers to living a
healthy lifestyle: a qualitative descriptive study. BMC Nurs.
2014;13(1):38.
25 Risenga SM, Shivambu GP, Rakgole MP, Makwela ML, Nthuli
S, Malatji TA, et al. Latex allergy and its clinical features
among healthcare workers at Mankweng Hospital, Limpopo
Province, South Africa. S Afr Med J. 2013;103(6):390–4.
71
26 Potter PC, Crombie I, Marian A, Kosheva O, Maqula B,
Schinkel M. Latex allergy at Groote Schuur Hospital –
prevalence, clinical features and outcome. S Afr Med J.
2001;91(9):760–5.
27 Brathwaite, N, Motala C, Toerien A, Schinkel M, Potter PC.
Latex allergy – the Red Cross Children’s Hospital experience.
S Afr Med J. 2001;91(9):750–1.
28 De Beers C, Cilliers J. Accurate diagnosis of latex allergy
in hospital employees is cost-effective. Curr Allergy Clin
Immunol. 2004;17:33–6.
29 Rossouw T M, van Rooyen M, Louw JM, Richter KL. Blood-
borne infections in healthcare workers in South Africa. S Afr
Med J. 2014;104(11:732–25).
30 Malangu N, Legothoane A. Analysis of Occupational
Infections among Health Care Workers in Limpopo Province of
South Africa. Glob J Health Sci. 2013;5(1):44–51.
31 Nyathi M, Jooste K. Working conditions that contribute to
absenteeism among nurse in a provincial hospital in the
Limpopo Province. Curantionis. 2006;31(1):28–37.
16 6
32 Rothmann S, van der Colff JJ, Rothmann JC. Occupational
stress of nurses in South Africa. Curantionis. 2006;29(2):
20 IL
22–33.
33 van der Colff JJ, Rothmann S. Occupational stress
of professional nurses in South Africa. J Psychol Afr.
2014;24(4):375–84.
Y T
A N
34 Kennedy M, Julie H. Nurses’ experiences and understanding
of workplace violence in a trauma and emergency department
in South Africa. Health SA Gesondheid. 2013;18(1),
M U
Art.#663.
35 Bam NE, Naidoo J. Nurses experiences in palliative care
4 ED
of terminally-ill HIV patients in a level 1 district hospital.
Curationis. 2014;37(1):1–9.
36 South African National Department of Health. Human
O
Resources For Health South Africa: HRH Strategy for the
Health Sector 2012/13–2016/17. Pretoria: National
Department of Health; 2011.
G
37 Office of the Presidency, South Africa: National Planning
R
Commission. National Development Plan: Vision for 2030.
Pretoria: National Planning Commission; 2011. [Internet].
BA
[cited 12 February 2016].
N
URL: http://www.gov.za/sites/www.gov.za/files/devplan_2.
pdf
O
38 Mayosi BM, Lawn JE, van Niekerk A, Abdool-Karim SS,
EM
Coovadia HM. Health in South Africa: changes and
challenges since 2009. Lancet. 2012;380(9858):2029–43.
39 Motsoaledi A. Progress and changes in the South African
health sector. Lancet. 2012;380(9858):1969–70.
40 South African National Department of Health. Occupational
Health for HCW in the National Health Service of South
Africa. May 2003. [Internet]. [cited 12 February 2016].
URL: http://www.kznhealth.gov.za/occhealth/OHmanual.pdf
41 World Health Organization/International Labour
Organization/Joint United Nations Programme on HIV/AIDS.
The joint WHO-ILO-UNAIDS policy guidelines on improving
health workers’ access to HIV and TB prevention, treatment,
care and support services – a guidance note. Geneva,
Switzerland; November 2010. [Internet]. [cited 29 March
2016].
URL: http://www.inpracticeafrica.com/~/media/Guidelines/
WHO_ILO_UNAIDS_HIV_TB.pdf
72 S A H R 20 1 6
42 South African National Department of Health. National
Tuberculosis Management Guidelines 2014. Pretoria:
National Department of Health; 2014. [Internet]. [cited 29
March 2016].
URL: http://www.hst.org.za/sites/default/files/NTCP_Adult_
TB-Guidelines-27.5.2014.pdf
43 Naidoo S. Compensation reporting of occupationally
acquired TB in health care workers in public sector hospitals,
eThekwini municipality, KwaZulu-Natal. Occupational Health
Southern Africa. 2006; 12(4):3–7.
44 Ehrlich R. Persistent failure of the COIDA system to
compensate occupational disease in South Africa. S Afr
Med J. 2012;102:95–7.
45 South African National Department of Public Service and
Administration. Public Service Act 1994, as amended by Act
30 of 2007. [Internet]. [cited 4 April 2016].
PM
URL: http://www.dpsa.gov.za/legislation.php.
46 South African National Department of Public Service and
Administration. Policy and Procedure in Incapacity Leave and
Ill-Health Retirement. 2009. [Internet]. [cited 12 February
2016].
URL: http://www.dpsa.gov.za/dpsa2g/cs_documents.
asp#pilir.asp
47 South African National Department of Labour. Labour
Relations Act 66 of 1995. [Internet]. [cited 12 February
2016].
URL: http://www.labour.gov.za/DOL/legislation/acts/labour-
relations/labour-relations-act
48 South African National Department of Labour. Basic
Conditions of Employment Act 75 of 1997. [Internet]. [cited
12 February 2016].
URL: http://www.labour.gov.za/DOL/legislation/acts/basic-
conditions-of-employment/basic-conditions-of-employment-act-
and-amendments
49 South African National Department of Labour. Employment
Equity Act 55 of 1998. [Internet]. [cited 12 February 2016].
URL: http://www.labour.gov.za/DOL/legislation/acts/
employment-equity/employment-equity-act
50 Public Service Co-ordinating Bargaining Council. Resolution 7
of 2000. [Internet]. [cited 12 February 2016].
URL: http://www.pscbc.org.za/wp-content/uploads/
Resolution-7-of-2000.pdf
51 Public Service Co-ordinating Bargaining Council. Resolution 5
of 2001. [Internet]. [cited 12 February 2016].
URL: http://www.pscbc.org.za/wp-content/uploads/
Resolution-5-of-2001.pdf
52 Department of Public Service and Administration. Application
of the compensation for occupational injuries and diseases
act (COIDA) in the workplace: a guide for government
departments. 2005. [Internet]. [cited 12 February 2016].
URL: http://www.dpsa.gov.za/dpsa2g/documents/
cos/2005/COIDA_04_2005.pdf
53 South African Public Service Commission. Evaluation of the
Impact of the Policy and procedure on Incapacity Leave and
Ill-health Retirement (PILIR) on Sick Leave Trends in the Public
Service. Pretoria: The Public Service Commission; 2010.
54 South African National Department of Health. Departmental
Steering Committee Report – A7: Pretoria: National
Department of Health; 2012.
Language barriers in health: lessons from the
experiences of trained interpreters working in
7
public sector hospitals in the Western Cape

Authors:
Ereshia Benjamin i
Leslie Swartz ii

PM
Linda Hering iii
Bonginkosi Chiliza iv

16 6
T 20 IL
here has been a longstanding call to employ trained interpreters to address The emerging themes suggest
language barriers in health care in South Africa. The international literature
Y T
shows that while trained interpreters can be effective, the existing sophisticated that interpreters experience
A N
models of upper-income countries are expensive and contextually inappropriate for their work as challenging
low-resource settings like South Africa. In community interpreter models, members of
on practical and emotional
M U

the community are given brief training in interpreting; these models have a number
of potential advantages for our context, but have not been sufficiently reviewed in levels, and that there is
4 ED

the literature. uncertainty about where

In this chapter, we describe the findings of a pilot project in which community they belong and fit into
interpreters were introduced to hospitals in the Western Cape to address the language
the health system.
O

barrier experienced by isiXhosa-speaking healthcare users. Using participatory

action research methods, we discuss emerging themes identified by the interpreters,
G

from mentor sessions conducted with them over a three-year period. The emerging
R

themes suggest that they experience their work as challenging on practical and
emotional levels, and that there is uncertainty about where they belong and fit into
BA

the health system.

O

The experiences of the interpreters raise crucial questions about current language
issues in our hospitals, while offering important insights into the potential to develop
EM

a multilingual health service for South Africa’s culturally and linguistically diverse
population. We make recommendations for the promotion of language access in
health services, the professionalisation of health interpreters, and suggest areas for
further research.

i Department of Psychiatry and Mental Health, Facult y of Health Sciences, Universit y of Cape Town
ii Department of Psychology, Facult y of Arts and Social Sciences, Universit y of Stellenbosch
iii General Specialist Hospitals, Department of Health, Western Cape Government
iv Department of Psychiatry, Facult y of Medicine and Health Sciences, Universit y of Stellenbosch

73
Introduction
In the 2012/13 edition of the South African Health Review, Nadia
Hussey1 suggests that the ‘overlooked’ language barrier remains a
crucial challenge to providing equitable and quality health care in
South Africa. She makes an important contribution to a growing
body of work on issues of language access in health care over the
last three decades,2–29 and in her recommendations to improve the
situation, echoes a longstanding call to employ trained interpreters
in health institutions across the country.
In this chapter, we describe an initiative to heed this call by the
Western Cape (WC) Department of Health (DoH), and highlight
lessons learnt from the experiences of the trained community
interpreters involved in the project. In introducing this work, we offer
of minority immigrants but the multilingual population at large.14
The result is that South Africa essentially has “… monolingual health
services in a multilingual society”.7
There is extensive literature on strategies to manage linguistic
diversity in health care in high-income countries with refugee
populations. However, Swartz et al.24 have recently shown that
the issue of language diversity is in fact greater in many low- and
middle-income countries, due largely to high levels of external and
internal migration. However, affordable models for making health
services available to a range of linguistic communities are scarce.
In South Africa, common language practices to address barriers in
health care include linguistic code-switching, the use of a few key

PM
a brief overview of language access issues in South Africa.
terms in the healthcare user’s language, and ad hoc arrangements5
involving the use of family members, hospital security guards, nurses
Language in South Africa
or household aides as informal interpreters.
South Africa is a multi-cultural and heteroglossic society with 44

16 6
While South African researchers have demonstrated both the
living languages (11 of which have official status), and is home
complexity of informal, ad hoc interpreting, and the potential to
to a large number of African refugees. South Africa scores 18th

20 IL
improve communication and health care,2,19,25 the use of informal
highest worldwide on Greenberg’s language diversity index,30
or untrained interpreters is more often seen as “not suitable or
which means that the likelihood of two people meeting at random
Y T
and sharing the same mother tongue is slim. Although language
trends are shifting, particularly with Afrikaans and English no longer
sustainable.”1,35,15 Informal interpreting has raised a number of
clinical, ethical and human rights concerns. Recent research has
A N
shown that in a relatively well-resourced tertiary mental health
being ‘white languages’,31 isiZulu remains the most common home
facility in the WC, where informal interpreting is conducted for
M U

language in South Africa. In the WC, the most commonly spoken

isiXhosa-speaking patients on an ad hoc basis, every interpreting
languages are Afrikaans (41.4%); isiXhosa (28.7%) and English
error likely to be of diagnostic significance occurred in the direction
(27.9 %).
4 ED

of making the patient appear more psychiatrically ill.12

English is only the fourth most-common home language in South
The lack of linguistic capacity among informal interpreters was
Africa,31 but is typically the preferred language of healthcare
demonstrated in two separate informal interpreting community
O

providers, resulting in more than 80% of medical interactions

groups.8,11 There is also concern that untrained interpreters may find
occurring across language and cultural barriers.9,18 In exploring
the triadic interpreter-mediated relationship particularly challenging
G

language as a barrier to care at a South African paediatric hospital,

to negotiate, and that the arrangements can have a negative impact
Levin15 found that only 6% of medical interviews were conducted
on healthcare user autonomy, informed consent and confidentiality.
R

partly or fully in the patient’s home language despite the patient’s

Informal interpreters, for their part, may run the risk of long-term
preference for the latter. This is a right which is enshrined in
BA

distress due to emotional over-identification with healthcare users.21

South Africa’s Constitution and national and provincial language
policies.32–34,17 According to these policy documents, healthcare
O

The need for trained interpreters

users have the right to be informed of and/or use interpreter
EM

or translator services “by choice regardless of their ability to
communicate in English” (emphasis added).a However, Williams
and Bekker26 found that “knowledge about public-language policy
in the State health sector is vague and inadequate” resulting in “little
accommodation” for users who prefer using their mother tongue.
The situation in South Africa is such that medical interviews
are generally conducted in the healthcare user’s second or third
language1 and it is therefore not surprising that the healthcare users
in Levin’s study15 experienced language and culture as more of a
barrier than South Africa’s notorious structural and socio-economic
issues. This is in line with international findings where “… the
language barrier is the primary challenge for meeting the healthcare
needs of the immigrant population”,35 except that in South Africa
the linguistically disadvantaged population is not made up solely
a The language rights of all citizens are enshrined in the Constitution,33
while the language rights of healthcare users are further elaborated in the
National Department of Health’s Policy on Language Services34 and the
Provincial Government of the Western Cape’s (PGWC) Language Policy.32
These policies also govern the establishment of the PGWC Language Unit
through which an external interpreter service (telephonic and face-to-face on
request) is made available to health establishments in the WC.
Interpreting in healthcare settings is a highly complex process that
aims to achieve “a workable interpretation which has use in the
clinical setting”21 and requires of the interpreter accomplishment
in both languages as well as familiarity with the healthcare user’s
culture, professional jargon,36,27 and emotional vocabularies.2
Words do not always translate easily or accurately, particularly
medical terms,29 and cultural and other socio-political differences
(e.g. educational levels) expressed in language through, for
example, proverbs, emotional undertones and humour, can prove
challenging for even highly trained interpreters.14
Interpreters also act as “cultural broker(s)”27 or “mediators”1
providing a ‘bridge’ between clinicians and healthcare users24 –
which adds another level of complexity to the interpreter-mediated
clinical encounter. The concept of culture is easily reified,
ignoring important differences such as social class, religious
beliefs, educational levels, degrees of acculturation, urbanisation
and explanatory models of illness between healthcare users and
interpreters, and both clinicians and interpreters may mistakenly

74 S A H R 20 1 6
 Language barriers

assume that the interpreter ‘knows’ the healthcare user’s culture and available only for simultaneous or conference interpreting, and
is able to offer judgments about the user’s behaviour.24 Fulfilling this therefore not for community or health interpreting.
role requires a sophisticated ability on the part of interpreters to hold
It is in this context that the Interpreter Project was implemented. The
their own cultural constructions37 while fostering and foregrounding
project is part of a larger action research project exploring a range
the clinician–healthcare user relationship.14,19
of issues related to language and interpreting in health/mental
Adding to this complexity is the fact that the intepreter-mediated health care, including the experience of interpreters (both untrained
health encounter reflects deep historical and contemporary socio- and trained), clinicians and patients.8,10–13,21,24
political, cultural and economic divisions.1,16 The healthcare users
An action research method was adopted as such an approach
who require interpreter services in the health system are frequently
is best suited to a deep exploration of the subjectivities and lived
among the most marginalised socially and economically,14 and often
experiences of participants, particularly in research areas with a
have particularly traumatic histories. In public hospitals, untrained
limited knowledge base.46,47
interpreters often share the healthcare users’ cultural and socio-
economic background and may overidentify with them, and may
The Interpreter Project
be vulnerable to these unconscious and unspoken dynamics and

alliances within the interpreter-mediated encounter, which heightens
the emotional impact of the work.38
Furthermore, language itself may be associated with traumatic
PM
Following years of grappling with language access and motivating
for interpreter posts to be created in hospital establishments, the
WC DoH engaged in a collaborative project with the Provincial
Government of the Western Cape (PGWC), Extended Public Works

16 6
memories and emotional meaning for interpreters, as suggested Programme (EPWP) and Stellenbosch University (SU) to train and
by Busch and Deumert.39 This is particularly relevant in the South place community interpreters in hospitals in the WC.

20 IL
African context where language continues to play a central role
in the political landscape and lived experience, particularly of In December 2011, 15 first-language isiXhosa speakers with formal
marginalisation, of ordinary people. Y T schooling to Matric level were recruited as health interpreters on a
contract basis by the EPWP. They underwent a three-day intensive
These issues are exacerbated in the context of mental health care,
A N
training course in Interpreting and Psychiatry by the Departments of
where assessment and treatment of all conditions are strongly Afrikaans and Nederlands, Psychology and Psychiatry at SU. The
M U

based on language. Disordered language and communication trained interpreters were then placed in six public hospitals in the
are commonly part of the symptomatology of serious mental WCb as interns and commenced duty in December 2011. However,
disorder; where this is the case, the question of communication and
4 ED

interpretation is not simply one of facilitating a discussion between
two people (clinician and healthcare user), each being able to
communicate well, but in different languages.
O
in March 2012, EPWP funding was reduced and the interns were
re-appointed as administrative interns by the DoH for a period of
12 months from 1 May 2012. At this point, 12 interpreters were
appointed due to attrition and resource constraints, with a further

The international literature has shown that the use of trained interpreter resigning to take up another post shortly thereafter.
G

interpreters raises the quality of care and levels of satisfaction for By May 2013, the DoH had successfully motivated for the creation
healthcare users with limited English proficiency to approximate of permanent posts and the remaining 11 interpreters were officially
R

that of healthcare users without language barriers.40–43 Trained employed as interpreters on salary level 4 by the WC DoH. Two
interpreter services are therefore now widely viewed as an essential interpreters subsequently resigned to take up other posts in the
BA

part of quality health care, and service models in higher-income Department of Health, which currently leaves nine interpreters
countries include sophisticated professional interpreter services such
O

formally employed by the DoH.

as Mothertongue in the United Kingdom.44 While there is much to
EM

All the interpreters are self-identified as African, with five females

be learnt from these services, they are expensive and contextually
and four males making up the remaining nine interpreters. The
inappropriate in South Africa.24
average age of the interpreters is 36 years, with an age range of
‘Community interpreting’ models hold more promise for low- 27–43 years.
resourced, culturally and linguistically diverse settings like South
To augment the intensive training course, ongoing mentoring and
Africa.45 Community interpreters are drawn from among the
support for the interpreters was conducted initially every fortnight
members of the community being served and have received some
and later monthly in order to facilitate the placement of the novice
training in interpreting. Community interpreting is usually done
interpreters, all of whom were working in health and mental health
in less formal settings, such as hospitals or police stations, and is
institutions for the first time. Once the interpreters were absorbed
usually done in consecutive mode, involving less formal speech.
into the health system in 2013, concerns were raised about the time
Community interpreting is cost-effective, offers task-shifting away from the hospitals required for the mentor sessions, and the
opportunities and, because interpreters usually share the sessions were eventually reduced to quarterly meetings.
healthcare user’s cultural and social background, promotes cultural
Using practice-based action research48 principles, two key meetings
competence.24 However, questions about whether such low-cost
were held, giving interpreters the opportunity to explore and develop
solutions work in practice remain unanswered.
themes reflecting their experience. Some of the emerging themes are
Until recently, dedicated interpreters were employed only in the discussed in the following section.
Department of Justice, despite the reliance on similar accuracy of
information by the Health Department.7 Furthermore, accreditation
b Alexandra, Lentegeur, Mowbray Maternity, Somerset, Stikland and
through the South African Translators’ Institute (SATI) is currently
Valkenberg Hospitals.

S A H R 20 1 6 75
Emerging themes
The experiences of the interpreters in this project are consistent
with local and international literature on the subject where the
work is described as “complex, challenging, exhausting, and
often invisible”.6,49,50 Additionally, the “negotiating of blurred role
boundaries and competing, often conflicting, expectations was an
additional work burden for health care interpreters and contributed
to feelings of being exploited, disrespected, misunderstood, or
excluded from membership on the health care team”.49
A key aspect of the experience of the interpreters in our project is the
question of where they ‘belong’, which is not unique to our project.
In a similar local community interpreter projectc conducted more than
a decade ago, there was also “conflict and disagreement, overt and
covert, about where interpreters fit into the new order of things”.6
Internationally, Rosenberg et al.51 also found that this “absence of a
place for interpreters in the institution … [and] not [being] part of the
healthcare or the administrative staff” was consistent with research
16 6
findings.
Another key aspect highlighted by this project is the underutilisation
20 IL
of trained interpreters, which is paradoxical given that the need for
such trained capacity is frequently expressed in the literature. While it
Y T
is possible that this is merely the result of logistical problems resulting
from a serendipitously introduced service, or of clinicians trying to
A N
do their best in a pressurised, challenging service environment,13
M U
local literature suggests that there is more to consider.
Conditions of service
4 ED
Discussions in the group were dominated by issues related to
conditions of service, particularly during the period when the
interpreters were transferred to the Health Department. This was
O
not surprising, given that this was the first time that most of the
G
interpreters were employed in government structures, and they knew
very little about how the hospital system worked. They used the
R
group space to learn about procedures from each other, and to
measure consistency of experience.
BA
Salary levels, job descriptions, performance evaluation and
O
career-pathing all came under discussion at various points over
the course of the mentor sessions. The new post of interpreter was
EM
created under the authority of the quality assurance manager and
the job description included an administrative function. It was clear
that the system was ill-prepared for the interpreters, with no clear
parameters on the administrative/interpretation split, no standards
for performance evaluation and the absence of career-pathing,
leading the interpreters to say frequently “… we don’t know where
we belong in the system”.
c In 1997, the National Language Project’s (NLP) Community Health
Interpreter Training and Employment Programme (CHITEP) trained 20
interpreters and placed them in 10 healthcare sites in the Western Cape.
The interpreters were first-language isiXhosa speakers with Matric, and
completed a two-month training course.6
76 S A H R 20 1 6
Nature of interpreting and interpreting challenges
The interpreters distinguished between what they referred to as
‘clinical’ and ‘general’ interpreting. Clinical interpreting involved
interpreting in a variety of clinical encounters, from individual
healthcare user–clinician interviews, to family and group sessions,
ward rounds, healthcare user meetings in wards, and telephonic
consultations with healthcare users and family members. They
described the demands as differing in these contexts, from long and
exhausting sessions in forensic wards, to shorter but high volumes of
sessions in busier admission units.
‘General’ interpreting involved patient care activities such as
helpdesk duties, assisting healthcare users to complete forms,
explaining rights and responsibilities, translating medication
instructions, conducting healthcare user surveys, and managing
PM
complaints and compliments. Helpdesks and queue marshalling
in general hospital settings were often experienced as stressful,
because of the high number of healthcare users as well as having
to deal with healthcare users who were frustrated after long hours
of waiting.
Administrative duties varied and included such tasks as data
capturing, filling out Review Board forms, recording admission and
discharge statistics, delivering incident and periodical reports, and
updating the forensic service database.
The issue of where interpreters ‘belong’ in the system arose
frequently. Interpreters felt that the nature of their work was largely
clinical, and that they should be seen as part of the clinical team in
the hospital.
At the same time, they noted that administrative duties ranged
between 20% and over 80% of their job descriptions. Interpreters
noted that while these functions presented an opportunity to
learn new skills and to be more competitive in the job market,
there was also the risk of losing their core identity as interpreter.
Additionally, this function required that interpreters stand in for
absent administrative staff who are remunerated on a higher salary
level, leaving some of the interpreters feeling exploited. Interpreters
also frequently expressed frustration with being evaluated on tasks
that they were not trained to do.
Interpreters battled to reconcile the low utilisation of their services
in some areas with the appreciation they received from healthcare
users for their services, which led to some questioning whether the
low utilisation was related to staff rather than healthcare user need:
The patients do need us, but do the staff?
The staff … do not treat me as an interpreter … they treat
me as a clerk.
This also raised the questions of access to interpreters. Some
clinicians used a booking system, while others expected them to be
available when needed. This was particularly difficult in the larger
psychiatric hospitals where there are large distances between wards
and the interpreters did not have access to transport. Interpreters
described instances of arriving at a ward after being called, only to
find an informal interpreter being used instead because they could
not get to the ward timeously.

This was juxtaposed with less frequent experiences of feeling valued
and respected by clinicians, as in instances of being called to
interpret despite the presence of isiXhosa-speaking staff members,
or in linguistically challenging encounters (e.g. Setswana/English-
speaking clinician; isiZulu/isiXhosa-speaking client and isiXhosa/
English/isiZulu-speaking interpreter).
Lack of in-hospital transport was one of the resources frequently cited
by interpreters as an obstacle to meeting their job requirements.
Others included access to computers to complete administrative
tasks such as minute-taking, and the absence of isiXhosa–English
dictionaries to aid them in the translation of more technical terms
and difficult concepts. Furthermore, interpreters frequently discussed
the lack of on-site supervision, and a lack of referral pathways to
interpreters with more experience or better training in scenarios
where engagements were difficult to interpret for clients.
A further challenge was that of the interpreters finding themselves
in compromising positions between clinicians and healthcare users.
16 6
These ranged from experiences of healthcare users saying to the
interpreter “Don’t tell the doctor … ” to a clinician reportedly telling
20 IL
the interpreter “Don’t worry about it, he’s talking nonsense” when a
healthcare user disclosed sexual assault by another healthcare user
during an interpreted session. Y T
A N
Emotional experiences of the work
Much of the emotional experience of the work was initially linked
M U
to the precarious position of the interpreters in the system and was
expressed as feelings of job insecurity, powerlessness and frustration.
4 ED
Low utilisation of the interpreter services in some areas, together
with the unchecked and ongoing use of informal interpreters, left
interpreters feeling undervalued. These feelings were reinforced
O
by the lower salary level assigned to interpreters, and their
G
perception that their administrative functions were more valued
than their interpretation services. Some interpreters experienced the
R
administrative tasks as demeaning:
The stuff we get asked to do are what others don’t want to do
BA
or there is no-one doing it.
O
The clerical work is available more than interpreting work.
EM
For one of the interpreters, this was particularly painful after she was
unsuccessful in her application for an administrative post:
I am working as a clerk … but I didn’t get the job … I’m the
joke of the hospital.
The interpreters frequently expressed that the hospital system does not
understand their role as interpreter and had unrealistic expectations
in this regard, e.g. the focus on patient numbers, and availability.
They also felt unsupported by the lack of access to resources, and the
lack of on-site supervision related to their interpreter function. Very
few clinicians offered them the opportunity for debriefing following
interpreted sessions, and with the mentorship group meeting less
frequently, they were often left to find their own supports. They
could appreciate the longer-term value in this, but sometimes found
acute periods of distress difficult to manage. One interpreter who
found a session with a child rapist to be “too close to home” as
the child victim was the same age as his daughter, sought support
from a fellow interpreter, in addition to the mentor group. Another
S A H R 20 1 6
Language barriers
interpreter who used the employee assistance agency following a
traumatic incident found it unhelpful, but with the encouragement of
the group, returned to the agency and worked successfully with a
different counsellor.
Feelings of vulnerability were linked to feeling poorly trained
to work in hospitals generally, and in psychiatry in particular for
those in such settings. Because they entered the hospital system
initially as administrative interns, and were later transferred to
permanent posts, the interpreters did not undergo the standard
induction and orientation programme for new appointees. Despite
ongoing requests, only one interpreter underwent the Introduction to
Psychiatry course offered in the hospitals.
Interpreters also felt ill-prepared for the effects of listening to the
traumatic experiences of healthcare users, and felt that training in
PM
counselling skills could help them contain the difficult emotions they
were left having to process.
Furthermore, their experiences of different cultural practices led one
interpreter to the realisation that “We are all Xhosa, but we are all
different”. The interpreters felt that they needed “a course on culture”
to help them fulfill their role as cultural broker, the complexity of
which became clearer during the discussions in the group.
As interpreters were exposed to various physical and emotional
risks, the question was raised of indemnity and protection by their
employer. Such risks included exposure to healthcare users who
could become aggressive, as well as interpreters witnessing abuse
and discrimination. With regard to the latter, one interpreter warned
another about formally reporting incidences:
if you write a report, you must protect yourself…it can be
used against you.
while another was concerned about the effect on relatioships
with other staff members:
… because they’ll feel like I’m spying.
Discussion
Despite the legislative ideal, the slow progress in addressing
language access in health services in South Africa has led a number
of authors to question whether the South African healthcare system
‘silences’ non-English healthcare user voices1,3,23 and benefits from
constructing them “as voiceless, dependent, powerless, healthcare
users.”10 Elkington and Talbot7 add that the healthcare system’s
‘reluctance’ may result from conflating language and race, and thus
“ironically further entrenching the notion that indigenous languages
do not deserve recognition and conveying to indigenous language
speakers that this aspect of their need is unimportant”.
Regardless of the factors that may be at play in mitigating the
promotion of language access, the question is: who is responsible
for the service? The interpreter-mediated session is traditionally
viewed as having three main players: interpreter, healthcare user
and clinician. Zimanyi52 suggests that “in reality, there are usually
more participants, although not always physically present, whose
contributions (or non-contribution as the case may be) also greatly
affect the outcome of such sessions”. These ‘institutional participants’
include health services, the State and the community. Our project
suggests that these levels, particularly those of the health services and
77
the State, have a direct impact on the provision of quality interpreter
services, and dialectically, on the experiences of interpreters.
At State level, the lack of policy guidelines and standards for quality
interpreting services, as well as lack of regulation of the language
professions7 impacts negatively on service development. This is
compounded by the lack of recognition of health interpreters by
professional bodies and the lack of accredited training programmes
available for community interpreters in general, and health
interpreters in particular. This leaves community interpreters without
the protection of ethical standards and practice guidelines.
At the level of health services, the WC DoH has gone a long way
towards operationalising national and provincial policy directives,
such as the National Development Plan 2030 (NDP 2030),53 by
creating interpreter posts in the Health Department. The project
policy is implemented, hospitals must ensure that all staff are familiar
with national and provincial language policies and the role that
interpreters play in complying with these.
Hospitals should also ensure that healthcare users are informed of
their right to express themselves in their mother tongue, and to use
interpreter services. In order to improve the interpreting services
provided, healthcare users should be invited to provide feedback on
the quality of these services.
Utilisation of interpreter services should be closely monitored, with
appropriate responses in the case of both under- and over-utilisation.
Here, practical responses such as integrated booking systems57 or
the use of interpreters across centres7 could be considered. More
importantly, the possible drivers of utilisation patterns should be
given adequate consideration at institutional level, keeping in

demonstrates what can be achieved through cross-sectoral
collaboration and decisive and innovative leadership.
However, as pointed out by Swartz et al.,24 the challenge in
PM
mind the institutional dynamics that may be at play. Courageous
conversations of this nature may need to be had, and may benefit
from external facilitation.

16 6
growing this fledgling service lies in examining the organisational Supervision and debriefing are crucial for interpreters to function
as well as the linguistic dimensions of the service. This requires a at optimal levels. On-site supervision is also more likely to support

20 IL
meaningful engagement with questions of how language issues, ‘team functions’ rather than ‘profession-specific functions’,6 thus
and interpreters, are viewed at the institutional level, and what the facilitating integration while responding to the unique dynamics at
Y T
institutional responsibility is for supporting and growing the service.
In practice, this means that institutions must take full responsibility for
institutional level. Our intervention has also highlighted the value of
peer supervision, and occasional joint supervision with members of
A N
the utilisation of interpreter services, and provide structural support the clinical team may also be necessary.
M U

for interpreters to fulfil their roles.6,50

The literature suggests a number of areas that should be addressed
At the level of community, a pertinent issue is the fact that healthcare
in good supervision. These are listed in Box 1.
4 ED

users are uninformed of their language rights and their right to

access interpreter services. Interpreters, however, through their Box 1: Elements of good interpreter supervision
close association with marginalised healthcare users,54 represent
an opportunity for the healthcare system to “inscribe traces of the
O

❖❖ Understanding of emotional, ethical, systems and workload issues

excluded other into the dominant language”,55 and thereby bring ❖❖ Understanding of complex dynamics in teams in different institutions
G

marginalised healthcare user voices into dominant discourses in

❖❖ Appreciation of the varying needs of patients in different wards
institutions. As pointed out by Brisset, et al.:56
❖❖ Focus on clarifying professional and personal boundaries
R

Interpreters are more than communication helpers … they

❖❖ Focus on the emotional impact of the work, highlighting problematic
are witnesses of how our institutions deal with socio-cultural
BA

reactions in this regard

and linguistic diversity. The extent to which interpreters are
❖❖ Recognition of the potential growth inherent in interpreting and
O

recognized by those institutions and their voices heard is a trauma

sign of how society and its members, particularly healthcare
EM

❖❖ Recognition of the dangers of one-off sessions with healthcare users

administrators and practitioners, handle differences. Ignoring or
who have particularly traumatic histories and presentations
depreciating interpreters’ contributions to the healthcare process
❖❖ Recognising signs of burnout in the interpreter
is equivalent to ignoring or depreciating our own diversity.

Sources: Splevins et al., 2010;38 Miller et al., 2005.50

Conclusion and recommendations

The aim of action research is to influence practice and the conditions
under which it occurs, as well as how it is understood.48 This
exploratory study points to the need for more in-depth research into
the experiences of community interpreters in our health settings, and
into key gaps at the level of hospital services, policy and training.
We offer suggestions to facilitate the integration of community
interpreters in health settings at each level.
Hospital services
With the task of providing access to health care and ensuring that
Although the issue of healthcare users also needing a clearer
understanding of the role of the interpreter5 and what to expect
from them did not emerge in the project’s thematic analysis, we
suggest that a pamphlet may be useful to present this information
together with guidance on healthcare user language rights and how
to access the service.
Evidence-based guidelines and standards of evaluation57,58 should
be developed to clarify the interpreter function. The question of
where interpreters belong in the system should also be engaged
with critically at institutional level, taking into consideration that
much of the literature recommends integration of interpreters into the
multidisciplinary team.49,59,60 Williams and Bekker26 go as far as to
suggest that there should be an:

78 S A H R 20 1 6
 Language barriers

acknowledgement of officially trained medical interpreters as a Research is needed to gain a deeper understanding of the
‘related profession’ in health services. Such acknowledgement interpreter’s role, and how to support the integration of interpreters
ought to be equal to the status of social worker, psychologist or into low-resourced, linguistically limited health systems such as ours.
physiotherapist.

This has implications for the salary levels of interpreters. There have
been attempts to address the question of appropriate remuneration
levels and utilisation (for example, appointing interpreters as
administrative clerks with interpreting as a key job output). While
such proposals may be expedient in addressing the issue of salary
level, the risk of entrenching the invisibility of language issues would
remain.
Acknowledgements
The Language Project is supported by a grant from the National
Research Foundation. We express our appreciation to the interpreters
in this project for their generous willingness to help us learn about
providing better health services.

Policy
All policies should be reviewed in terms of language access issues.

PM
For example, the NDP 2030,53 and a number of other key policy
documents, do not consider the impact of language barriers on
health outcomes.

16 6
The accreditation of health interpreters should be addressed, as
well as guidelines for practice and ethical standards. In this regard,

20 IL
registration as a ‘language practitioner’ under the South African
Language Practitioners’ Council Act61 may present an opportunity
for professionalisation. Y T
A N
Training
M U

There is an urgent need to develop formal training programmes to

prepare interpreters to work specifically in health and mental health
care in South Africa.7
4 ED

Although not a focus of this intervention, our work in the broader

project13 suggests that training of clinicians and supervisors/man-
O

agers would facilitate interpreter-assisted programmes. There is

also a need for clinicians to be aware of their profession-specific
G

responsibilities towards healthcare users with limited English

proficiency, and the use of interpreters in their fields.
R

Training on how to “collaborate with (and not … ‘use’)”51 inter-

BA

preters should be included in the formal training of all healthcare

professionals.
O

Research
EM

The vast majority of studies in this area have been conducted in high-
income countries,62,56 and while there is a burgeoning body of work
in South Africa dating from the 1980s,1–29 there is a clear gap in the
literature on the careful description and appraisal of innovative and
low-cost ways of attempting to address these issues in South Africa.

The experience of interpreters, and the impact of their personal

histories and trauma on their work, are also starting to come under
the focus of global research interests.38,54,56 This is particularly
pertinent to South Africa where, as stated by Penn,18 “the majority
of health interactions … are mediated by a third party whose role
is little understood”.

S A H R 20 1 6 79
References
1 Hussey N. The Language Barrier: The overlooked challenge 18 Penn C. Factors affecting the success of mediated medical
to equitable health care. In: Padarath A, English R, editors. interviews in South Africa. Curr Allergy Clin Immun.
South African Health Review 2013. Durban: Health Systems 2007;20(2):66–72.
Trust; 2013. p.189.
19 Penn C, Watermeyer J. When asides become central: small
URL: http://www.hst.org.za/sites/default/files/Chapter15_
talk and big talk in interpreted health interactions. Patient
LanguageBarriers.pdf
Educ Couns. 2012;88:391–8.
2 Anthonissen C. On interpreting the interpreter – experiences
20 Schlemmer A, Mash B. The effects of a language
of language practitioners mediating for the TRC. J Multicult
barrier in a South African district hospital. S Afr Med J.
Discour. 2008;3(3):165–88.
2006;96(10):1084–7.
3 Deumert A. ‘It would be nice if they could give us more
21 Smith J, Swartz L, Chiliza B, Kilian S. Mediating words,
language’ – serving South Africa’s multilingual patient base.
mediating worlds: interpreting as hidden care work in
Soc Sci Med. 2010;71(1):53–61.
a South African psychiatric hospital. Transcult Psychiatr.
4 Drennan G. Counting the cost of language services in 2013;50(4):493-514
psychiatry. S Afr Med J. 1996;86(4):343-5.
22 Swartz L. Culture and mental health: a Southern African view.

PM
5 Drennan G. Psychiatry, post-apartheid integration and the Cape Town: Oxford University Press; 1998.
neglected role of language in South African institutional
23 Swartz L, Drennan G. Beyond words: notes on the
contexts. Transcult Psychiatr. 1999;36:5–22.
‘irrelevance’ of language to mental health services in South
6 Drennan G, Swartz L. A concept over-burdened: institutional Africa. Transcult Psychiatr. 2000;185–201.

16 6
roles for psychiatric interpreters in post-apartheid South Africa.
24 Swartz L, Kilian S, Twesigye J, Attah D, Chiliza B. Language,
Interpreting. 1999;4(2):169–98.
culture and task-shifting – an emerging challenge for global

20 IL
7 Elkington EJ, Talbot KM. The role of interpreters in mental mental health. Glob Health Action. 2014;7:23433.
health care. S Afr J Psychol. 2015;1–12.
25 Watermeyer J. “She will hear me”: how a flexible interpreting
8
Y T
Hagan S, Swartz L, Kilian S, Chiliza B, Bisogno P, Joska
J. The accuracy of intepreting key psychiatric terms by ad
style enables patients to manage the inclusion of interpreters
in mediated pharmacy interactions. Health Commun. 2011;
A N
hoc interpreters at a South African psychiatric hospital. Afr J 26(1):71–81.
Psychiatry. 2013;16;424–9.
26 Williams M, Bekker S. Language policy and speech practice
M U

9 Heap M, Haricharan HJ, London L. Sign (South AfricaSL) in Cape Town: an exploratory public health sector study. S Afr
language intepreting services. Working to advance the right Linguist Appl Lang Stud. 2008;26(1):171–83.
4 ED

of access to healthcare. Provincial Cape Government: Health.

27 Wood B. Interpreters in medical consultations – A literature
Provincial Research Newsletter – June 2013; 3:3. [Internet]
review. South Africa Fam Pract. 1993;14(8):347–353.
[cited 8 July 2013].
URL: www.westerncape.gov.za/eng/pubs/public_ 28 Levin ME, Murie K. Effects on quality of care and Health Care
info/H/213781
O

Worker satisfaction of language training for Health Care

Workers in South Africa. Afr J Health Prof Educ. 2011; 3(1).
10 Kilian S. Interpreting within a South African psychiatric
G

hospital: a detailed account of what happens in practice. PhD 29 Levin ME. Different use of medical terminology and culture-
thesis: Stellenbosch University, Stellenbosch, South Africa; specific models of disease affecting communication between
2013.
R

Xhosa-speaking patients and English-speaking doctors at

a South African paediatric teaching hospital. S Afr Med J.
11 Kilian S, Swartz L, Joska J. Competence of interpreters in a
2006;96(10):1080–4.
BA

South African psychiatric hospital in translating key psychiatric

terms. Psychiatr Serv. 2010;61:309–12. 30 Lewis MP, Simons GF, Fennig CD, editors. Ethnologue:
O

languages of the world. 18th edition. Dallas, TX: SIL

12 Kilian S, Swartz L, Dowling T, Dlali M, Chiliza, B. The
International; 2015. [Internet]. [cited 22 March 2016].
potential consequences of informal interpreting practices for
EM

URL: http://www.ethnologue.com
assessment of patients in a South African psychiatric hospital.
Soc Sci Med. 2014;106:159–67. 31 South African Institute of Race Relations. Afrikaans and
English no longer ‘white languages’. Press Release. Cape
13 Kilian S, Swartz L, Chiliza B. Doing their best: strategies
Town: South AfricaIRR; 2013. [Internet] [cited 22 April 2013].
used by South African clinicians in working with psychiatric
URL: http://www.sairr.org.za
inpatients across a language barrier. Glob Health Action.
2015,8:28155. 32 Western Cape Department of Health. Language Policy. Cape
Town: Provincial Government Western Cape: Department of
14 Lesch H. Plain language for interpreting in consulting rooms.
Health; 2008.
Curationis. 2007;30(4):73–8.
33 Republic of South Africa. The Constitution of the Republic of
15 Levin M. Language as a barrier to care for Xhosa-speaking
South Africa, Act 108 of 1996. Pretoria: Government Printer;
patients at a South African paediatric teaching hospital. S Afr
1996.
Med J. 2006;96(10):1076–9.
34 Republic of South Africa. Policy on Language Services for the
16 Mkhize N, Kometsi MJ. Community access to mental health
National Department of Health. Pretoria: National Department
services: lessons and recommendations. In: Barron P,
of Health; 2011.
Roma-Reardon J, editors. South African Health Review 2008.
Durban: Health Systems Trust; 2008. p.103–13.
17 Ntshona MS. Are professional interpreters needed in
the South African health care services? S Afr Med J.
1997;10/87(9):1143.

80 S A H R 20 1 6
 Language barriers

35 Kale E, Kumar B. Challenges in Healthcare in Multi-Ethnic
Societies: Communication as a Barrier to Achieving Health
Equity. In: Maddock J, editor. Public Health – Social and
Behavioral Health. 2012. p.295. [Internet]. [cited 22 March
2016].
URL: http://www.intechopen.com/books/public-health-
social-and-behavioral-health/communication-and-dialog-in-a-
multiethnic-population
36 Paone T, Malott K. Using interpreters in mental health
counselling: A literature review and recommendations. J
Multicult Couns Devel. 2008;36(3):130–42.
37 Tribe R, Lane P. Working with interpreters across language
and culture in mental health. J Ment Health. 2009;18(3):233–
41.
38 Splevins KA, Cohen K, Joseph S, Bowley, CM. Vicarious
posttraumatic growth among interpreters. Qual Health Res.
52 Zimanyi K. Narrative Enquiry into Mental Health Interpreting
in Ireland: The responsibilities of quality service provision.
Critical Link 5 Conference; 2007, April 11–15. Parramatta,
Sydney, Australia. [Internet]. [cited 22 March 2016].
URL: http://criticallink.org/wpcontent/uploads/2011/09/
CL5Zimanyl.pdf
53 The Presidency of the Republic of South Africa. National
Planning Commission. National Development Plan: Vision for
2030: 2011. [Internet]. [cited 22 March 2016].
URL: http://www.gov.za/sites/www.gov.za/files/devplan_2.
pdf
54 Norstrom E, Fioretos I, Gustafsson K. Working conditions
of community interpreters in Sweden. Interpreting.
2012;14(2):242–60.
55 Busch B. The Linguistic Repertoire Revisited. Appl Linguist.
2012;33(5):503–23.

PM
2010;20:1705–16.
56 Brisset C, Leanza Y, Laforest K. Working with interpreters in
39 Busch B, Deumert A. Multilingualism, traumatic experience health care: a systematic review and meta-ethnography of
and resilience workshop announcement. Cape Town: qualitative studies. Patient Educ Couns. 2013;91:131–40.
University of Cape Town; 2012.
57 Granhagen Jungner J, Lutzen K, Pergert P. Creating a

16 6
40 Jacobs E, Chen AH, Karliner LS, Agger-Gupta N, Mutha meeting point of understanding: Interpreters’ experiences
S. The need for more research on language barriers in in Swedish childhood cancer care. J Paediatr Oncol Nurs.

20 IL
health care: a proposed research agenda. Milbank Q. 2015;33(2):1–9.
2006;84(1):111–133.
58 Cambridge J, Singh SP, Johnson M. The need for measurable
41 Karliner L, Jacobs E, Chen A, Mutha S. Do professional
Y T standards in mental health interpreting: a neglected area.
interpreters improve clinical care for patients with limited Psychiatrist. 2012;36:121–4.
english proficiency? A systematic review of the literature.
A N
Health Serv Res. 2007;42(2):727–54. 59 Butow PN, Lobb E, Jefford M, Goldstein D, Eisenbruch M,
Girgis A, et al. A bridge between cultures: interpreters’
M U

42 Ribera J, Hausman-Muela S, Peeters K, Toomer E. Is the use of perspectives of consultations with migrant oncology patients.
interpreters in medical consultations justified? A critical review Support Care Cancer. 2012;20:235–44.
of the literature. PASS Int v.z.w. 2008. [Internet]. [cited 22
4 ED

March 2016]. 60 Fatahi N, Mattsson B, Hasanpoor J, Skott C. Interpreters’

URL: http://tvgent.be/downloads/ experiences of general practitioner–patient encounters. Scand
interpretersinmedicalconsulations.acriticalrev.pdf J Prim Health Care. 2005;23(3):159–63.
61 Republic of South Africa. South African Language
O

43 Tribe R, Tunariu A. Mind your language: working with

intepreters in healthcare settings and therapeutic encounters. Practitioners’ Council Act 8 of 2014. Government Gazette
Sex Relatsh Ther. 2009;24(1):74–84. No. 37660, 19 May 2014. Pretoria: Government Printer;
G

2014.
44 Costa B. Interpreting in mental health contexts via skype. 4th
62 Bauer A, Alegria M. Impact of patient language proficiency
R

International Conference on Public Service Interpreting and

Translation. Madrid: Universidad de Alcala; 2011. and interpreter service use on the quality of psychiatric care:
A systematic review. Psychiatr Serv. 2010;61(8):765–73.
BA

45 Bot H. Dialogue interpreting in mental health. Amsterdam:

Rodopi; 2005.
O

46 Holloway I, Biley FC. Being a qualitative researcher. Qual

EM

Health Res. 2011;21(7):968–75.

47 Yach D. The use and value of qualitative methods in
health research in developing countries. Soc Sci Med.
1992;35(4):603–12.
48 Kemmis S. Action research as a practice-based practice. Educ
Action Res. 2009;17(3):463–74.
49 McDowell L, Messias DK, Estrada RD. The work of language
interpretation in health care: complex, challenging,
exhausting, and often invisible. J Transcult Nurs.
2011;22:137–47.
50 Miller KE, Martell ZL, Pazdirek L, Caruth M, Lopez D. The role
of interpreters in psychotherapy with refugees: an exploratory
study. Am J Orthopsychiatry. 2005;75:27–39.
51 Rosenberg E, Seller R, Leanza Y. Through interpreters’ eyes:
comparing roles of professional and family interpreters.
Patient Educ Couns. 2008;70(1):87–93.

S A H R 20 1 6 81
82
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Bridging the gap between biomedical and
traditional health practitioners in South Africa
8

Authors:
Mosa Moshabela i,ii,iii
Thembelihle Zuma iv

PM
Bernhard Gaede iii,v

16 6
T 20 IL
raditional health practitioners (THPs) in South Africa are increasingly The merging of biomedical
acknowledged as essential providers of health care and the National Department
Y T
of Health is taking firm steps towards the formal regulation of THPs. However, and traditional healing
A N
tensions continue to dominate the landscape of research and policy debates on the paradigms provides for a
role and practices of THPs, particularly with respect to historical injustices, gaps in
complementary system of
M U

scientific evidence, mistrust on the part of biomedical practitioners and toxicity of

medicines. plural health care, which
4 ED

In this chapter, we report on the findings of a study of peer reviewed and grey could offer patients a truly
literature related to THPs up to 2015 and argue that the world view of the biomedical holistic and comprehensive
paradigm is very different from that of the healing paradigm as the former uses a
form of care.
O

scientific knowledge lens while the latter uses an indigenous knowledge lens.
G

We argue that in subscribing to indigenous knowledge systems, the merging of

biomedical and traditional healing paradigms provides for a complementary system
R

of plural health care, which could offer patients a truly holistic and comprehensive
form of care.
BA

The current body of evidence demonstrates much progress in the way that traditional
O

healing is perceived in South Africa, having shifted from a derogatory ‘witchcraft

EM

paradigm’ supported by the Witchcraft Suppression Act (3 of 1957), to a more

tolerant, and in some instances reconciliatory, discourse of a ‘healing paradigm’ now
protected under the Traditional Health Practitioners Act (22 of 2007).

i Africa Centre for Population Health

ii Department of Rural Health, School of Nursing and Public Health, Universit y of KwaZulu- Natal
iii Centre for Rural Health, School of Nursing and Public Health, Universit y of KwaZulu- Natal
iv Department of Public Health Medicine, School of Nursing and Public Health, Universit y of KwaZulu- Natal
v Department of Family Medicine, School of Nursing and Public Health, Universit y of KwaZulu- Natal

83
Introduction
The National Department of Health (NDoH) in South Africa has taken
firm steps towards the official recognition and institutionalisation
of Traditional Healing and Medicine.1 These steps include the
establishment of a directorate of Traditional Medicine within the
National Department of Health, as well as the enactment of the
Traditional Health Practitioners Act (22 of 2007), which founded
the Interim Traditional Health Practitioners Council.2 In November
2015, the Minister of Health published the Regulations for
Traditional Health Practitioners in Government Gazette No. 39358,
Notice No 1052 in terms of Section 47,3 read with Section 21 of
the Traditional Health Practitioners Act,2 reportedly after consultation
with the Council. Consultation meetings are currently taking place
across the country, with the aim of clarifying the legislation and
regulations, and to obtain support from different sectors, including
traditional health practitioners (THPs).4
The political economy of indigenous health care can be divided
16 6
into two major areas: THPs as providers, and traditional medicines
(TMs) as their medicinal products. Therefore, policies and regulatory
20 IL
processes have to treat these two as related, but distinctly different in
order to facilitate progress. There is an urgent need for a regulatory
Y T
council of THPs as practitioners of health care,5 much like the Health
Professions Council of South Africa, and for a regulatory council for
A N
TMs,6 either though the Medicines Control Council or through a new
similar structure. While there are many debates on TMs including in
M U
a previous edition of this Review, 7 in this chapter we focus on THPs
rather than TMs.
4 ED
The past decade has been marked by renewed interest in the role of
THPs in relation to South Africa’s healthcare system. This has been
mediated largely by two factors – the Traditional Health Practitioners
O
Act of 2007,2 and the controversies around management of people
living with HIV and AIDS8–11 which has resulted in an increase in
G
the number of both research and media publications relating to the
R
challenges of managing people living with HIV. While most of this
literature paints a negative picture of the role of THPs, there is also
BA
a growing body of evidence generated for the purposes of building
bridges between traditional and biomedical (allopathic, Western,
O
conventional or modern) systems of health care in South Africa.
EM
Methods
Given the dearth of evidence to guide the implementation of the
Traditional Health Practitioners Act and efforts by the NDoH to
recognise, regulate and institutionalise THPs,4 we conducted
a scoping review on published research evidence on the role of
THPs in relation to the predominantly biomedical healthcare system
in South Africa. Publications not based on empirical research,
including opinions, commentaries, discussions, policy reviews, case
studies, media stories and articles were also reviewed. We sought
to identify all articles relevant to THPs in South Africa since 2004,
but included relevant prior seminal papers. Results of this review are
presented in the discussion below.
84 S A H R 20 1 6
Discussion
Four main themes arose from our review. Firstly, we found strong
evidence of the existence of medical pluralism in South Africa where
there are multiple forms of understanding, explaining and treating
illness.8,12,13 Secondly, there is evidence of conflicting paradigms of
knowledge, and of polarisation between the ‘biomedical paradigm’
based on scientific knowledge and the ‘healing paradigm’ based
on indigenous knowledge.14–16 Thirdly, work has been conducted
on the current understanding of traditional healing as it occurs in
the context of indigenous knowledge systems, and in close relation
to religious knowledge systems.17–19 Lastly, the collaboration
between traditional healing and biomedical systems occurs against
a backdrop of mistrust, tensions and unresolved issues.16,20,21 The
latter area of research is located within the discourse of medical
PM
syncretism, which represents the evolution of combining, blending or
merging different medical approaches and systems.22
Medical pluralism
South Africa is arguably one of the few countries in Africa regarded
as being unanimous in diversity, yet the rich diversity of culture,
race, language, ethnicity and religion presents challenges for the
country’s social dynamics, including its healthcare system.23–25 These
multiple forms of diversity represent different world views, and as a
result, many fellow South Africans become aware of or experience
characteristic differences, which may at times result in tension or
conflict.26 In visiting a health provider, patients take with them a
certain world view relevant to health and wellbeing which is likely
to be informed by either religious or indigenous belief systems.17,21
Similarly, health providers also have their own world views, and
most hold either indigenous or religious beliefs, irrespective of
whether they provide care in the biomedical or traditional healing
system.11,27 These diverse world views predispose patients and
providers to a range of ways in which health can be understood,
explained and treated. This is known as medical pluralism. Medical
pluralism can also be seen in the co-existence of multiple medical
systems, which manifest in the way patients engage with health
care, or their care-seeking behaviour.8
Co-existence
The co-existence of traditional healing and biomedical systems has
been adequately demonstrated in the literature, especially among
patients seeking mental healthcare and HIV and AIDS services.12,28,29
What is poorly understood, however, is whether engagement in both
traditional healing and biomedical care is beneficial for achieving
optimal health status for the person accessing the service.8 Evidence
among people living with HIV and AIDS and mental health patients
suggests that medical pluralism results in delays in reaching
appropriate biomedical services, high medical costs, and toxicity
from traditional medicines.8,11,30–35 Expenses incurred by users of
THPs across five provinces ranged from R200 to nearly R3 000,32,36
while others have incurred expenses up to R5 000.37 These expenses
can amount to catastrophic expenditure levels of more than 10%
of the household income, especially among poor households.31,32
However, the literature on reasons for use of traditional healing
indicates that medical pluralism may be the only option for patients
who subscribe to indigenous belief systems.38,39 There remain,
however, outstanding questions regarding the evidence, safety and
effectiveness of engaging in dual systems of care.4,7,33,36 Despite

this, the use of THPs remains highly prevalent, with rates of 20%
among patients on antiretroviral treatment (ART).12,40
The plural healthcare system in South Africa offers a multiplicity of
options for healthcare seekers and it is in the best interest of South
Africans that their healthcare providers function together in harmony
so as to best serve the people first, before serving their professions,
their trades or themselves.8,32,41,42 Historically, biomedical structures
have been used by missionaries as a vehicle to convert people,
many of whom held traditional world views, to Christian world
views.43,44 Ultimately, the conflict of values and interests between
patients and health practitioners, both biomedical and traditional,
exists as a result of co-existing world views, but the disproportionate
social power of practitioners may serve to compromise patients’
views and values. There is a need to recognise and acknowledge
the co-existence of plural healthcare systems, and to optimise these
in ways that can most benefit the patient.
Conflicting paradigms
16 6
The relationship between traditional healing and biomedical systems
is characterised by mistrust, tension and conflict, which constitutes a
20 IL
major setback for the current effort to forge collaboration between
the two systems.15 On the one hand, providers of biomedicine
Y T
are vocal in their criticism of traditional healing and the fact that
traditional healing lacks a body of evidence to substantiate its
A N
practice through a scientific knowledge lens;27 on the other hand,
M U
THPs have difficulty understanding the lack of appreciation shown
by biomedical providers of their role in health and wellbeing as
viewed through the indigenous knowledge lens.16,45
4 ED
As a result, patients visiting biomedical health facilities are unlikely
to disclose their engagement in traditional healing; however, THPs
O
are almost always informed about engagement with the biomedical
system. It has been observed that “to acknowledge a practice does
G
not necessarily mean to endorse it”,46 and if collaboration between
traditional healing and biomedical systems is to succeed, both
R
systems must reach some degree of mutual understanding based on
respect and an equal footing.7,21,26 Much of the current literature
BA
refers to the need for traditional healing to achieve standards
O
Figure 1: A complementary model combining healing and biomedical paradigms
EM
HIGH Biological
BIOMEDICAL PARADIGM
MED Psychological
LOW Social
N/A Spiritual
S A H R 20 1 6
Traditional health practitioners
equating to biomedicine if THPs are to be allowed to manage
patients and treat illness.47 These standards are unlikely to be met by
traditional healing and we argue that this is due to comparing two
different paradigms using a one-sided biomedical paradigm.15,16,48
Several authors make reference to the problem of examining
traditional healing from a purely biological point of view, since
traditional healing is not founded on the science of biology.15,37,49
Wreford for example,20,50 has argued that any true exchange
relevant to collaboration is dependent on THPs acknowledging
the perceived supremacy of the biomedical paradigm. Therefore,
the challenge of establishing collaboration between biomedicine
and traditional healing exists in part as a result of the hierarchical
classification of knowledge,47 whereby the scientific knowledge of
biomedicine is located above other forms of knowledge. Likewise,
PM
most of what constitutes religious knowledge locates itself above
indigenous knowledge, in which case indigenous knowledge is
driven underground and lost to society.14,51–54 It has thus been
argued that the study of Indigenous Knowledge Systems is not
simply a scientific endeavour but an opportunity to reclaim Africa’s
‘scientific’ and sociocultural heritage.
Biomedicine promotes what is thought of as ‘culture-free
representations of disease’16 that are seen to be neutral and
realistic, while traditional healing is considered rife with ‘dangerous
and ultimately mistaken metaphors’; yet biomedicine tends to
operate along quasi-missionary lines seeking to liberate people from
‘irrational’ beliefs that are based on religious knowledge systems.51
THPs can be called to the practice by the ancestors, knowledge
can be passed on orally without documentation, and their remedies
can be determined by spiritual forces rather than pharmaceutical
qualities.14,16 For biomedicine, issues of qualification,
standardisation and training are mostly clear-cut, and attempting
to assess traditional healing in comparable terms is perhaps nigh
on impossible, which renders the notion of establishing equivalence
largely meaningless.16 The primarily biological worldview of
biomedical science and its interventions has led to attempts by allied
professionals, psychotherapists and social workers to incorporate
the psychosocial aspects of illness and wellbeing into biomedical
LOW
HEALING PARADIGM
MED
HIGH
HIGH
85
science.51 The shift resulted in what is now seen as bio-psychosocial
medicine, with the relatively new field of family medicine being the
case in point.55
The recognition of synergistic possibilities between the two systems,
shown in Figure 1, is likely to cultivate common ground for a more
progressive and constructive form of mutual understanding.
Approaches to illness
The strength of biomedicine lies in its biological curative approach,
while traditional healing dominates in terms of a spiritual approach
with the two modalities representing potentially opposing world
views.16 Curing is a largely biological process that results in the
clearing of disease from the body.37 In traditional healing, illness
is generally viewed as a more psychosocial condition involving
against the background of a largely uninterested universe.16 In this
respect, a ‘healing paradigm’ offers a degree of solace to patients;
their suffering can be seen to have been caused by malevolent forces
deployed against them, sometimes out of jealousy or turbulence in the
spirit world, rather than having simply come about through random
infections and mutations. Jealousy-as-causation is a recurring theme
within the majority of the discussions on witchcraft that arise, with
both patients and healers in broad agreement on this aspect.16 At
the same time, within such a world view, it must be emphasised that
for every victim of witchcraft there must be a perpetrator, and if not
adequately handled, unnecessary harm may ensue.62–64
According to Kale,65 there are three key principles of traditional
healing relevant to this debate, and the extent to which THPs form an
integral part of their people and community. Firstly, THPs endeavour

spiritual or mental health aspects in need of healing.
Current evidence suggests that the hitherto mutually exclusive debates
regarding the existence of ancestors or God can both be located in
PM
to ensure that patients are satisfied that they, as individuals, and
their symptoms are taken seriously, and that patients are given
enough time to express their fears. Secondly, THPs study the
patient as a whole and deserve credit for not splitting the body

16 6
the realm of the spirit world and that people with indigenous beliefs
and mind into two entirely separate entities. Thirdly, THPs do not
have a natural ability to merge ancestral reverence with worship
consider the patient as an isolated individual, but as an integral

20 IL
for God.18,56 The ancestors are conceptualised as the ‘living dead’
component of a family and a community, and members of the
– compassionate spirits who are blood-related to the people who
patient’s family participate in the treatment process. Therefore, the
hold indigenous beliefs and who show an interest in the daily lives
Y T services of traditional healers go far beyond the uses of herbs for
of the living.18,56,57 This belief is a source of comfort when family
physical illnesses.66 THPs serve many roles, including but not limited
A N
members die or when people are faced with their own imminent
to custodianship of the traditional African traditions and customs,
death. Ancestors are not worshipped, but remembered and revered
M U

cultural education, counselling, social mediation and healing of the

by their relatives and God is perceived to be above and beyond the
mind, body and spirit.65
ancestors, and is understood as the Supreme Creator or Being, and
4 ED

the main pillar of the universe.58

Medical syncretism
In South Africa, there is a notable pattern of using the traditional
The imminent institutionalisation of traditional healing should be
healing system, comprising both indigenous and religious sectors.
seen in the context of medical syncretism, with the reconciliation
O

Five types of THPs are found: diviners, herbalists, faith healers,

at least or the fusion at best, of two medical systems.41 The history
traditional birth attendants and traditional surgeons.7,19,59 Most
G

of biomedicine attests to the evolution of health care over many

THPs, such as diviners, are called by their ancestors to the practice,
centuries; and some of the advances in biomedicine developed as
and others, such as herbalists, are inducted into the practice through
R

a result of bio-prospectors following in the footsteps of traditional

an apprenticeship model. Practising faith healers and prophets,
medicine men, and ‘finding’ new pharmaceutical drugs. Likewise,
BA

often found in the so-called African Christian Churches, are for all
traditional healing has also adopted tools and practices from
intents and purposes classified here under the religious sector of
biomedicine, as well as other modern inventions in order to
O

THPs; they are currently not classified under THPs by law and may
appropriate itself in modern society.67 Therefore, medical systems
constitute an independent sector of healers.60,61
EM

unlike biomedicine, traditional healing, is often communal rather
than individualistic or private.37 In all cases, patients are asked to
be part of the process in the interests of contributing to their own
healing. Furthermore, due to the ways in which the spirit world is
perceived to impact on people’s health, treatments and ceremonies
are tailored to the requirements of individuals and their families,
as is any prescribed traditional medicine. Traditional healing is
therefore a highly personalised and interactive experience for
patients, in which healers are facilitators.37 This differs substantially
from the expert-driven and standardised approaches that are central
to biomedicine.
As with biomedical practitioners, traditional healers identify what
is wrong with their patients – naming the presenting illness is
viewed as a significant aspect of the treatment process. Where the
systems diverge is that traditional healing places significance on the
patient’s personal experiences surrounding ill health.16 In contrast,
biomedicine has little to offer patients in terms of explanations for
their misfortune – diseases are seen to be contracted randomly
evolve over time and through this evolution, adopt and incorporate
new ways of functioning suited to the time and place of their
practice, thus generating another form of medical syncretism. Much
can be learned from medical syncretism in relation to the need for
biomedicine to work alongside traditional healing. However, a
number of pertinent issues should be addressed urgently for the new
change to gain traction.
Firstly, South Africa needs to resolve ‘old wounds’ inflicted upon
traditional healing by colonisation, missionaries and apartheid.52
Secondly, the country must resolve current threats, including the
prevailing atmosphere of mistrust between traditional healing and
biomedicine, the potential harm of traditional medicines and in
some cases bogus THPs.15 Lastly, discussions on the action plan
and next steps must shift from barriers to opportunities; these may
include the potential complementary nature of biomedicine and
traditional healing,68 incorporation of traditional healing into the
education curriculum,11 the role of dual practitioners of biomedicine
and traditional healing,69 and the contemporary landscape of HIV
and AIDS.8,70

86 S A H R 20 1 6

Redressing injustices
One argument put forth in policy debates around the need for the
institutionalisation of traditional healing is that of a social justice
imperative to redress past injustices. Ingle for example recounts how
attempts by traditional healers to regulate themselves in the seventies
were met with opposition and their name of choice, ‘Traditional
Medical Practitioners Association’, was disputed by the then
Department of National Health and Population, which preferred
the term ‘traditional healers’ and not ‘medical practitioners’.52 Ingle
also recounts how traditional healing was simplistically reduced to
herbalism and was associated with other herbal practices, including
those of Whites, Coloureds and Indians, to the detriment of the depth
of knowledge normally associated with being a THP. These efforts
to co-opt traditional healing into a narrow biomedical framework
of herbalist practices were specifically aimed at undermining
the socio-cultural practices that maintained the social fabric and
coherence of the colonised populations.71 THPs were criminalised
under the Witchcraft Suppression Act (3 of 1957),72 and labelled
16 6
as witchdoctors.26 The derogatory language describing traditional
practices as backward, barbaric and primitive was meant to label
20 IL
and stigmatise THPs as inferior. Culturally and socially traditional
healers had a much greater role, including governance, advising,
Y T
and responsibility for the social wellbeing of the community;
however, these roles were eroded in the re-emerging definitions of
A N
culture.73,74
M U
Overcoming threats
4 ED
Beyond these deep old wounds, there exist several current threats
to the intended institutionalisation of traditional healing. Also, both
groups need to engage mutually to understand each other’s world
and work so as to alleviate existing tensions.75 Overall, biomedical
O
practitioners have limited knowledge and experience of traditional
healing, and should be encouraged to engage in activities that
G
would enhance their knowledge and experiences in this sphere.27,76
R
Wreford77 maintains that
if the communication that does take place insists on scientific
BA
supremacy and refuses reciprocity, the effort is likely to
O
disappoint” and that “it is vital…that Western-trained medical
personnel start to make serious and respectful efforts to connect
EM
intellectually with the ideas that underline traditional practice.
Most THPs are willing to learn and refer patients to clinics
and hospitals, while this deference is not true of biomedical
practitioners.10,39,78 Mokgobi76 showed how certain sub-groups of
biomedical practitioners, such as XiTsonga- and Sesotho-speaking
biomedical practitioners, expressed clear intentions to work with
THPs in the future. Similarly, biomedical practitioners working
with psychiatric conditions had more positive opinions of the
envisaged involvement of THPs in primary health care than did
general physicians and general nurses, who could logically form
part of the initial platforms of engagement.21,34,35,78 Therefore, in
order to build bridges between the two systems, two-way in-service
exchanges and trainings between THPs and biomedical providers
are necessary and important.75 Pre-service training is needed for
students to become acquainted with traditional healing at an early
stage of their careers, and traditional healing should be included
in the higher education curriculum for nursing, medicine and
pharmacy.33
S A H R 20 1 6
Traditional health practitioners
Wreford,50 herself both an anthropologist and a THP, has argued
that the first step towards meaningful accommodation would be a
change in the biomedical mind-set, for the biomedical establishment
to view THPs as allies.16 However, through a biomedical lens, the
perceived weaknesses of the traditional healing system include
harmful treatment regimens.11
Walwyn and Maitshotlo36 showed that 88% of THPs prepared their
own medication, mostly from plant material, and sold their products
as aqueous extracts in labelled bottles. None of these products had
been systematically evaluated, and there was generally no record-
keeping, either of the patient or of the medicine itself. Quality control
practices such as expiry dates, controlled storage conditions and
batch records were totally unknown in our sample. The revenue
associated with this production of medicines is large, which has led
PM
some to manufacture and produce TMs for the treatment of HIV and
AIDS, and to make claims for marketing purposes such as the ability
to cure HIV.16
As with many medicines, traditional or otherwise, ingredients utilised
by traditional practitioners can be toxic – at times, fatally so. For
the most part, traditional remedies are based on directives outlined
in practitioners’ dream-conversations with ancestors rather than
the pharmaceutical properties of the ingredients concerned.14,16
One may therefore wonder how a biomedical practitioner could
consider THPs as allies and treat them with respect when their
practices do not meet the standards of biomedicine and their
prescriptions could be based on dreams.16 The questions on the
therapeutic aspects of traditional medicines need further discussion
beyond the scope of this chapter, although some authors have
already begun framing the discussion in constructive ways.7,38,79
A scientific biomedical lens is unlikely to yield positive answers,
and expecting traditional medicines to meet the standards of
biomedicine will endorse a position of supremacy for biomedicine.
Any insistence on following this path will yet again lead to a cul-de-
sac. However, THPs must resolve outstanding controversial issues
among themselves,79 address the question of identifying bogus
THPs who should be excluded from platforms of engagement with
biomedical practitioners to enable more genuine partnerships, and
perhaps be prevented from conducting any harmful practices in the
community.75 Practices of ‘muti’ murders, witchcraft accusations
and witch-hunts continue to threaten the integrity of engagement
with biomedical practitioners, and the THP community should
address them.11,64,80,81 These engagements would help to address
challenges of delayed appropriate health care when traditional
remedies fail to produce the desired effect,8,11,82 as well as
catastrophic healthcare expenditure associated with the nature of
out-of-pocket payments for THPs.31,32 Currently, the care economy of
THPs functions more like a private sector, largely because clients pay
out-of-pocket, and there is no State subsidy of their care economy.
However, THPs also function more like community health workers
given their community-embeddedness and the informal nature of
their indigenous health sector. Tshehla83 and Mbatha et al.84 argue
that although the law allows THPs to issue sick certificates, the
current legal and policy landscape is not conducive to this practice,
and there are still inconsistencies and gaps within these legal and
policy documents. For example, employers may not be obligated to
accept such sick certificates for as long as regulatory structures are
not in place. Therefore, the new THP regulations3 constitute a step in
this direction; otherwise, the lack of a conducive policy environment
will continue to threaten efforts to recognise THPs.
87
Harnessing Opportunities
Rudolph et al.85 argue that THPs constitute an untapped resource
with enormous potential. Traditional healers are often seen as a
solution to the growing human resource crisis in healthcare services,
particularly to assist with the extension of the health services at
community level.65 However, a valuable bridge should be built to link
traditional healing with modern medicine, particularly in the struggle
against HIV and AIDS.70,77,86 The current policy efforts pertaining
to THP regulation1,3 offer a window of opportunity to adopt a more
informed direction. We further argue that HIV and AIDS creates a
more practical window of opportunity for the creation of linkages
between THPs and biomedical practitioners. Although claims by
certain THPs to cure HIV and AIDS have been disputed, much harm
has been caused due to such money-making schemes and practices
George et al. show that THPs are enthusiastic about the prospect of
collaborating with biomedical practitioners in the prevention and
care of HIV and AIDS.87 Flint16 presents the mission statement of
the Traditional Healers Organisation (THO) as unambiguous in its
assertion that “while modern medicine is needed for the accurate
diagnosis of HIV and AIDS, it is the THPs who would probably be
the primary care providers and in the front line in the prevention
and control of the spread of this disease”. This notion resonates
with the findings of Schuster et al.45 and Davids et al.88 that THPs
tend to deal with the ultimate or distal causes of ill-health, whereas
biomedicine deals with the more immediate and proximal causes.
This progressive view lends itself to a more collaborative approach
between traditional healing and biomedicine for people who
hold indigenous belief systems. Dual practitioners of biomedicine

PM
that are considered to have tainted the traditional health sector. and traditional healing, such as nurse-Sangomas and Sangoma-
Literature shows that THPs often negotiate payment according to the physicians, could offer further wisdom on how to reconcile
ability of the user to pay, and the treatment also includes all other differences between the two systems.11,69,89

members of the family for the duration of care.16,37 Furthermore,

16 6
Conceptually, it is possible for biomedicine to adopt a scientific
THPs tend to accept payment at the end of the treatment rather than biological approach to attend largely to the biological aspects of

20 IL
at the outset. In fact, THPs who demand payment upfront are often
suspected of being charlatans, which means payment should be
made when the healer and the client are satisfied with the care
Y T
provided.16,37 A distinction should also be made between payments
A N
made as part of the treatment course, and for therapeutic purposes
for the benefit of the client, as opposed to payment made as healer’s
M U
disease, while indigenous and religious approaches could be used
mainly to address the socio-cultural and spiritual aspects, while
we resolve tensions regarding biological therapies. In this way, as
shown in Figure 1, the combination of biomedicine and traditional
or religious healing could afford patients a more complete and
holistic form of care that would synergise biological, psychological,

charge for consultation and care. social and spiritual approaches. Instead of a culture-free healthcare
system, South Africa could boast, at the least, a culture-sensitive, and
4 ED

at best, a culture-appropriate, plural healthcare system, as depicted

in Figure 2.
O

Figure 2: The shift from culture-free to culture-appropriate plural health systems

G

Scientific Knowledge Systems

R
BA

Culture Free
O
EM

Culture Neutral

BIOMEDICAL HEALING
PARADIGM PARADIGM
Culture Sensitive

Culture Appropriate

Indigenous Knowledge Systems

88 S A H R 20 1 6
 Traditional health practitioners

Conclusion
A radical shift towards integrating traditional healing in South
Africa’s healthcare system is imminent. The challenge of collaboration
between traditional healing and biomedical systems is now going
beyond ‘calls and talks’, and reaching a level of planning for
action. Currently, there are still more questions than answers, and
little is known about how the regulation of THPs will unfold, and
more importantly, what implications this will have for the country’s
healthcare system. The current body of evidence demonstrates much
progress in the way that traditional healing is perceived in South
Africa, having shifted from a derogatory ‘witchcraft paradigm’
supported by the Witchcraft Suppression Act (3 of 1957), to a
more tolerant, and in some instances reconciliatory, discourse of
a ‘healing paradigm’ now protected under the Traditional Health

PM
Practitioners Act (22 of 2007). However, the progress to date does
not represent a success story, but only the beginning of a long
journey ahead. A number of issues still need to be resolved, the
main one being the atmosphere of animosity between THPs and

16 6
biomedical practitioners, which is compounded by the perceived

20 IL
supremacy of biomedicine. Traditional healing is regarded as being
based on unregulated, unscientific and dangerous practices that
lend themselves to delayed access, high healthcare costs, herbal
Y T
toxicity, bogus practitioners, ‘muti’ murders and witch-hunts. There
A N
is a real threat to the future of the health system in South Africa
if the details of the issues raised in this chapter are not carefully
M U

considered and adequately addressed.

We have argued that the world view of the biomedical paradigm

4 ED

is very different from that of the healing paradigm; the former uses
a scientific knowledge lens while the latter uses an indigenous
knowledge lens. The two systems, therefore, neither exist nor
O

function in the same sphere of knowledge and do not have the

same goals, and should therefore not be compared head-to-head.
G

While the polarised nature of knowledge between biomedicine and

traditional healing could be seen as dichotomous and irreconcilable,
R

we argue that in subscribing to indigenous knowledge systems,

the merging of biomedical and traditional healing paradigms
BA

provides a complementary system of plural health care, which

could offer patients a truly holistic and comprehensive form of
O

care: a bio-psycho-socio-spiritual care model. The merging of these

EM

worlds can only happen if the best interest of a large proportion

of the patient population is prioritised, rather than power struggles
between authority structures and bodies. Both THPs and biomedical
practitioners will have to set aside their personal values and pride,
work together to resolve current threats, and leverage existing
opportunities. The recognition and institutionalisation of THPs bears
implications not only for THPs themselves, but also for providers of
biomedical care, as well as the people of South Africa. Decisions
made by South African policy-makers are likely to have an impact on
the rest of the African region, given the fact that other countries on
the continent are also seeking to institutionalise traditional healing.

S A H R 20 1 6 89
References
1 South African National Department of Health. Efforts to
Strengthen and Promote Traditional Medicine. Pretoria:
Department of Health; 2015. [Internet]. [cited 4 March
2016].
URL: http://www.gov.za/sites/www.gov.za/files/
gcis_documents/traditional-medicine.pdf
2 Traditional Health Practitioners Act of 2007, Republic of South
Africa. Government Gazette No. 30660, January 2008.
[Internet]. [cited 4 March 2016].
URL: http://www.gov.za/sites/www.gov.za/files/a22-07.pdf
3 Traditional Health Practitioners Regulations, Republic of South
Africa. Government Gazette No. 39358, Notice No. 1052,
November 2015. [Internet]. [cited 4 March 2016].
URL: https://www.greengazette.co.za/documents/national-
gazette-39358-of-03-november-2015-vol-605_20151103-
GGN-39358.pdf
4 de Roubaix M. The decolonialisation of medicine in
South Africa: Threat or opportunity? S Afr Med J.
2016;106(2):159–61.
16 6
5 Pinkoane MG, Greeff M, Koen MP. A model for the
incorporation of the traditional healers into the National
20 IL
Health Care delivery system of South Africa. Afr J Tradit
Complement Altern Med. 2012; 9(3S):12–8.
6 Y T
Ngcobo M, Nkala B, Moodley I, Gqaleni N.
Recommendations for the Development of Regulatory
A N
Guidelines for Registration of Traditional Medicines in
South Africa. Afr J Tradit Complement Altern Med. 2012;
M U
9(1):59–66.
7 Gqaleni N, Moodley I, Kruger H, Ntuli A, McLeod H.
Traditional and complementary medicine: health care delivery.
4 ED
In: Harrison S, Bhana R, Ntuli A, editors. South African Health
Review. Durban: Health Systems Trust; 2007:175–88.
8 Moshabela M, Pronyk P, Williams N, Schneider H, Lurie
O
M. Patterns and implications of medical pluralism among
HIV and AIDS patients in rural South Africa. AIDS Behav.
G
2011;15(4):842–52.
9 Mills E, Singh S, Wilson K, Peters E, Onia R, Kanfer I. The
R
challenges of involving traditional healers in HIV and AIDS
care. Int J STD AIDS. 2006;17(6):360–3.
BA
N
10 Peltzer K, Mngqundaniso N, Petros G. A controlled study
of an HIV and AIDS/STI/TB intervention with traditional
O
healers in KwaZulu-Natal, South Africa. AIDS Behav.
2006;10(6):683–90.
EM
11 Summerton J. Western health practitioners’ view about African
traditional health practitioners’ treatment and care of people
living with HIV and AIDS. Curationis. 2006;29(3):15–23.
12 Pantelic M, Cluver L, Boyes M, Toska E, Kuo C, Moshabela
M. Medical pluralism predicts non-ART use among parents
in need of ART: a community survey in KwaZulu-Natal, South
Africa. AIDS Behav. 2015;19(1):137–44.
13 Baer HA. Medical pluralism. In: Ember CR and Ember M,
editors. Encyclopedia of Medical Anthropology. New York:
Kluwer Academic/Plenum Publishers; 2004. p.109–16.
14 Cumes D. South African indigenous healing: how it works.
Explore: The Journal of Science and Healing. 2013;9(1):58–
65.
15 Wreford J. Negotiating relationships between biomedicine
and Sangoma: Fundamental misunderstandings, avoidable
mistakes. Cape Town: Centre for Social Science Research,
University of Cape Town; 2005.
16 Flint A, Payne J. Reconciling the Irreconcilable? HIV and AIDS
and the potential for middle ground between the traditional
and biomedical healthcare sectors in South Africa. Forum Dev
Stud 2013;40(1):47–68.
90 S A H R 20 1 6
17 Wreford J. Worlds Apart? Religious interpretations and
witchcraft in the negotiation of health strategies for HIV and
AIDS in South Africa. Cape Town: Centre for Social Science
Research; 2009.
18 Mokgobi M. Understanding traditional African healing.
African Journal for Physical Health Education, Recreation and
Dance. 2014;20(Suppl 2):24.
19 Peltzer K. Traditional health practitioners in South Africa.
Lancet. 2009;374(9694):956–7.
20 Wreford J. Missing each other: Problems and potential for
collaborative efforts between biomedicine and traditional
healers in South Africa in the time of AIDS. Social Dynamics.
2005;31(2):55–89.
21 Mokgobi M. Towards integration of traditional healing and
PM
western healing: Is this a remote possibility? African Journal
for Physical Health Education, Recreation and Dance.
2013;(Suppl 1):47.
22 Muela SH, Ribera JM, Mushi AK, Tanner M. Medical
syncretism with reference to malaria in a Tanzanian
community. Soc Sci Med. 2002;55(3):403–13.
23 Flint K. Indian-African Encounters: Polyculturalism and African
Therapeutics in Natal, South Africa, 1886–1950s. Journal of
Southern African Studies. 2006;32(2):367–85.
24 Flint KE. Healing traditions: African medicine, cultural
exchange, and competition in South Africa, 1820–1948.
Athens, Ohio: Ohio University Press; 2008.
25 Petros G, Airhihenbuwa CO, Simbayi L, Ramlagan S, Brown
B. HIV and AIDS and “othering” in South Africa: The blame
goes on. Culture, Health and Sexuality. 2006;8(1):67–77.
26 Wreford J. Shaming and blaming: medical myths, traditional
health practitioners and HIV and AIDS in South Africa. Cape
Town: Centre for Social Science Research; 2008.
27 Mokgobi M. Western-trained health care practitioners’
knowledge of and experiences with traditional healing.
African Journal for Physical Health Education, Recreation and
Dance. 2014;2014(Suppl 2):1.
28 Sorsdahl K, Flisher A, Wilson Z, Stein D. Explanatory models
of mental disorders and treatment practices among traditional
healers in Mpumulanga, South Africa. Afr J Psychiatry.
2010;13(4).
29 Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ,
Williams DR, et al. Traditional healers in the treatment of
common mental disorders in South Africa. J Nerv Ment Dis.
2009;197(6):434.
30 Barker R, Millard F, Malatsi J, Mkoana L, Ngoatwana T,
Agarawal S, et al. Traditional healers, treatment delay,
performance status and death from TB in rural South Africa.
Int J Tuberc Lung Dis. 2006;10(6):670–5.
31 Nxumalo N, Alaba O, Harris B, Chersich M, Goudge J.
Utilization of traditional healers in South Africa and costs to
patients: findings from a national household survey. J Public
Health Policy. 2011:S124–S136.
32 Moshabela M, Schneider H, Silal SP, Cleary SM. Factors
associated with patterns of plural healthcare utilization among
patients taking antiretroviral therapy in rural and urban
South Africa: a cross-sectional study. BMC Health Serv. Res.
2012;12(1):1.
33 Van Rooyen D, Pretorius B, Tembani NM, Ten Ham W.
Allopathic and traditional health practitioners’ collaboration.
Curationis. 2015;38(2):1–10.

34 Sorsdahl K, Stein DJ, Flisher AJ. Traditional healer
attitudes and beliefs regarding referral of the mentally ill to
Western doctors in South Africa. Transcultural Psychiatry.
2010;47(4):591–609.
35 Berg A. Ancestor reverence and mental health in South Africa.
Transcultural Psychiatry. 2003;40(2):194–207.
36 Walwyn D, Maitshotlo B. The role of South African traditional
health practitioners in the treatment of HIV and AIDS: a study
of their practices and use of herbal medicines. South Afr J HIV
Med. 2010;11(2):11–7.
37 Flint A. Traditional Healing, Biomedicine and the Treatment
of HIV and AIDS: Contrasting South African and Native
American Experiences. Int J Environ Res Public Health.
2015;12(4):4321–39.
38 Truter I. African traditional healers: Cultural and religious
beliefs intertwined in a holistic way. SA Pharmaceutical
Journal. 2007;74(8):56–60.
39 Mngqundaniso N, Peltzer K. Traditional healers and nurses: A
qualitative study on their role on sexually transmitted infections
including HIV and AIDS In KwaZulu-Natal, South Africa. Afr J
16 6
Tradit Complement Altern Med. 2008;5(4):380–6.
20 IL
40 Babb DA, Pemba L, Seatlanyane P, Charalambous S,
Churchyard GJ, Grant AD. Use of traditional medicine by HIV-
infected individuals in South Africa in the era of antiretroviral
therapy. Psychol Health Med. 2007;12(3):314–20.
Y T
41 Stoner BP. Understanding medical systems: Traditional,
A N
modern, and syncretic health care alternatives in medically
pluralistic societies. Med Anthropol Q. 1986;17(2):44–8.
M U
42 Chimbindi N, Bor J, Newell M-L, Tanser F, Baltussen R,
Hontelez J, et al. Time and money: the true costs of health
4 ED
care utilization for patients receiving “free” HIV/tuberculosis
care and treatment in rural KwaZulu-Natal. J Acquir Immune
Defic Syndr. 2015;70(2):e52–e60.
43 Thornton R. The transmission of knowledge in South African
O
traditional healing. Africa. 2009;79(01):17–34.
44 Zimba ZF, Tanga PT. Challenges Faced by Traditional Healers
G
when Treating People Living with HIV and AIDS: The Case of
Intsika Municipality, Eastern Cape Province of South Africa.
R
Ethno Med. 2014;8(3).
BA
45 Shuster JM, Sterk CE, Frew PM, Del Rio C. The cultural and
N
community-level acceptance of antiretroviral therapy (ART)
among traditional healers in Eastern Cape, South Africa. J
O
Community Health. 2009;34(1):16–22.
EM
46 Woolf AD. Herbal remedies and children: do they work? Are
they harmful? Pediatrics. 2003;112(Supplement 1):240–6.
47 Nyika A. Ethical and regulatory issues surrounding African
traditional medicine in the context of HIV and AIDS.
Developing World Bioethics. 2007;7(1):25–34.
48 Van Bogaert DK. Ethical considerations in African traditional
medicine: a response to Nyika. Developing World Bioethics.
2007;7(1):35–40.
49 Van Niekerk JdV. Traditional healers formalised? S Afr Med J.
2012;102(3):iv–iv.
50 Wreford JT. Working with spirit: Experiencing izangoma
healing in contemporary South Africa. New York; Oxford:
Berghahn Books; 2008.
51 Waldron I. The marginalization of African indigenous healing
traditions within Western medicine: Reconciling ideological
tensions and contradictions along the epistemological terrain.
Toronto: University of Toronto Scarborough; 2010.
52 Ingle DR. No healer is an island. S Afr Fam Pract.
2012;15(10).
S A H R 20 1 6
Traditional health practitioners
53 Mathibela MK, Egan BA, Du Plessis HJ, Potgieter MJ. Socio-
cultural profile of Bapedi traditional healers as indigenous
knowledge custodians and conservation partners in the
Blouberg area, Limpopo Province, South Africa. J Ethnobiol
Ethnomed. 2015 Jun 6;11(1):1.
54 Semenya SS, Potgieter MJ. Bapedi traditional healers in the
Limpopo Province, South Africa: Their socio-cultural profile
and traditional healing practice. J Ethnobiol Ethnomed. 2014
Jan 10;10(1):1.
55 McWhinney IR. A textbook of family medicine: New York:
Oxford University Press; 1997.
56 Bogopa D. Health and ancestors: the case of South Africa and
beyond. Indo-Pac J Phenomenol. 2010;10(1).
57 Van Dyk AC. Traditional African Beliefs and Customs:
Implications for AIDS Education and Prevention in Africa. S
Afr J Psychol. 2001;31(2):60–6.
PM
58 Thorpe A. God for Beginners. Philosophy Now. 1993;8:38–
9.
59 Pretorius E. Traditional healers. In: Crisp N, Ntuli A, editors.
South African Health Review. Durban: Health Systems
Trust;1999;18:249–56.
60 Oosthuizen GC. Indigenous Christianity and the future of the
church in South Africa. International Bulletin of Missionary
Research. 1997;21(1):8.
61 Ibanez-Gonzalez DL, Tollman SM. Clinics and Churches:
lifeworlds and health-seeking practices of older women with
noncommunicable disease in rural South Africa. BMC Int
Health Hum Rights. 2015;15(1):12.
62 Legare CH, Gelman SA. Bewitchment, biology, or both:
The co-existence of natural and supernatural explanatory
frameworks across development. Cognitive Sci.
2008;32(4):607–42.
63 Ashforth A. An epidemic of witchcraft? The implications
of AIDS for the post-apartheid state. Afr Stud. 2002 Jul
1;61(1):121–43.
64 Federici S. Witch-hunting, globalization, and feminist
solidarity in Africa today. J Int Womens Stud. 2013;10(1):21–
35.
65 Kale R. Traditional healers in South Africa: a parallel health
care system. BMJ. 1995 May 6;310(6988):1182.
66 Wreford J. ‘Sincedisa – We Can Help!’ A Literature Review
of Current Practice Involving Traditional African Healers in
Biomedical HIV and AIDS Interventions in South Africa. Soc
Dynamics. 2005;31(2):90–117.
67 Snyman T, Stewart MJ, Grove A, Steenkamp V. Adulteration
of South African traditional herbal remedies. Ther Drug Monit.
2005;27(1):86–9.
68 Dickinson D. Traditional healers, HIV and AIDS and
company programmes in South Africa. Afr J AIDS Res.
2008;7(3):281–91.
69 Naidu M, Darong G. When illness is more than just a sick
body: Probing how isiZulu-speaking nurses construct illnesses
and healing. The Oriental Anthropologist. 2015;15(1):91.
70 Henderson PC. A gift without shortcomings: Healers
negotiating the intersection of the local and global in the
context of HIV and AIDS. Soc Dynamics. 2005;31(2):24–54.
71 Xaba T. Marginalized medical practice: The marginalization
and transformation of indigenous medicines in South Africa.
In: Boaventura de Sousa Santos, editor. Another knowledge
is possible: Beyond Northern epistemologies. London: Verso;
2007; p.317–351.
91
72 Republic of South Africa. Witchcraft Suppression Act 3 of 89 Naidu M, Darong G. The ancestors have caused this: isiZulu-
1957. February 1957. [Internet]. [cited 22 March 2016]. speaking nurses’ understandings of illness and patient care.
URL: http://www.justice.gov.za/legislation/acts/1957-003. Anthropological Notebooks. 2015;21(2).
pdf
73 Gumede MV. Traditional healers: a medical practitioner’s
perspective. Braamfontein: Skotaville; 1990.
74 Van Wyk B-E. A broad review of commercially important
southern African medicinal plants. J Ethnopharmacol.
2008;119(3):342–55.
75 Pinkoane M, Greeff M, Koen M. Policy makers’ perceptions
and attitudes regarding incorporation of traditional healers
into the national health care delivery system. Curationis.
2008;31(4):4–12.
76 Mokgobi M. Health care practitioners’ opinions about
traditional healing. African Journal for Physical Health
Education, Recreation and Dance. 2014;20(Suppl 2):14.

PM
77 Wreford J. Myths, masks and stark realities: traditional African
Healers, HIV and AIDS narratives and patterns of HIV and
AIDS avoidance. Cape Town: Centre for Social Science
Research; 2008.

16 6
78 Campbell-Hall V, Petersen I, Bhana A, Mjadu S, Hosegood

20 IL
V, Flisher AJ. MHaPP Research Programme Consortium.
Collaboration between traditional practitioners and primary
health care staff in South Africa: developing a workable
partnership for community mental health services. Transcult
Y T
Psychiatry. 2010 Sep 1;47(4):610–28.
A N
79 Devenish A. Negotiating healing: Understanding the
dynamics amongst traditional healers in KwaZulu-Natal
M U

as they engage with professionalisation. Soc Dynamics.

2005;31(2):243–84.
4 ED

80 Petrus T. Defining witchcraft-related crime in the Eastern

Cape Province of South Africa. Int. J. Sociol. Anthropol.
2011;3(1):1–8.
81 Ranger T. Scotland Yard in the bush: Medicine murders, child
O

witches and the construction of the occult: a literature review.

Africa. 2007;77(02):272–83.
G

82 Dahab M, Charalambous S, Hamilton R, Fielding K, Kielmann

K, Churchyard GJ, et al. “That is why I stopped the ART”:
R

Patients’ and providers’ perspectives on barriers to and

enablers of HIV treatment adherence in a South African
BA

workplace programme. BMC Public Health. 2008;8(1):1.

83 Tshehla B. Traditional health practitioners and the
O

authority to issue medical certificates. S Afr Med J. 2015

EM

Apr;105(4):279–80.
84 Mbatha N, Street RA, Ngcobo M, Gqaleni N. Sick certificates
issued by South African traditional health practitioners:
Current legislation, challenges and the way forward. S Afr
Med J. 2012 Mar;102(3):129–31.
85 Rudolph M, Ogunbodede E, Mistry M. Management of the
oral manifestations of HIV and AIDS by traditional healers and
caregivers. Curationis. 2007;30(1):56–61.
86 Mills E. HIV illness meanings and collaborative healing
strategies in South Africa. Soc Dynamics. 2005;31(2):126–
60.
87 George G, Chitindingu E, Gow J. Evaluating traditional
healers’ knowledge and practices related to HIV testing
and treatment in South Africa. BMC Int Health Hum Rights.
2013:13(1):1–7.
88 Davids D, Blouws T, Aboyade O, Gibson D, De Jong JT, Van’t
Klooster C, et al. Traditional health practitioners’ perceptions,
herbal treatment and management of HIV and related
opportunistic infections. J Ethnobiol Ethnomed. 2014;10(1):1.

92 S A H R 20 1 6
 EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM

93
Service Delivery
 Service Delivery

94
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Achieving universal access to sexual and
reproductive health services: the potential and
9
pitfalls for contraceptive services in South Africa

Authors:
Naomi Lince-Deroche i Melanie Pleaner ii
Jane Harries iii Chelsea Morroni ii,iii,iv

PM
Saiqa Mullick ii Cindy Firnhaberv,vi
Masangu Mulongo v Pearl Holele vii

16 6
Edina Sinanovic viii

U 20 IL
niversal access to sexual and reproductive health services was included in South Africa’s laws,
the Millennium Development Goals and has been carried forward in the
Y T
new Sustainable Development Goals (SDGs). Access to contraception is policies and guidelines
A N
highlighted in the Family Planning 2020 (FP2020) initiative. Given South Africa’s on contraceptive service
ongoing commitment to the SDGs and FP2020, this chapter explores the potential
provision in the public
M U

for achieving universal access to contraceptive services in South Africa against the
backdrop of the country’s domestic policies, current implementation efforts and HIV sector are progressive and
4 ED

epidemic. comprehensive, and

South Africa’s laws, policies and guidelines on contraceptive service provision in the promote integrated, rights-
public sector are progressive and comprehensive, and promote integrated, rights-
based service delivery.
O

based service delivery.

G

The chapter begins with a description of South Africa’s enabling policy environment
with regard to sexual and reproductive health and rights generally, and contraception
R

specifically. Service delivery norms and approaches for budgeting and expenditure
tracking are described, and national and provincial contraceptive statistics are
BA

presented.
O

Public sector delivery of contraceptive services nationally faces both similar and
EM

unique challenges as compared to other health services. Issues relating to health

systems constraints are identified, including scarce resources and the burden of HIV
in the country, and their impact on delivery of contraceptive services is discussed. The
recent introduction and roll-out of the subdermal contraceptive implant is highlighted
as a case study illustrating both successes and challenges.

Finally, key recommendations are provided for contraceptive service delivery in the
future in light of ongoing research and changes on the horizon – such as National
Health Insurance, national-level efforts to integrate HIV and primary care services,
and efforts under-way as part of the National Development Plan.

i Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine,
Facult y of Health Sciences, Universit y of the Wit watersrand, Johannesburg
ii Wits Reproductive Health and HIV Research Institute, Universit y of the Wit watersrand, Johannesburg
iii Women’s Health Research Unit, School of Public Health and Family Medicine, Universit y of Cape Town
iv EGA Institute for Women’s Health and Institute for Global Health, Universit y College London
v Right To Care
vi Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Facult y of Health Sciences,
Universit y of the Wit watersrand, Johannesburg
vii South African National Department of Health
viii Health Economics Unit, School of Public Health and Family Medicine, Universit y of Cape Town

95
Introduction
The Millennium Development Goals (MDGs) were established
in 2000, and 2015 marked the deadline for taking stock of
achievements. Large strides were made in some areas; however,
much remains to be addressed on a global scale.1 MDG 5b called
for “universal access to sexual and reproductive health services.”2
In sub-Saharan Africa, use of contraception among women aged
15 to 49, married or in a union, more than doubled from 1990
to 2015, yet 24% of these women still have an unmet need for
contraception.1 Recognising the need for further action, the new
Sustainable Development Goals (SDGs) were established in 2015,
and these again include universal access to sexual and reproductive
health.3
Family Planning 2020 is a global initiative founded in London in
2012 with the aim of making modern contraceptives accessible to
an additional 120 million women by 2020.4 Individual countries are
expected to make their own, locally applicable commitments, which
16 6
are then made public and tracked through various mechanisms.
20 IL
South Africa adopted both sets of development commitments
– the MDGs and the SDGs – and has also established domestic
commitments for FP2020. These commitments are aligned to the
Y T
country’s laws, policies and guidelines on health. However, looking
back, the country has struggled to make progress on health-related
A N
MDGs for various reasons. In this chapter, we explore the potential
M U
for achieving universal access to sexual and reproductive health
services in South Africa under the new SDGs, focusing specifically
on access to contraceptive services for pregnancy prevention and
4 ED
birth spacing. This is not meant to minimise the importance of access
to other essential sexual and reproductive health services such as
screening and treatment for reproductive cancers, maternity services,
O
safe termination of pregnancy services, and care and recourse for
survivors of gender-based violence. Indeed, we acknowledge that
G
too much attention on one indicator can work to the detriment of
R
other services.5 With that said, access to contraception has become
a de facto proxy indicator for access to sexual and reproductive
BA
health services within the global SDG framework and therefore
warrants special attention.
O
The chapter begins with a description of South Africa’s enabling
EM
policy environment with regard to sexual and reproductive health
and rights generally, and contraception specifically. Service delivery
norms and approaches for budgeting and expenditure tracking are
described, and national and provincial statistics for contraceptive
services are presented. We then highlight challenges – based
on past and current experiences – which are critical to consider
given South Africa’s goals for improving and scaling up access
to services. The delivery of contraceptive services in the public
sector faces both similar and unique challenges as compared with
other health services. Health systems constraints and provider- and
women-focused issues are identified, and their impact on delivery of
contraceptive services is discussed. South Africa recently introduced
a new contraceptive method into the mix available in the public
health sector – the subdermal contraceptive implant (hereafter
referred to as ‘the implant’). Introduction of this method provides
an opportunity to explore in-depth the opportunities and pitfalls the
country has experienced with the introduction of a new method and
what we can learn for the provision of quality contraceptive services
into the future. Throughout the chapter we take into consideration
96 S A H R 20 1 6
the changing landscape of South Africa’s HIV epidemic, which
permeates virtually all aspects of service delivery and presents
particular challenges for contraceptive service delivery.
South Africa’s contraception laws, policies, and
guidelines
South Africa’s excellent laws, policies and guidelines provide a
supportive, rights-based framework for delivery of sexual and
reproductive health services. Access to health care is valued at
the highest levels. The country’s Constitution guarantees the right
to access healthcare services, including sexual and reproductive
health services, for all,6 and the National Development Plan
PM
considers “providing affordable access to quality health care while
promoting health and wellbeing” as central to achieving its domestic
development goals.7 The National Health Act (61 of 2003)
acknowledges the particular health needs of vulnerable groups,
including women, and provides for free health care for pregnant
women, including women undergoing termination of pregnancy.8
The new National Adolescent Sexual and Reproductive Health and
Rights Framework Strategy (2014–2019)9 and the Strategic Plan for
Maternal, Newborn, Child, and Women’s Health and Nutrition in
South Africa (2012–2016)10 are broadly supportive of adolescents’
and women’s rights and access to health services and specifically
acknowledge the challenges faced by young women in accessing
sexual and reproductive health services.
The National Contraceptive Policy Guidelines released in 2001
contained a focus on the right of all women to choose a method and
stressed quality of care.11 This was a significant departure from the
perceived coercive, population control-focused policies that targeted
Black women under apartheid.12 The 2001 guidelines were updated
in 2012 and released as the National Contraception and Fertility
Planning Policy and Service Delivery Guidelines and the National
Contraceptive Clinical Guidelines (hereafter we refer to both jointly
as ‘the guidelines’ or the ‘CFP policy and guidelines’).13 The revised
CFP policy and guidelines acknowledge the role of contraception
in prevention of maternal mortality. The country’s HIV epidemic is
also addressed in the guidelines through discussion of the pivotal
role of contraception in prevention of mother-to-child transmission
of HIV; the special needs of HIV-positive women and men regarding
contraception, conception and fertility planning; and potential
pharmacokinetic interactions between hormonal contraceptive
methods and other medications, including antiretroviral drugs
(ARVs) and tuberculosis (TB) medications.
Perhaps most importantly, the guidelines establish the importance of
addressing women’s needs – at all ages. The overall emphasis is on
high-quality services giving all women the freedom to choose from
a range of options and methods, from healthy conception to long-
acting and permanent methods of contraception. According to the
guidelines, contraceptive clients should have access to “accurate,
unbiased information about all available methods in order to make
an informed choice,” and, “clients should be provided with the
method/s that they request, subject to meeting relevant medical
eligibility criteria and availability”.13 Table 1 provides a listing of the
contraceptive methods that should be available in the public sector.
Other methods, such as the Nuva Ring and the contraceptive patch
 Contraceptive services

(not listed in Table 1), are available in the private sector, but at a
cost. According to the CFP guidelines, methods should be offered in
the public sector in a comprehensive, integrated manner and include
discussion of fertility plans, offer of voluntary HIV counselling,
screening for sexually transmitted infections and TB, and education
on breast and cervical cancer screening.13
High knowledge and uptake of contraceptive
methods
The Contraceptive Prevalence Rate (CPR) is used to represent current
use of contraception. It is defined as the proportion of women aged
15 to 49 who are ‘currently’ using a contraceptive method. The
CPR has traditionally been reported for women who are married
in 2010 to be 63.7%, suggesting a possible gain of 3.8% for this
group since 2003.17 This estimated rate for women married or in
a union in South Africa is similar to the rate estimated for Southern
Africa in 2010 (62.2%), and is much higher than the estimated CPR
for Africa as a whole (30.9%). However, South Africa’s CPR is lower
than that of other upper-middle-income countries (Mexico 72.1%,
Russia 78.6%, Brazil 79.5%), and lower than rates in the United
States (77.1%) and Europe (72.0%).17
The most popular method of contraception in the 2003 SADHS
was the injectable; 26.7% of all women aged 15 to 49 used this
method at the time of the survey (Figure 1). Among women who
were currently using a contraceptive method at the time of the
survey, 53.2% were using an injectable method (data not shown).16
Use of long-acting and permanent methods such as the intrauterine

PM
or ‘in a union’, although more recently the data are also available contraceptive device (IUCD) or sterilisation was much lower at 0.6%
for women who are sexually active and for all women combined.15 and 7.3% of all women aged 15 to 49.

The most often-cited source of information on CPR for South Africa

is the South Africa Demographic and Health Survey (SADHS).16 The

16 6
last SADHS in the country was conducted in 2003 – well over a

20 IL
decade ago.16 Considering use of modern contraceptive methods,
the CPRs for all women, married or in a union, and sexually
active women aged 15 to 49 were 50.1%, 59.8% and 64.6%
Y T
respectively.17 A more recent analysis, which used modelling,
A N
estimated the CPR for South African women (married or in a union)
M U

Table 1: Modern contraceptive methods that should be available in the public sector based on national guidelines

Method Effectiveness*10 Duration Availability according to guidelines**

4 ED

Female sterilisation (tubal ligation) Typical use: 0.5% Permanent Limited current availability; guidelines emphasise
Perfect use: 0.5% creating one service point per district.
Male sterilisation (vasectomy) Typical use: 0.15% Permanent Limited facilities.
O

Perfect use: 0.10%

Levonorgestrel releasing Typical use: 0.2% 5 years Only available for contraception in the public sector
G

intrauterine system (LNG-IUS) Perfect use: 0.2% as second-line option for select women.
Copper intrauterine contraceptive Typical use: 0.8% 5 years**** All service levels
R

device (IUCD)*** Perfect use: 0.6%

Subdermal implants Typical use: 0.05% Implanon-NXT 3 years All service levels
BA

Perfect use: 0.05% Jadelle 5 years*****

Progestogen-only injectables Typical use: 6% DMPA (Depo) 12 weeks All service levels
O

Perfect use: 0.2% Net-EN 8 weeks

EM

Low-dose combined-oral Typical use: 9% Daily All service levels

contraceptive pills Perfect use: 0.3%
Progestogen-only pills Typical use: 9% Daily All service levels
Perfect use: 0.3%
Emergency contraceptive pills****** 58-95% effective depending on Up to 5 days after All service levels
how early it is taken. unprotected sex
Male condoms Typical use: 18% Coitally dependent All service levels
Perfect use: 2%
Female condoms Typical use: 21% Coitally dependent All service levels
Perfect use: 5%

Sources: National Department of Health, 2012;13 Hatcher and Trussell, 2014.14

DMPA/Depo – Depot medroxyprogesterone acetate, Net-EN – Norethisterone enanthate

* Expressed as failure rates.
** Actual availability differs. For some methods access is extremely limited.
*** Also available as an emergency contraceptive method.
**** The product currently available ‘on tender’ in South Africa is registered for five years; however, the Copper T380a IUCD is effective for 10 years.
***** This method is not yet available in the public sector despite being registered for use there.
****** Some clinics provide combined oestrogen and progestogen methods (i.e. essentially combined oral contraceptive pills (COCs)); however, the
dedicated product is recommended instead of COCs.

S A H R 20 1 6 97
Figure 1: Knowledge of, ever use and current use of modern contraceptive methods by all women aged 15 to 49 in South Africa, by
method

100%
93.4
90%
84.5
79.9
80% 78.1

70.5
70%

60%
53.2
50.1
50% 47.2
45.1
39.7
40%

30% 28.1 29.6

26.7
23.3
19.6
20%

10% 9.0 9.0

PM
7.3 7.3 6.0
3.7 2.6
0.3 0.3 0.6 0.2 0.0 0.1 0.5 0.0
0%
Any modern Female Male Pill IUCD Injectables Implants Male Female Emergency
method sterilization sterilization condoms condoms contraception

16 6
Knowledge of Ever use Current use

Source: SADHS, 2003.16

20 IL
Note: The implant was not available in South Africa in 2003. Also, condom use represents only those women who used condoms exclusively (i.e. the condom
data exclude women who used condoms plus another method).
Y T
Reported use of methods is higher if one considers sexually active
A N
women only, rather than all women. Figure 2 presents ‘ever use’ and
‘current use’ of contraceptive methods in 2003 for sexually active
M U

women; for this group, the CPR rises to 64.6%.

4 ED

Figure 2: Ever use and current use of contraceptive methods by sexually active women aged 15 to 49 in South Africa, by method (2003)12*

100%
O

90% 85.2

80%
G

70%
64.8
R

60% 56.0
BA

50%

38.4
40%
O

32.8
29.2
30%
EM

20%
12.2
10.110.1
7.8
10%
5.0 3.0
0.6 0.5 0.8 0.2 0.0 0.9 0.5 0.0
0%
Any modern Female Male Pill IUCD Injectables Implants Male Female Emergency
method sterilization sterilization condoms condoms contraception

Ever use Current use

Source: SADHS, 2003.16

*Sexually active = Sex in the last four weeks

Note: The implant was not available in South Africa in 2003.

More up-to-date information on the CPR and patterns of contraceptive
use is urgently needed in South Africa in order to understand the
impact of recent policy and service delivery changes. Fortunately,
data collection for the next SADHS will be initiated in 2016. To track
progress on contraceptive services on a more current and routine
basis, dispensing data are collected in health facilities. These data
are collated at the national level in the District Health Information
System (DHIS) and used to calculate a Couple Years of Protection
Rate (CYP). The CYP measures the level of protection from pregnancy
over one year given the amount of contraceptives dispensed.18 The
denominator is the total ‘couple-years’ in which there is an assumed
risk of pregnancy at the national level. The numerator is the number of
couple-years in which protection from pregnancy is assumed based
on the number of contraceptives dispensed and a conversion factor
which allows for standardisation of effectiveness duration across
methods. The CYP allows for comparison of methods in terms of their

98 S A H R 20 1 6
 Contraceptive services

Figure 3: Couple-Years of Protection Rate for South Africa for financial years 2000, 2005, 2010 and 2014, by province
70%

60.0
60% 57.8

49.2
50% 46.8
44.9
43.7 42.7
39.4 38.7 39.8
40%

32.1 32.7
30.7 30.1
29.5
30%
25.5 25.3
24.2

20% 18.8 18.7

10%

PM
0%
EC FS GP KZN GP MP NC NW WC SA

2000 DHIS 2005 DHIS 2010 DHIS 2014 DHIS

16 6
Source: Massyn et al., 2015.19

20 IL
contributions to the total CYP; however, it is impossible to know how ‘Unmet need for family planning’ is used to measure progress on
Y T
many or the proportion of individuals who have accepted a method.
For these reasons, the CYP is considered an imperfect metric, but it
contraceptive access. The term is defined as the proportion of
women, married or in a union, who are fecund and who do not want
A N
is widely used and can be useful for comparing statistics within a any more children or who want to postpone childbearing to beyond
M U

particular country over time or for cross-country comparisons.
The DHIS database provides CYP information based on financial
4 ED
the next two years, but who are not currently using a contraceptive
method.23,24 In South Africa, unmet need was estimated at 12.7%
for 2010.17

year DHIS data.19 Figure 3 indicates that for the financial year
ending in 2000, the CYP for the country was 25.3%. Growth in Addressing unmet need is important, especially for countries like
CYP was slow and even declined in some provinces between 2000 South Africa, given the important role of contraception in the
O

and 2010; however, it increased for the country to 46.8% in 2014.a armamentarium of HIV prevention strategies. However, some
A significant portion of the increase occurred in 2014 as a result of researchers have suggested that this indicator alone is insufficient
G

the introduction of the implant, which as a long-acting method, offers for assessing progress with contraceptive access, in that it is a
2.5 couple-years of protection for each insertion (for Implanon-NXT) time-dependent, variable indicator and may not address unintended
R

according to the internationally accepted conversion factor for this pregnancy among self-reported ‘current’ contraceptive users.24 In
method.20 It is worth noting that the official CYP data for South Africa fact, research has shown that in countries where the proportion
BA

represent method provision in the public sector only. It is generally of women using a contraceptive method greatly outweighs the
accepted that 20% of the population receives health care in the proportion with unmet need, the greatest number of unintended
O

private sector,21 and in the 2003 SADHS, 13% of women reported pregnancies may actually come from current contraceptive users as
EM

obtaining their contraceptive method there.16
Existing challenges
South Africa is arguably doing well with contraception considering
its laws, policies and guidelines on service provision, and
comparing its CPR with to that of other African nations. Indeed,
almost all women in the country (93.4%) have heard of modern
contraceptive methods, and close to three-quarters (70.5%) have
ever used one (Figure 1). However, these figures mask problems
with service delivery; equitable access; and correct, consistent, and
continuous use of methods, especially among certain groups such as
young or rural women.22
a result of incorrect or inconsistent use.24–26 Some women who are
late in refilling methods or who take a ‘break’ from use may be
counted as continuous users in routine data collection or surveys,
masking their risk of pregnancy.27
In South Africa, Baumgartner et al.28 found that among women in
need of continuation of their injectable contraceptive in the Western
Cape and Eastern Cape Provinces, 25% were between two and
12 weeks late for reinjection. Of those who were late, 2% in
the Western Cape and 36% in the Eastern Cape were refused a
reinjection by the nursing staff.28 In Gauteng Province, in a cohort
of 189 new injectable users, 78 (41.3%) discontinued use before
one year.29They reported that they were “taking a break”; the
mean length of the break was seven months during which no other
contraceptive method was used.29

a South Africa has historically used conversion factors for the CYP that
are slightly different from today’s internationally harmonised conversion
factors. The CYP could be higher if South Africa shifted to the international
conversion factors.

S A H R 20 1 6 99
Drug-drug interactions may also put current contraceptive users at risk
of pregnancy due to reduced contraceptive efficacy. For example, a
particular antibiotic may interfere with oral contraceptive efficacy.30
Some epilepsy medications may also reduce hormonal contraceptive
efficacy,31 and new research (discussed further hereafter) suggests
that use of certain ARV, or TB drugs may also reduce the efficacy of
some hormonal methods.
Understanding the gaps in South Africa in terms of contraceptive
use and how to intervene requires a broad understanding of
contraceptive delivery, uptake, and usage. Many women are
already using contraception, but generally, use is limited to a
few, relatively shorter-acting methods, such as the injectable, oral
contraceptive pills, and condoms. Access to a range of methods,
including information about them, is lacking for many women.
Method availability through forecasting, budgeting, and
supply chain management
A multi-country study of global DHS data found that “perfect
availability” of contraceptives would reduce method discontinuation
and increase the CPR by 1–2 percentage points. This analysis
concluded that, looking across countries, for every additional
method “fully available”, the CPR increases by 5–8 percentage
points.33
Few methods are “fully available” in South Africa. Despite guidance
from the CFP guidelines on what should be offered and where
(Table 1), in practice, some higher-level facilities or special facilities,
such as HIV or TB clinics, do not offer contraceptive services, and
what is available in primary-level facilities varies. Requests for

Figure 4 offers a conceptual framework to bring together the many
factors contributing to contraceptive use or non-use. It illustrates
the importance of a strong health system, including financing for
services and the pivotal role of healthcare providers, and the role of
PM
sterilisation, and sometimes also IUCD insertion, are often referred
to higher-level facilities, and in some districts access to these services
is extremely limited at any level.13 Finally, for some methods, the
commodity may be in stock at the facility, but due to lack of clear

16 6
community-focused outreach and education in generating demand messaging about drug–drug interactions or concerns about the
for services. The following sections refer to this figure and provide appropriateness of some methods for particular women, the method

20 IL
discussion on areas requiring special attention. may not be offered or discussed.

Y T
A N
Figure 4: Understanding contraceptive supply and demand – A conceptual framework
M U

Community beliefs/attitudes, gender norms

4 ED
O

Awareness raising/education for women and communities

G
R

Knowledge of reproduction and contraceptive methods

BA

N
O

Follow-up after
Ability to choose
method choice
EM

Provider skills and attitudes

Budgets/finance

Comprehensive
Affordability
counselling

Methods available
(number, type, and geographic proximity)

Supply chain management

Forecasting/tendering

Source: Shaded items represent indicators of service quality according to the framework put forward by Bruce.32

Note: ‘Providers’ can be broadly interpreted as all healthcare providers involved in service delivery, including nurses, doctors, pharmacists, financial
managers and administrators.

100 S A H R 20 1 6
 Contraceptive services

Budget allocations for provision of contraceptive services, like all
sexual and reproductive health services, fall within the primary health
care budget. This budget is allotted from the ‘Provincial Equitable
Share’ provided to provinces as a lump sum meant to accommodate
service delivery for all sectors, including health.34,35 Because the
Provincial Equitable Share is not linked to a particular service or
specific service targets, planning for and tracking expenditure on
sexual and reproductive health services can be challenging. In
contrast, HIV and TB services are supported through a separate
fund, called the ‘HIV and TB conditional grant’.36 Although the
conditional grant allows for greater accountability on HIV and TB,
the separation of funds for HIV- and TB-related care and treatment
complicates provision of integrated services, such as the provision of
contraception within HIV care and treatment facilities.
to purchase or access contraceptive methods. In South Africa, nurses
in primary health care services play a major role in contraceptive
provision. Research from South Africa shows that nurses have
strong preferences about which methods are appropriate for
women – especially those who are HIV-positive, unmarried, and/
or young.39,40
Nurses can also influence method choice and/or continuation of
methods – intentionally or unintentionally – through sub-standard or
biased counselling. Almost all of the issues identified through research
that are said to be barriers to contraceptive use or continuation
could be addressed through improved counselling and support
from healthcare providers. Misinformation about methods, health
concerns, language challenges, and provider biases are significant
barriers to initial uptake,41 and reasons for discontinuation among

The contraceptive method mix available in facilities is heavily
dependent on systems for procurement and supply chain
management, which are in turn influenced by healthcare providers,
administrators and pharmacists. Commodities are purchased
PM
‘current’ contraceptive users include desire for pregnancy, method
failure and method side-effects.27 Counselling on all of these issues
could help to prepare women for use, to choose the methods that
are best for them, and to assist them with method switching when

16 6
through tendering, which involves forecasting by provinces based necessary.
on anticipated demand. Prospective provincial estimates are often

20 IL
Improvements to counselling services must include consideration of
based on historical ordering and dispensing records, which are
the approach and environment in which counselling is provided.
unfortunately prone to data errors and misinterpretation in terms of
Y T A brief face-to-face counselling session in a busy clinic may not
their potential to represent future demand. Once the tender is in
be sufficient to convey all the information a woman needs on the
place, timely ordering from suppliers and distribution to facilities is
A N
reproductive cycle, return to fertility after method discontinuation,
another hurdle. Problems with supply chain management have been
potential drug–drug interactions, the need for dual protection,
M U

highlighted for HIV-related medications in the country;37 however,

etc. There is growing evidence for use of novel approaches
these challenges affect most, if not all, services to some extent.
and technologies such as interactive, Internet-based sources of
4 ED

Forecasting and supply chain management for contraceptive services
are uniquely complicated by the desire to provide women with
multiple choices. Budgeting for choice is complicated by variations
in method duration and the tendency of some women to stop early
O
information, text message reminders for renewal, pamphlets, etc.
in improving women’s understanding of how methods work and
method uptake and continuation.42–44

Innovation should be encouraged; however, face-to-face interactions

and/or switch between methods. It is further complicated if there
between nurses and contraceptive clients will continue to be
G

is an intention to shift women’s method preferences (at population

required. Healthcare workers in the public sector in South Africa
level) and/or to increase usage overall or by particular groups.
are burdened by a scarcity of human and other resources and
R

This shifting and scale-up are precisely what is called for in the
ever-increasing demands on their time. Efforts to improve access
CFP policy and guidelines. There is an expressed aim of increasing
BA

to contraceptive services – or any public sector services for that

N

uptake of long-acting methods, such as the new implant, revitalising

matter – must carefully consider the conditions in which healthcare
interest in the IUCD, improving dual protection and access to the
O

workers operate and how those conditions impact on morale and

female condom, and reducing dependency on progestogen-only
service quality.
EM

injectables such as depot medroxyprogesterone acetate (DMPA or

Depo) and norethisterone enanthate (Net-EN).13 Finally, assessing
stock management failings for contraception also requires special
attention. Globally, there are arguments that limited method choice
should be considered as a “stock-out.” For example, if fewer than
three modern methods are available, a facility should be seen to
have a stock-out problem requiring attention.38
The pivotal role of the healthcare provider
Figure 4 illustrates the central role of method availability and the
ability of women to choose between methods in contraceptive
service delivery. It also highlights the influence of healthcare
providers – nurses, doctors, pharmacists, financial managers and
administrators working on service delivery – on access to services.
Healthcare providers at all levels essentially control access to services
based on their influence on the purchasing and supply of methods.
Nurses and doctors play a significant role in the availability and
provision of contraceptives globally as a result of regulations in
many settings that require women to see a nurse or doctor in order
Access to services: accessibility, affordability and
service quality
Service quality has been identified as a crucial aspect of
contraceptive service provision. The most commonly used paradigm
for assessing contraceptive service quality is the ‘Bruce-Jain
Framework’.32,45,46 It comprises several dimensions including: the
range of contraceptive options available; women’s ability to choose
a method; comprehensive counselling on the methods; provider
knowledge, skills and attitudes; and the opportunity for interaction
and follow-up support after method choice.47,48 Service quality, as
defined in the Bruce-Jain Framework, is represented by blue boxes
in Figure 4. Extensive evaluations using this framework have shown
that improving service quality is potentially the most important factor
for increasing contraceptive uptake.49–52
However, service quality, which speaks to user acceptability, is
just one of the defining attributes of access to services. Access to
health care must also include physical accessibility and financial

S A H R 20 1 6 101
affordability.53–55 There are many documented problems with
contraceptive service accessibility in South Africa. The CFP
guidelines state that contraceptives should be available at all
levels of care. However, many facilities do not offer the full method
mix – sometimes even when the commodities are in stock – and
some offer no contraceptives at all. Personnel shortages, lack of
training on method provision, and lack of equipment are sometimes
to blame. Counselling is often limited to one to two methods (if
given at all), and stigma and/or discrimination by healthcare
providers is commonplace. HIV-positive, unmarried, and young
women are particularly at risk of discrimination by healthcare
providers.39,40,56,57
Given these barriers, women with the financial means may choose
to access their contraceptive method in the private sector. For women
who cannot afford private sector access, contraceptives, including
long-acting and permanent methods, are offered free of charge in
the public sector, but women may still incur costs. These include:
the costs associated with searching for information about methods
16 6
and where to obtain them; the time and travel costs associated
with obtaining them; costs associated with managing side-effects
20 IL
associated with use; and psychological costs associated with not
obtaining one’s desired method or managing the stigma associated
with use.58,59
Y T
A N
The user perspective
M U
According to South African law, anyone aged 12 and older has
the right to receive contraception without parental consent.60
4 ED
Unfortunately, this legal right to access services is not reflected in the
rates of adolescent pregnancy in the country. This is in part because
healthcare providers’ opinions often differ from the law. Holt et al.40
reported that many of the healthcare providers at three public health
O
facilities in Soweto thought that young women should not have sex
G
before marriage and therefore should not access contraceptives.
When probed about what methods were most appropriate for
R
young women if used, the majority of the providers responded that
young women should use injectables. Pills were not seen to be an
BA
option due to the reported inability of young women to remember
to take them every day, and IUCDs were also not recommended.40
O
These beliefs are contrary to international recommendations which
EM
recommend long-acting, reversible methods such as the IUCD and
implant as first-line methods for young women.61–63
HIV-positive women also require special consideration – clinically
and psychosocially – when considering access to contraception.
Research from South Africa conducted before large-scale changes
in ARV access showed that HIV-positive women had fertility desires
similar to those of HIV-negative women; however, their ability to
achieve their desired family size was mediated by fear of the risk of
partner and child infection and perceived disapproval from society of
childbearing while HIV-positive.64 Today, ARVs are widely available,
and South Africa’s prevention of mother-to-child transmission of HIV
(PMTCT) programme is considered highly successful.65 However,
access to fertility counselling and assisted reproductive technologies
is still limited, especially in the public sector.
All women, regardless of HIV status or age, could benefit from
additional information on contraception. Although challenging
and not the ideal solution, some women can overcome barriers
to access, particularly those posed by unhelpful or discriminatory
1 02 S A H R 20 1 6
healthcare providers, if they have the information and agency to
do so. The 2003 SADHS showed that educated women were more
likely to be using a contraceptive method at the time of the survey,16
and qualitative research from Soweto revealed that tenacious,
highly motivated young women can sometimes obtain contraceptive
methods from disapproving healthcare providers despite the odds.39
Demand-creation activities, such as awareness-raising campaigns
and education on reproduction and contraception in schools,
have been shown to be cost-effective strategies for increasing
contraceptive uptake;58 however, the importance of offering a high-
quality service should not be underestimated.
Finally, women’s access to contraceptive services must be considered
within the larger social context. Despite progressive laws and
policies, strong power differentials in heterosexual relationships and
PM
social and structural barriers to educational, economic and political
advancement strongly disadvantage women.66 South Africa’s
rates of interpersonal and gender-based violence are exceedingly
high,67 and attitudes about young women’s sexuality are generally
disapproving, with the dominant discourse presenting young
mothers as promiscuous and representative of the degradation of
cultural and social mores.40,68,69 All of these factors undoubtedly
impact on women’s ability to access services and their prioritisation
of contraceptive access in terms of their day-to-day needs.
The implant in South Africa
Introduction of the implant in South Africa in 2014 was relatively
late compared with other countries on the continent; however,
it is an example of a step taken towards improving the quality of
contraceptive services through expanding women’s options and
increasing access to long-acting reversible contraception, and
raising awareness regarding method availability nationally. The
implant is registered for use in over 100 countries globally, including
countries in the Southern African region.70 It consists of matchstick-
sized rods filled with progestogen, which are inserted under the skin
of a woman’s upper arm. The implant is effective for three to five
years depending on the implant type.70 Both Jadelle and Implanon-
NXT have been approved for use in South Africa, but distribution
has focused on Implanon-NXT.
Throughout 2013 and early 2014, training manuals were developed
and over 6 000 healthcare providers, mainly nurses, were trained
on insertion of Implanon-NXT. Cascade of this training and training
on implant removal is ongoing. In the same time period, supplies
were procured, and distribution systems were readied and tested.71
To complement supply-side preparations for service delivery, in
February 2014 the National Department of Health launched a
grass-roots campaign to promote the release of the CFP guidelines
and raise awareness on various issues including availability of the
implant, the benefits of longer-acting methods, and the importance
of condom use for dual protection against pregnancy and HIV.72
The availability of a new method, training of providers and demand
creation resulted in swift uptake. Provincial preliminary reports
show provision of 807 079 implants to women through December
2014.71
Interestingly, in parallel with the success of the campaign and
distribution thereafter, introduction of the implant has highlighted
existing challenges with South Africa’s contraceptive service delivery.
The implant is a temporary or ‘reversible’ method of contraception,
 Contraceptive services

but unlike the pill and injections, which are also temporary, the
implant requires that a woman see a healthcare provider to have it
removed. This forces women to re-engage with the healthcare system
if they are not satisfied with the method or if they have changed their
mind about its use.
There has been growing concern about the number of women
returning for early removal of the implant, some within a few
months of insertion. Establishment of formal monitoring systems for
the implant lagged behind roll-out of the method, which has posed
a challenge in determining the true extent of removals. However,
estimates and preliminary data collection from the provinces suggest
that as of December 2014, 820 implants were removed, suggesting
a possible 0.1% removal rate in the early part of the roll-out.71
More refined data collection and careful observation over time are
HIV-positive women in Kenya.82 Women using the implant and EFV-
based ART were three times more likely to become pregnant than
women using nevirapine-based ART. However, the risk of pregnancy
for women using all other forms of contraception – except for IUCDs
or sterilisation – was higher than for women using the implant and
EFV-based ART regimens. This is further supported by Pyra et al.83
The authors combined data from seven African countries. They
found decreased effectiveness among women using EFV-based ART
and the implant; however, women using EFV-based ART and the
implant still benefited from lower pregnancy risk than did women
using EFV-based ART and other contraceptive methods.
This kind of situation – where technical, nuanced information needs
to be filtered to the public through healthcare providers – is not
new in the contraceptive field. There is an ongoing yet unanswered

needed. The removal rate is likely to have increased in 2015 as
access to removal services increased; however, the rate for 2014
is lower than anecdotally reported in South Africa and compares
favourably with removal rates from other countries. A study from the
PM
scientific debate regarding the potential for use of progestogen-only
injectables (DMPA/Depo and Net-EN) to elevate women’s risk of
HIV acquisition.84 To date, there is no consensus on this question.
Research currently under way (the ‘ECHO study’) aims to answer this

16 6
Netherlands showed that 8% of women who chose to use Implanon question directly. In the meantime, the World Health Organization
had discontinued its use within 12 months.73 In a study in the US, has issued a cautionary statement advising women at risk of HIV to

20 IL
31% of women and adolescents who chose an implant discontinued use dual protection.85 This issue is discussed in the CFP guidelines,
using that method before 24 months,74 and in a study in Australia, and is cited as one of the reasons for the aim of reducing the
Y T
47% of women discontinued the implant during a follow-up period
of three years.75
country’s heavy reliance on injectable contraceptives. This issue,
as well as the new research on the implant and ARVs, highlights
A N
the need for careful messaging on contraceptive use and ongoing
Despite South Africa’s implant removal rate being both expected and
M U

training for and communication with healthcare providers who are

in line with data from other contraceptive services internationally, the
expected to convey messages to the public.
demand for removal spurred attention and negative press, – and has
4 ED

called into question the quality and safety of the method.76 Concerns
have also been raised in academic publications and reported Conclusions
by the media about the efficacy of the method for HIV-positive
South Africa’s laws, policies and guidelines on contraceptive service
women taking ARVs.76 Implants contain synthetic progesterone:
O

provision in the public sector are progressive and comprehensive,

either etonogestrel (Implanon, Implanon-NXT and Nexplanon) or
and promote integrated, rights-based service delivery. Most women
G

levonorgestrel (Jadelle, Sino-implant). Efavirenz (EFV)-based anti-

have heard of modern contraception and many are already using it.
retroviral treatment (ART), which is the leading first-line treatment
The CFP guidelines call for increased uptake of long-acting methods
R

regimen for HIV-positive women in resource-limited settings,75

and reduced dependency on progestogen-only injectables.13
stimulates metabolism of the synthetic progesterone released by
BA

the implant, thus potentially reducing blood concentrations in some In this environment, achieving the SDGs and National Development
women.78,79 Research conducted prior to the introduction of the Plan goals on universal access to sexual and reproductive health
O

implant in South Africa showed that women may respond differently services and the FP2020 goals on scaling up contraceptive access
EM

to reduced etonogestrel or levonorgestrel concentrations; there were
conflicting study results on the potential for the reductions caused by
EFV to lead to increased risk of pregnancy.79–81
Based on evidence available at the time, in October 2014, the
National Department of Health released a circular to the provinces
indicating that women taking EFV-based ART or certain epilepsy- and
TB-related drugs (which work similarly to EFV in the body) should
not be given the subdermal implant, and that women taking these
medications who had already received the implant should be given
the option of having the implant removed and taking up another
method. Regrettably, the circular did not indicate that the implant
was safe to continue using if a woman chose to do so and that, in
fact, the method would still offer protection from pregnancy albeit
with reduced efficacy.
Since then, newly published work has underscored the idea that the
subdermal implant may still be a good option for some HIV-positive
women taking EFV-based ART. Patel et al. conducted a retrospective,
longitudinal cohort analysis based on data from roughly 25 000
specifically, will require careful consideration of existing service
delivery and opportunities for incremental progress. Improvements
should build on existing infrastructure, policies and service delivery
successes.
HIV has been a game-changer for health care in South Africa. It
has forced discussion on equitable access to care and demanded
innovation in the context of limited resources. The National
Department of Health has responded to the HIV epidemic and
other health-related challenges with considered solutions, which
will benefit the population as a whole. Today, the environment with
regard to healthcare provision in South Africa is rapidly evolving. A
plan for National Health Insurance (NHI) has recently been released
and outlines a phased approach for bringing together the public
and private sectors under a single-payer system.86 Ongoing pilots
for NHI have included public-private partnerships for delivery of
contraception, to increase access by making affordable contraception
available in more geographic locations. The NHI initiative also
presents opportunities for the merging of quality control and data
collection and management systems – potentially allowing a more

S A H R 20 1 6 1 03
complete picture of access and uptake in the country. Primary health
care re-engineering is also under way and could further increase
access to contraception through community-based distribution via
Ward-based Primary Health Care Outreach Teams, School Health
Services, and District Clinical Specialist Teams.87
Given this shifting landscape, goals for shifting and scale-up of
contraceptive use in South Africa present unique challenges for the
road ahead. Fortunately there is renewed attention on contraceptive
services globally, and plenty of available evidence on effective and
cost-effective strategies for intervention. Accountability at every
stage – from budgeting for methods to dispensing to women – is
critical. CYP and unmet need for family planning will be important
to assess over time; however, women who report ‘current use’ of
contraceptives will require as much support as women who may
Address the role of the healthcare provider and access to
information
➢➢ Acknowledge the role of healthcare providers as “street-
level bureaucrats”.91 Engage them from the point of policy
development, ensuring buy-in before implementation.
➢➢ Recognise the role of healthcare personnel in data collection,
budgeting and planning for services.
➢➢ Prioritise training on contraceptive counselling. High-quality
counselling should include discussion of the availability of a
range of methods, the potential for side-effects including how
they may lessen over time, how to use each method correctly,
and the option to switch methods if necessary.
➢➢ Develop and promote innovative approaches for information-

not be currently using a method, and certain key groups, such as
unmarried women, young women and HIV-positive women, require
special attention. All women will require counselling, education and
supportive interactions with the healthcare system throughout the
PM
sharing on reproduction and contraception, such as websites,
social media, mobile phone applications, and interactive
learning platforms.
➢➢ Provide healthcare workers with clear guidance on effective

16 6
continuum of their reproductive lives – focusing on both conception messaging for complicated, technical issues and the tools
and contraception – in order for South Africa to reap the benefits of

20 IL
required to convey messages to diverse audiences.
improved contraceptive uptake.
➢➢ Recognise the severe scarcity of resources in the public sector.
Y T Strive to improve working conditions and improve throughput
Recommendations in the country’s clinical and nursing training institutions.
A N
The following are specific recommendations to meet the goals of the ➢➢ Given existing resources and possible limitations on improving
M U

CFP guidelines and address South Africa’s commitment to FP2020 all health facilities overnight, consider the creation of ‘centres
and achieving universal access to sexual and reproductive health, of excellence’ that could allow for focused development
measured here through contraceptive access and uptake: of expertise, establishment of best practice, and provision
4 ED

of comprehensive, high-quality, integrated sexual and

Policy implementation, financing reproductive health services.
➢➢ Identify best practices for policy implementation. Draper et
O

Create demand while addressing societal barriers

al. highlighted the need for “communication between national
and provincial levels, the need for provincial structures to take ➢➢ Deepen outreach and awareness-raising efforts for
G

responsibility for implementation, and capacity-building to communities so that they address more than the availability of
enable policymakers and planners to develop, monitor and methods. Provide information on topics such as reproductive
R

implement policy”.88 cycles, correct and consistent use of contraception, dual

BA

protection, and the advantages and disadvantages of long-

N

➢➢ Consider changes to budgeting/financing for contraceptive

acting reversible and permanent methods.
services that would allow for improved tracking and greater
O

accountability – possibly a conditional grant for sexual and ➢➢ Target key groups with ethical and appropriate information
EM

reproductive health services. and services. Prevention of unintended pregnancy among

HIV-positive women is part of UNAIDS’ four-pronged strategy
➢➢ Improve forecasting and supply chain management for contra-
for HIV prevention.92 However, it remains paramount that
ceptive commodities through use of available technologies
healthcare providers are trained to allow HIV-positive
and training for the personnel involved.89
women (and men) to make their own choices with regard to
Access and method mix contraception and childbearing, and that they are provided
with the information they require both to conceive and prevent
➢➢ Emphasise integration of services and the availability of a mix
pregnancy safely.
of methods at all service levels.
➢➢ Address the social determinants of health – poverty, employ-
➢➢ Consider limited method choice to be a form of stock-out.
ment, gender dynamics, etc. – which may affect women’s ability
The Reproductive Health Supplies Coalition provides a list of
to prioritise and seek contraceptive services.
indicators for measuring reproductive health commodity stock-
outs.38 ➢➢ Engage men, acknowledging their role as potential barriers
and facilitators to access.
➢➢ Ensure that all facilities offer long-acting reversible methods
and that permanent methods are easily available by referral. ➢➢ Educate communities on the rights of young and/or unmarried
These are cost-effective and least likely to be discontinued.74,90 women to have healthy, satisfying sexual lives and to use
contraception.
➢➢ Capitalise on existing and planned relationships and agree-
ments with the private sector to improve service provision and
monitoring.

104 S A H R 20 1 6
 Contraceptive services

Research
➢➢ Engage the research community to determine the best ways to
improve healthcare provider attitudes and counselling quality.
➢➢ Develop and test messages for providers and communities
regarding complex technical information on contraception.
➢➢ Elicit women’s input on when, where and how to engage them
with regard to contraceptive use.
➢➢ Support continued exploration of the complex interactions
between HIV, ARVs and other medications, including hormonal
contraceptives.
Acknowledgments
This work was made possible by the generous support of the
American people through the United States Agency for International
Development (USAID). The contents are the responsibility of the
authors and do not necessarily reflect the views of USAID or the
United States Government. This work was funded through the South
Africa Mission of the US Agency for International Development
(USAID) under the terms of Cooperative Agreement 674-A-12-
00029 to the Health Economics and Epidemiology Research Office
(HE2RO), a Division of the Wits Health Consortium (Pty) Ltd.

Monitoring progress
➢➢ In addition to unmet need, the CPR and CYP, consider other

PM
indicators to measure progress over time, including:
-- Percentage of facilities offering a mixture of short-acting
and long-acting modern contraceptive methods

16 6
-- Percentage of facilities offering a permanent method of
family planning

20 IL
-- Number of health providers trained in long-acting and
permanent services
Y T
-- Percentage of facilities meeting minimum standards with
regard to essential supplies and equipment to support
A N
provision of long-acting and permanent services
M U

-- Percentage of facilities with appropriate staff to support

quality long-acting and permanent services
4 ED

-- Percentage of clients who receive high-quality, compre-

hensive counselling for long-acting and permanent services
-- Percentage of women and men aged 15 to 49 who had
O

more than one sexual partner in the past 12 months

reporting the use of a condom during their last sexual
G

intercourse
-- Percentage of family planning clients who received HIV
R

testing at the family planning service delivery point or who

BA

were referred for HIV testing

N

-- Percentage of female clients of reproductive age attending

O

HIV-related service delivery points with unmet need for

EM

family planning.

More information on all of these indicators is available through

MEASURE Evaluation’s Family Planning and Reproductive Health
Indicators Database.93

S A H R 20 1 6 105
References
1 United Nations. The Millennium Development Goals Report
2015. New York: United Nations; 2015.
2 United Nations Statistics Division. Millennium Development
Goals Indicators: The official United Nations site for the MDG
indicators [Internet]. 2008 [cited 13 January 2016].
URL: http://mdgs.un.org/unsd/mdg/host.
aspx?Content=indicators/officiallist.htm
3 United Nations Department of Economic and Social Affairs.
Sustainable Development Goals [Internet]. Sustainable
Development Knowledge Platform. 2015 [cited 26 November
2015].
URL: https://sustainabledevelopment.un.org/topics
4 FP2020. What We Do [Internet]. 2016 [cited 5 February
2016].
URL: http://www.familyplanning2020.org/microsite/about-us
5 Austveg B. Perpetuating power: Some reasons why
reproductive health has stalled. Reprod Health Matters.
Reproductive Health Matters. 2011;19(38):26–34.
16 6
6 Republic of South Africa. Constitution of the Republic of South
Africa, No 108 of 1996. Pretoria: Government Printer; 1996.
20 IL
7 National Planning Commission Republic of South Africa.
Our future - make it work: Executive Summary. National
Development Plan 2030. Pretoria: The Presidency, Republic of
Y T
South Africa; 2013.
A N
8 Republic of South Africa. National Health Act, 61 of 2003.
Government Gazette, No. 26595. Cape Town: Government
M U
Printer; 2004.
9 South African Department of Social Development. National
4 ED
Adolescent Sexual and Reproductive Health and Rights
Framework Strategy 2014–2019. Pretoria: South Africa;
2015.
10 South African National Department of Health. Strategic
O
Plan for Maternal, Newborn, Child and Women’ s Health
(MNCWH) and Nutrition in South Africa 2012-2016.
G
Pretoria: South Africa; 2012.
11 South African National Department of Health. National
R
Contraception Policy Guidelines. Pretoria, South Africa;
2001.
BA
12 Burgard S. Factors associated with contraceptive use in
late- and post-apartheid South Africa. Stud Fam Plann.
O
2004;35(2):91–104.
EM
13 South African National Department of Health. National
Contraception and Fertility Planning Policy and Service
Delivery Guidelines. Pretoria, South Africa; 2012.
14 Hatcher R, Trussell J. Typical and Perfect Use Effectiveness
of Contraceptive Methods: Seven approaches to decreasing
unintended pregnancy [Internet]. 2014 [cited 12 February
2016].
URL: http://www.contraceptivetechnology.org/wp-content/
uploads/2014/09/LB-13-Handout-Unintended-Pregancies-7-
Approaches-9-4-14.pdf
15 MEASURE Evaluation. Contraceptive Prevalence Rate
[Internet]. [cited 6 January 2016].
URL: http://www.cpc.unc.edu/measure/prh/rh_indicators/
specific/fp/cpr
16 South African National Department of Health, Medical
Research Council, ORCMacro. South Africa Demographic
and Health Survey 2003. Pretoria: National Department of
Health; 2007.
1 06 S A H R 20 1 6
17 Alkema L, Kantorova V, Menozzi C, Biddlecom A. National,
regional, and global rates and trends in contraceptive
prevalence and unmet need for family planning between
1990 and 2015: a systematic and comprehensive analysis.
Lancet. 2013;381:1642–52.
18 Stover J, Bertrand JT, Shelton JD. Empirically based conversion
factors calculating couple-years of protection. Eval Rev.
2000;24(1).
19 Massyn N, Peer N, Padarath A, Barron P, Day C, editors.
District Health Barometer 2014/15. Durban: Health Systems
Trust; October 2015.
20 United States Agency for International Development (USAID).
Couple Years of Protection [Internet]. 2014 [cited 6 January
2016].
URL: https://www.usaid.gov/what-we-do/global-health/
PM
family-planning/couple-years-protection-cyp
21 Keeton C. Bridging the gap in South Africa. Bull World Health
Organ. 2010 Nov 1;88:803–4.
22 Flanagan A, Lince N, Durao de Menezes I, Mdlopane L. Teen
Pregnancy in South Africa: A Literature Review Examining
Contributing Factors and Unique Interventions. Johannesburg:
Ibis Reproductive Health; 2013.
23 MEASURE Evaluation. Unmet Need for Family Planning
[Internet]. [cited 14 January 2016].
URL: http://www.cpc.unc.edu/measure/prh/rh_indicators/
specific/fp/unmet-need-for-family-planning
24 Sedgh G, Hussain R, Bankole A, Singh S. Women with an
unmet need for contraception in developing countries and
their reasons for not using a method. Occasional Report No.
37. New York: Guttmacher Institute; 2007.
25 Singh S, Darroch JE, Vlassof M, Nadeau J. Adding It Up: The
benefits of investing in sexual and reproductive health care.
New York: Guttmacher Institute; 2003.
26 Trussell J. Contraceptive efficacy. In: Hatcher RA, et al.,
editors. Contraceptive Technology. 18th ed. New York: Ardent
Media; 2004.
27 Castle S, Askew I. Contraceptive Discontinuation: Reasons,
Challenges, and Solutions. New York: Population Council;
2015.
28 Baumgartner JN, Morroni C, Mlobeli RD, Otterness C, Myer
L, Janowitz B, et al. Timeliness of contraceptive reinjections in
South Africa and its relation to unintentional discontinuation.
Int Fam Plan Perspect. 2007;33(2):66–74.
29 Beksinska ME, Rees HV, Smit J. Temporary discontinuation:
A compliance issue in injectable users. Contraception.
2001;64(5):309–13.
30 Dickinson BD, Altman RD, Nielsen NH, Sterling ML. Drug
interactions between oral contraceptives and antibiotics.
Obstet Gynecol. 2001;98(5):853–60.
31 Patsalos PN, Perucca E. Clinically important drug interactions
in epilepsy: interactions between antiepileptic drugs and other
drugs. Lancet Neurol. 2003;2(8):473–81.
32 Bruce J. Fundamental elements of the quality of care - a simple
framework. Stud Fam Plann. 1990;21(2):61–91.
33 Futures Institute. The impact of stock-outs on the use of modern
contraception. Presentation at the International Conference on
Family Planning. Ethiopia: 2013.
URL: http://www.xcdsystem.com/ICFP2013/abstract/
panels/78_3.pdf

34 Republic of South Africa. Division of Revenue Bill, Act 10 of
2014. Government Gazette Vol. 586, No. 37595. Cape
Town: Government Printer; 2014.
35 Alm J, Martinez-Vazquez J. South Africa’s Provincial Equitable
Share: An assessment of issues and proposals for reform.
International Studies Program, Working Paper 09-04. Atlanta,
USA: Georgia State University, Andrew Young School of
Policy Studies; 2009.
36 Guthrie T, Hickey-Tshangana A. Overview of the public
finance system in South Africa: The budgeting and
expenditure procedures. Cape Town: Centre for Economic
Governance and AIDS in Africa; 2012.
37 Bateman C. Drug stock-outs: Inept supply-chain management
and corruption. S Afr Med J. 2013 Sep;103(9):600–2.
38 Reproductive Health Supplies Coalition. Harmonized Suite
of Indicators to Measure Stockouts and Availability of
Contraceptives, version 1.0. Arlington: JSI Research and
Training Institute; 2015.
39 Lince-Deroche N, Hargey A, Holt K, Shochet T. Accessing
Sexual and Reproductive Health Information and Services:
16 6
A Mixed Methods Study of Young Women’s Needs and
Experiences in Soweto, South Africa. Afr J Reprod Heal.
20 IL
2015;19(1):73.
40 Holt K, Lince N, Hargey A, Struthers H, Nkala B, Mcintyre
J, et al. Assessment of Service Availability and Health Care
Y T
Workers’ Opinions about Young Women’s Sexual and
Reproductive Health in Soweto, South Africa. Afr J Reprod
A N
Health. 2012;16(2):283–93.
M U
41 Campbell M, Sahin-Hodoglugil NN, Potts M. Barriers to
Fertility Regulation: A review of the literature. Stud Fam Plann.
2006 Jun;37(2):87–98.
4 ED
42 Trent M, Thompson C, Tomaszewski K. Text messaging support
for urban adolescents and young adults using injectable
contraception: Outcomes of the DepoText pilot trial. J Adolesc
O
Heal. 2015;57(1):100–6.
43 Lou C-H, Wang B, Shen Y, Gao E-S. Effects of a community-
G
based sex education and reproductive health service program
on contraceptive use of unmarried youths in Shanghai. J
R
Adolesc Heal. 2004 May;34(5):433–40.
44 Pradhan A, Sparano D, Ananth C V. The influence of an
BA
audience response system on knowledge retention: An
application to resident education. Am J Obstet Gynecol.
O
2005;193(5):1827–30.
EM
45 Jain A, Bruce J, Kumar S. Quality of services programme
efforts and fertility reduction. In: Phillips JF, Ross JA, editors.
Family planning programmes and fertility. Oxford, England:
Clarendon Press; 1992. p. 202–21.
46 Jain A, Bruce J, Mensch B. Setting standards of quality in
family planning programs. Stud Fam Plann. 1992;23(6):392–
5.
47 Mwaikambo L, Speizer IS, Schurmann A, Morgan G, Fikree
F. What works in family planning interventions: a systematic
review. Stud Fam Plann. 2011 Jun;42(2):67–82.
48 Miller K, Miller R, Askew I, Horn MC, Ndhlovu L. Clinic-
Based Family Planning and Reproductive Health Services in
Africa : Findings from situational analysis studies. New York:
Population Council, Africa Operations Research and Technical
Assistance Project; 1998.
49 Mensch B, Arends-Kuenning M, Jain A. The impact of the
quality of family planning services on contraceptive use in
Peru. Stud Fam Plann. 1996;27(2):59–75.
50 Koenig M, Hossain M, Whittaker M. The influence of quality
of care upon contraceptive use in rural Bangladesh. Stud Fam
Plann. 1997;28(4):278–89.
S A H R 20 1 6
Contraceptive services
51 Mroz TA, Bollen KA, Speizer IS, Mancini DJ. Quality,
Accessibility, and Contraceptive Use in Rural Tanzania.
Demography. 1999;36(1):23–40.
52 Arends-Kuenning M, Kessy FL. The impact of demand factors,
quality of care and access to facilities on contraceptive use in
Tanzania. J Biosoc Sci. 2007;39:1–26.
53 Penchansky R, Thomas JW. The concept of access: definition
and relationship to consumer satisfaction. Med Care. 1981
Feb;19(2):127–40.
54 Evans DB, Hsu J, Boerma T. Universal health coverage and
universal access. Bull World Health Organ. 2013;91:546–
546A.
55 Mcintyre D, Thiede M, Birch S. Access as a policy-relevant
concept in low- and middle-income countries. Heal Econ Policy
Law. 2009;4:179–93.
PM
56 Ramkissoon A, Coovadia H, Hlazo J, Coutsoudis A, Mthembu
P, Smit J. Options for HIV-positive women: women’s health. In:
Ijumba P, Padarath A, editors. South African Health Review
2006. Durban: Health Systems Trust; 2006.
57 Wood K, Jewkes R. Blood blockages and scolding nurses:
barriers to adolescent contraceptive use in South Africa.
Reprod Health Matters. 2006;14(27):109–18.
58 Matheny G. Family planning programs: getting the most for
the money. Int Fam Plan Perspect. 2004 Sep;30(3):134–8.
59 Pritchett LH. Desired fertility and the impact of population
studies. Popul Dev Stud. 1994;20(1):1–55.
60 Republic of South Africa. Children’s Act, 38 of 2005.
Government Gazette Vol. 492, No. 28944. Cape Town:
Government Printer; 2006.
61 Republic of South Africa. Children’s Amendment Act, 41 of
2007. Government Gazette Vol. 513 No. 30884. Cape
Town: Government Printer; 2008.
62 American Congress of Obstetricians and Gynecologists. IUDs
and Contraceptive Implants Safe for Teens [Internet]. 2012
[cited 16 March 2016].
URL: http://www.acog.org/About_ACOG/News_Room/
News_Releases/2012/IUDs_and_Contraceptive_Implants_
Safe_for_Teens
63 World Health Organization. Medical eligibility criteria
for contraceptive use, Fifth edition. Geneva: World Health
Organization; 2015.
64 Cooper D, Harries J, Myer L, Orner P, Bracken H, Zweigenthal
V. “Life is still going on”: reproductive intentions among
HIV-positive women and men in South Africa. Soc Sci Med.
2007 Jul;65:274–83.
65 Barron P, Pillay Y, Doherty T, Sherman G, Jackson D,
Bhardwaj S, et al. Eliminating mother-to-child HIV transmission
in South Africa. Bull World Heal Organ. 2013;91:70–4.
66 Jewkes R, Morrell R. Gender and sexuality: emerging
perspectives from the heterosexual epidemic in South Africa
and implications for HIV risk and prevention. J Int AIDS Soc.
2010;13(6):1–11.
67 Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic
violence: Findings from a South African cross-sectional study.
Soc Sci Med. 2002;55(9):1603–17.
68 South African Press Association (SAPA). Zuma: Send teenage
moms to Robben Island. Mail & Guardian. 11 March 2015.
69 Nicolson A. Babies for bling: how teenage pregnancy
became emblematic of misspent youth in South Africa. Today’s
News, University of Cape Town. 14 January 2016. [Internet]
[cited 16 March 2016].
URL: http://www.uct.ac.za/dailynews/archives/?id=9525
1 07
70 World Health Organization, Department of Reproductive
Health and Research. WHO statement on progestogen-only
implants. Geneva: World Health Organization; 2015.
71 South African National Department of Health. National
Perspective: Subdermal Implant Roll-out Statistics. Meeting
Report: The Contraceptive Implant in South Africa, 27 August
2015. Centurion, South Africa; 2015.
72 South African National Department of Health 2013/14.
Department of Health Annual Report. Pretoria; National
Department of Health; 2014.
73 Teunissen AM, Grimm B, Roumen FJME. Continuation rates
of the subdermal contraceptive Implanon® and associated
influencing factors. Eur J Contracept Reprod Heal Care.
2014;19:15–21.
74 OʼNeil-Callahan M, Peipert JF, Zhao Q, Madden T, Secura
G. Twenty-four-month continuation of reversible contraception.
85 World Health Organization Department of Reproductive
Health and Research. Hormonal contraception and HIV:
Technical statement. Geneva: World Health Organization;
2012.
86 South African National Department of Health. National Health
Insurance for South Africa: Towards universal health coverage
(White Paper). Pretoria, National Department of Health;
2015.
87 Pillay Y, Barron P. The implementation of PHC re-engineering
in South Africa . Public Health Association of South Africa.
[Internet]. 2011 [cited 16 March 2016].
URL: https://www.phasa.org.za/the-implementation-of-phc-re-
engineering-in-south-africa/
88 Draper CE, Lund C, Kleintjes S, Funk M, Omar M, Flisher
AJ, et al. Mental health policy in South Africa: development
process and content. Health Policy Plan. 2009;24(5):342–56.

Obstet Gynecol. 2013;122(5):1083–91.
75 Weisberg E, Bateson D, McGeechan K, Mohapatra L. A
three-year comparative study of continuation rates, bleeding
patterns and satisfaction in Australian women using a
PM
89 Kumar D. Challenges facing Supply Chains in South Africa.
KPMG South Africa Blog [Internet]. 2013 [cited 16 January
2016].
URL: http://www.sablog.kpmg.co.za/2013/12/challenges-

16 6
facing-supply-chains-south-africa/
subdermal contraceptive implant or progestogen releasing-
intrauterine system. Eur J Contracept Reprod Heal Care. 90 Trussell J, Hassan F, Lowin J, Law A, Filonenko A. Achieving

20 IL
2014;19(1):5–14. cost-neutrality with long-acting reversible contraceptive
methods. Contraception. 2015;9(1):49–56.
76 Skosana I. Birth control implant needs a shot in the arm. Mail
& Guardian. Johannesburg, South Africa; 22 May 2015.
Y T 91 Walker L, Gilson L. “We are bitter but we are satisfied”:
nurses as street-level bureaucrats in South Africa. Soc Sci
77 World Health Organization. Consolidated guidelines on the Med. 59(6):1251–61.
A N
use of antiretroviral drugs for treating and preventing HIV
infection: recommendations for a public health approach. 92 World Health Organization Department of HIV/AIDS.
M U

Geneva: World Health Organization; 2013. Prevention of Mother-To-Child Transmission (PMTCT): Briefing
Note. Geneva: World Health Organization; 2007.
78 Vieira CS, Bahamondes M V, de Souza RM, Brito MB, Rocha
4 ED

Prandini TR, Amaral E, et al. Effect of Antiretroviral Therapy
Including Lopinavir/Ritonavir or Efavirenz on Etonogestrel-
Releasing Implant Pharmacokinetics in HIV-Positive Women. J
Acquir Immune Defic Syndr. 2014;66(4):378–85.
O
93 MEASURE Evaluation. Family Planning and Reproductive
Health Indicators Database [Internet]. [cited 2 January 2016].
URL: http://www.cpc.unc.edu/measure/prh/rh_indicators/
indicator-summary

79 Scarsi KK, Darin KM, Nakalema S, Back DJ, Byakika-Kibwika

P, Else LJ, et al. Unintended Pregnancies Observed With
G

Combined Use of the Levonorgestrel Contraceptive Implant

and Efavirenz-based Antiretroviral Therapy: A Three-Arm
R

Pharmacokinetic Evaluation Over 48 Weeks. Clin Infect Dis.

2016 Mar 15;62(6):675–82.
BA

80 Perry SH, Swamy P, Preidis G a, Mwanyumba A, Motsa N,

Sarero HN. Implementing the Jadelle implant for women
O

living with HIV in a resource-limited setting in sub-Saharan

Africa: concerns for drug interactions leading to unintended
EM

pregnancies. AIDS. 2014 Jan 2;28.

81 Kreitchmann R, Innocente AP, Preussler GMI. Safety and
efficacy of contraceptive implants for HIV-infected women in
Porto Alegre, Brazil. Int J Gynecol Obstet. 2012;117:81–9.
82 Patel RC, Onono M, Gandhi M, Blat C, Hagey J, Shade
SB, et al. Pregnancy rates in HIV-positive women using
contraceptives and efavirenz-based or nevirapine-based
antiretroviral therapy in Kenya: a retrospective cohort study.
Lancet HIV. 2015;3018(15):10–8.
83 Pyra M, Heffron R, Mugo NR, Nanda K, Thomas KK, Partners
in Prevention HSV/HIV Transmission Study, et al. Effectiveness
of contraception for HIV-infected women using antiretroviral
therapy combined data from 3 longitudinal studies. Abstract
MOPDB0103. In: 8th International AIDS Society Conference
on HIV Pathogenesis, Treatment, and Prevention. Vancouver,
Canada; 2015.
84 Polis CB, Phillips SJ, Curtis KM, Westreich DJ, Steyn PS,
Raymond E, et al. Hormonal contraceptive methods and
risk of HIV acquisition in women: a systematic review of
epidemiological evidence. Contraception. 2014;90:360–90.

108 S A H R 20 1 6
Breastfeeding in South Africa: are we
making progress?
10

Authors:
Lisanne du Plessis i
Nazia Peer ii

PM
Simone Honikman iii
René English ii

16 6
R 20 IL
ecent global evidence shows that breastfeeding benefits both mothers Creating an enabling
and babies in rich and poor nations. Furthermore, evidence suggests that
Y T
concerted national efforts to scale up breastfeeding interventions, policies environment to practise
A N
and programmes can bring about rapid change, and that creating an enabling breastfeeding has huge
environment to practise breastfeeding has huge potential as an investment in the
potential as an investment in
M U

future health of mothers and the healthy life course of their children.
the future health of mothers
In South Africa, available national data suggest that most mothers initiate
4 ED

breastfeeding after birth. However, it has been observed that very few babies are and the healthy life course of
exclusively breastfed during the first six months of life. Many babies also receive their children.
complementary foods between two and three months of age, and in some cases, even
O

within a few days of birth. This suboptimal early nutrition profile predisposes South
Africans to poor health outcomes in both their infant and young child years as well
G

as in adulthood.
R

This chapter interrogates whether we are making progress in our country to improve
breastfeeding practices. A review was done of breastfeeding progress globally, and
BA

South Africa’s commitment to breastfeeding as a component of infant and young

O

child feeding (IYCF) over the past few years. The chapter determines what has been
done to promote breastfeeding, including which policy changes have imminently
EM

promoted breastfeeding. Thereafter, the key determinants of breastfeeding in South

Africa are unpacked and detailed, together with a review of proven interventions
at different levels of society. Finally, the chapter makes practical recommendations
to restore breastfeeding as the ‘new’ norm for infant nutrition in all sectors of South
African society.

i Division of Human Nutrition, Facult y of Medicine and Health Sciences, Stellenbosch Universit y
ii Health Systems Trust
iii Perinatal Mental Health Project, Alan J Flisher Centre for Public Mental Health, Psychiatry and
Mental Mental Health Universit y of Cape Town

1 09
Introduction
It is now well established that breastfeeding holds substantial benefits Table 1: World Health Assembly Nutrition Targets 2025
for both mothers and babies in rich and poor nations. Estimates
World Health Assembly Baseline Baseline Target
indicate that improved global breastfeeding rates can prevent target year/s status for 2025
breast cancer deaths in 20 000 mothers and prevent mortality in 40% reduction in the number 2012 162 million ~100
823 000 infants annually.1 Promotion, protection and support of of children under five who are million
stunted
breastfeeding can therefore contribute substantially to achieving the
50% reduction of anaemia in 2011 29% 15%
Sustainable Development Goals (SDGs).2 women of reproductive age
(pregnant and non-pregnant)
Evidence suggests that concerted national efforts to scale up 30% reduction in low birth 2008–2011 15% 10%
breastfeeding interventions, policies and programmes can bring weight
about ‘rapid’ change, and that creating an enabling environment No increase in childhood 2012 7% 7%
overweight
to practise breastfeeding has huge potential as an investment in the
Increase the rate of exclusive 2008–2012 38% 50%
future health of mothers and the healthy life course of their children.1 breastfeeding in the first six

PM
months up to at least 50%
In South Africa, available national data show that most mothers
Reduce and maintain childhood 2012 8% <5%
initiate breastfeeding after birth.3,4 However, it has been observed wasting to less than 5%
that very few babies are exclusively breastfed during the first six
Source: World Health Organization, 2015.10
months of life.3–5 Many babies also receive complementary foods

16 6
between two and three months of age, and in some cases, even
A review by Rollins et al. in the Lancet 2016 Breastfeeding Series

20 IL
within a few days of birth.5 This suboptimal early nutrition profile
drew on data from countries1 that report on the World Health
predisposes South Africans to poor health outcomes in both their
Organization (WHO) IYCF indicators. The review showed that
infant and young child years as well as in adulthood. Within this
Y T
context, the chapter interrogates whether we are making progress in
our country to improve breastfeeding practices.
early initiation and EBF are compromised in all countries, regardless
of their economic status,1 and only 37% of infants are exclusively
A N
breastfed for the first six months in low- and middle-income countries
A review was done of breastfeeding progress globally, followed (LMICs).1 It has been noted that as a country’s national wealth
M U

by a review of South Africa’s commitment to breastfeeding as a increases, so breastfeeding practices decline and the breastfeeding
component of infant and young child feeding (IYCF) over the period shortens.1 Notably, in countries where rapid improvement
4 ED

past few years. We highlight what has been done to promote in EBF rates have been reported, such as in Bangladesh, Brazil,
breastfeeding in general (for both HIV-infected and non-infected Cuba and Togo, collaboration among the stakeholders and sectors
mothers), including which policy changes have imminently promoted in addressing the contributing factors correlated directly with the
O

breastfeeding. We also reflect on the findings of evaluations done overall success of nutritional interventions.2
in South Africa that assess how we have progressed as a country,
According to the Lancet 2016 Breastfeeding Series, the
G

and report on areas of deficiency highlighted in these documents.

Thereafter, key determinants of breastfeeding in South Africa breastfeeding prevalence rate at 12 months was found to be highest
R

are unpacked and detailed, together with a review of proven in sub-Saharan Africa, South Asia and parts of Latin America, with
interventions at different levels of society. Finally, the chapter makes EBF of infants younger than than six months estimated at 35.04% in
BA

practical recommendations to restore breastfeeding as the ‘new’ sub-Saharan Africa in 2012.12 Countries in East and southern Africa
norm for infant nutrition within all sectors of South African society. tend on average to have lower rates of continued breastfeeding but
O

higher rates of EBF than those in West Africa.2

EM

Global breastfeeding targets and practices

From the perspective of global public health nutrition, the current
optimal IYCF best practice guidelines are undisputed:6–8 early
initiation of breastfeeding, exclusive breastfeeding (EBF) for the first
six months of life, and the continuation of breastfeeding for up to two
years and beyond9 remain the goal. However, evidence suggests
that despite global commitment to promoting exclusive and other
forms of breastfeeding as the nutritional method of choice, these
targets are not being met effectively in many countries.2 In a move
to charter new nutritional targets on a global scale, the World Health
Assembly (WHA) endorsed six new nutrition goals for 2025,10 one
of which is to increase the global prevalence of EBF in the first six
months of life to at least 50% – from the current rate of 38% (Table
1).
Breastfeeding in South Africa over the past
few decades
There is limited national information on breastfeeding practices in
South Africa. Available data indicate that 88% of mothers initiate
breastfeeding almost immediately post-delivery.4 However, reviews
report an 8% EBF rate from birth to six months of age, with over
70% of infants being given solid foods before six months.3,4,13
The premature introduction of food and liquids to infants younger
than six months has a detrimental impact on infant and young child
nutrition (IYCN) and health, and has also been cited in smaller
studies in the country.5,14
Policy changes
The spread of HIV and AIDS in South Africa significantly altered
the circumstances under which women made decisions about how
to feed their infants, especially in the light of the risks involved in
various feeding methods. In the early days of the pandemic the

11 0 S A H R 20 1 6

widespread reality of mother-to-child transmission (MTCT) of HIV
led to the introduction of numerous policies that resulted in a swift,
sweeping move away from breastfeeding and a dramatic shift
towards the use of breast-milk substitutes.
Thus interventions to prevent MTCT – implemented since 2001 in
South Africa and updated in 2008, 2010,15 201316 and 201517,18
– have been accompanied by evidence-based transitions in IYCF
recommendations for HIV-positive women. Recommendations ranged
from avoiding breastfeeding and the provision of free commercial
infant formula,19 to avoiding breastfeeding if certain conditions
were met (affordability, feasibility, acceptability, sustainability and
safety), to breastfeeding under antiretroviral therapy (ART) cover.18
In the very first set of recommendations, women were counselled to
choose either EBF with early weaning at 4–6 months, or exclusive
formula feeding with free formula provided until six months. As
a result, breastfeeding practices were compromised, not only for
babies born to HIV-infected mothers, but also for HIV-unexposed
16 6
babies born to HIV-negative mothers, as a consequence of the
spill-over effects of mixed messaging, which caused HIV-negative
20 IL
mothers also to opt for alternatives to breastfeeding. Particular harm
to breastfeeding in South Africa stemmed from the following:
Y T
➢➢ Healthcare provider confusion about infant feeding and the
risks of HIV transmission through breastfeeding
A N
➢➢ Poor support for infant-feeding counsellors
M U
➢➢ Poor counselling skills
➢➢ A disconnect between feeding recommendations and the
4 ED
socio-cultural context within which feeding occurs.
The latter refers specifically to EBF guidelines and the practice of
early introduction of fluids and foods very soon after birth.20,21
O
In 2011, a decade after the first wave of policy change in 2001
G
and against the backdrop of new evidence emerging on the benefits
of exclusive and continued breastfeeding in both HIV-positive and
R
HIV-negative environments,7,18,19,22–24 South Africa embarked on a
process of restoring breastfeeding. It is important to note that much
BA
work was done in South Africa by various researchers who focused
O
specifically on breastfeeding in HIV-infected mothers.19–21,23
EM
To this end, a strong commitment by the National Department of
Health (NDoH) to advance both the IYCF and maternal nutrition
cause in the country culminated in the landmark Tshwane Declaration
of Support for Breastfeeding in South Africa.24 This declaration was
signed in August 2011 as a result of the National Consultative
Breastfeeding Meeting convened by Dr Aaron Motsoaledi, the
National Minister of Health.25 The meeting was attended by various
nutrition stakeholders, including government, non-governmental
organisations (NGOs), academic and research institutions, and
independent experts. It was a positive step towards promoting
inter-sector collaboration and demonstrated commitment to the
promotion, protection and support of breastfeeding in South Africa
by the various nutrition stakeholders.
Since the 2011 Tshwane Declaration there has been measurable
growth in some of the commitments outlined in the document. A
new guideline was included in the revised IYCF policy, representing
a unified national message in which HIV-infected mothers are
encouraged to breastfeed their infants exclusively for the first six
months of life, while receiving ART to prevent MTCT, and to continue
S A H R 20 1 6
Breastfeeding
breastfeeding until their infants are one year of age.26 Furthermore,
Regulation 991, which governs the Code of Marketing of Breast-
milk Substitutes and other foodstuffs for infants and young children,
was legislated in December 2012,27 with gradual implementation
of these Regulations over a three-year period, culminating in full
implementation in 2015.
The promotion, protection and support of breastfeeding has also
been prioritised in a number of policy documents, including the
NDoH Roadmap for Nutrition in South Africa 2013–2017;28
the National Strategic Plan for Maternal, Newborn, Child and
Women’s Health and Nutrition 2012–2016;29 and the National
Health Promotion Policy and Strategy 2015–2019.30 Nutrition
also featured in the National Development Plan (NDP), focusing on
the wellbeing of women and children and on interventions during
PM
the first 1 000 days of life, with breastfeeding as key to attaining
development outcomes in the country.31
Some lessons learned
The benefits of breastfeeding are increasingly emphasized
throughout the world in scientific literature. During pregnancy
most women express the desire to breastfeed. It has to be
established what influences women to not breastfeed or to stop
breastfeeding in the early postpartum period. Factors affecting
breastfeeding are economic factors; advertising and commercial
printing; the example set by the higher socio-economic group;
changing values and status symbols; competing ideologies;
perceived milk insufficiency; cultural preference for fat babies;
availability of support; impact of health education; hospital
policies; lack of support in the first critical days and lack of
confidence. There is a trend away from breastfeeding with serious
health implications and we therefore have a responsibility to
promote breastfeeding. Strategies include research; assistance
for working women; restrictions on the promotion of milk
formulas; counselling; training of health personnel; changes in
hospital routines; a national project to promote breastfeeding
and a support system in low socio-economic areas.32
The above quotation could have appeared in a 2016 publication
on breastfeeding in South Africa, but this summary was published in
1984 in an article titled “Breastfeeding in South Africa: Social and
Cultural Aspects and Strategies for Promotion”.32 Three decades
later, the determinants affecting breastfeeding, interventions needed
for change, and the subsequent outcomes and practices, remain
virtually unchanged. Reasons for this serve as lessons to inform
future practice.
In 2008, South Africa was classified as one of 36 countries with
the highest global prevalence of unsatisfactory birth outcomes,
such as intra-uterine growth restriction, childhood stunting and
underweight.28,33 This was despite the implementation of various
nutritional interventions, most notably those guided by the NDoH’s
Integrated Nutrition Programme (INP).34–36 It was acknowledged
that nutrition remained under-prioritised in the country, especially
in the revised primary health care (PHC) approach, despite the
PHC purview of the INP.28 Some of these deficiencies are discussed
below in relation to general government-led programmes.
In the 2008 South African Health Review, Swart et al. examined
nutritional trends in South Africa during the period from 1994
to 2008, in relation to nutrition-related services and the PHC
111
principles inherent in the country’s health system.37 Inadequate
capacity was identified as a key factor contributing to the poor
implementation of such nutrition services. Insufficient capacity was
found at various essential levels, such as information-management,
programme, strategic, technical and operational levels, and was
identified as having directly hindered progress in IYCN. Swart et
al. recommended that capacity be developed among trained staff
across a range of various specialities or roles, using both pre- and
in-service training. The report further recommended the prioritisation
of certain key nutritional interventions in order to facilitate greater
impact through a more focused and unified approach, rather than
diluting the pool of resources in an attempt to focus on too wide a
range of interventions.37
In 2009, a landscape analysis was undertaken in South Africa to
identify primary problem areas in the progress towards effective
implementation of nutritional intervention strategies.38 The findings
were encouraging, suggesting that South Africa does in fact possess
the ability and resources to implement pivotal nutritional interventions
16 6
targeting maternal and child under-nutrition. However, challenges
to operationalising these resources were found to lie in ineffective
20 IL
policy and programme implementation. The report specifically
identified policy and implementation inadequacies in terms of
Y T
budget allocations, human resources, inter-sector collaboration, and
nutritional surveillance systems to monitor and evaluate interventions
A N
and influence decision-making. In terms of implementation, there
M U
was poorer commitment and capacity at provincial than national
level.38
4 ED
The findings of an independent report prepared for the Department
of Performance Monitoring and Evaluation (DPME) in 2014,
“Evaluation of Nutrition Interventions for Children from Conception
to Age 5 in South Africa”,36 supported the national reports and
O
evaluations previously discussed. These findings indicate that there is
G
still a poor rate of progress regarding nutritional outcomes, which has
led to a lack of progress in improving child mortality and morbidity
R
in the country. As a result, South Africa showed delayed progress
in achieving its Millennium Development Goals (MDGs) by 2015
BA
(specifically MDGs 4 and 5 relating to child mortality and maternal
health), and ultimately failed to achieve them. Although there are
O
policies, strategies and regulations within the relevant individual
EM
departmental portfolios regarding nutrition intervention (i.e. within
the Departments of Health; Social Development; Agriculture,
Forestry and Fisheries; and Rural Development and Land Reform),
there is an indication of uneven commitment to nutrition across these
departments, evidenced in differing degrees of investment in the
allocation of budget, staff, planning, management and leadership.36
The core finding of the DPME report also indicates that there is an
overall lack of capacity, including systemic, organisational and
individual capacity, to address the IYCN problems adequately in
the country.
Key determinants of breastfeeding in South
Africa
Existing evidence suggests that numerous factors play a role in
determining choices that women make regarding breastfeeding.
Kent’s39 ‘nested rings of responsibility’ indicate these levels of
influence, which include the mother, the family, the community,
hospitals, work-places, employers, business, industry, the media,
112 S A H R 20 1 6
health services, and the State authority or local government in charge
of policies.39 These different role-players can assist in creating an
enabling environment for successful breastfeeding. Accordingly,
we reviewed the existing literature to identify documented local
determinants and interventions in an attempt to understand what
hinders or facilitates South African breastfeeding practices. We also
drew on the evidence from the Lancet Breastfeeding Series (2016)1
to supplement our findings.
The mother, family and community
A woman’s breastfeeding behaviour is influenced by personal
attributes (age, weight, education level, confidence, baby’s gender,
baby’s wellbeing, and baby’s temperament).1 Breastfeeding
involves an intimate relationship between mother and baby, as the
two interact constantly. The mother internalises her influence on the
PM
baby, notably whether the baby is satisfied and content with breast
milk.1
A study by Sibeko et al.40 showed that women choose to breastfeed
because they believe it is better for infant growth and health. Reasons
that women do not breastfeed exclusively include fears about milk
insufficiency and reduced milk production, due to the perception that
the infant is hungry41–43 or that the infant is not receiving optimal
nutrition. Bland et al. noted that the overarching concern of mothers
was the infant not being adequately fed and therefore remaining
unsatisfied when drinking breast milk only.42
Community dialogues conducted in KwaZulu-Natal in 2013 as part
of community engagement to ascertain barriers to EBF in the first six
months of life highlighted the influence of the community and elders,
especially grandmothers, in this regard.a The reasons for women
not breastfeeding were explored in another series of community
dialogues, also conducted in 2013, which aimed to identify barriers
to the uptake of antenatal care and prevention of mother-to-child
transmission (PMTCT) in three rural provinces in South Africa.b The
findings revealed a negative perception of breastfeeding among
younger women and girls. Lack of knowledge, desire for social
acceptance, and pressure to maintain an ideal body shape, fuelled
negative attitudes and perceptions in this age group. According to
the participants, women lacked information and therefore did not
understand the benefits and importance of breastfeeding.b In the
North West Province, young female participants spoke about the
possibility of breastfeeding damaging their bodies, making them
“too slim” and flattening their breasts. Some women wanted to
breastfeed in order to lose weight. Others did not want to breastfeed
so that they would not lose weight. Evidence from a study by Shah et
al.44 also highlights concerns about body shape. Women who had
not achieved their desired weight loss from breastfeeding chose not
to breastfeed.41 Across all age groups, women also claimed to have
insufficient breast milk to breastfeed exclusively for six months.41,42
Traditional and cultural factors are strong determinants of
breastfeeding in South Africa. In the Northern Cape, traditional
medicines are believed to prepare the baby for dentition and to
protect against witchcraft. In Limpopo Province, a traditional dish
called tshiunza, made from maize and roots, and fermented to form
a soft sour porridge, is given immediately after birth and promoted
by grandparents. This food is believed to provide babies with energy
a Personal communication: Lenore Spies, Integrated Nutrition Programme,
Department of Health, KwaZulu-Natal.
b Personal communication: Elise Levendal, Researcher, Health Systems Trust,
26 March 2016.

to grow well and to assist them in passing stools since breast milk
is believed to be insufficient for infants.45 In some cultural settings
in South Africa, mixed feeding, including complementary foods,
begins within one month of birth.41,42
Poor breastfeeding technique (poor latching/attachment and
positioning) are known to predispose women to breast health
problems, namely mastitis, sore or cracked nipples and breast
engorgement.41 These conditions interfere with the success and
duration of breastfeeding practice during the first six months,
especially among women with sub-clinical mastitis. The conditions
can also increase the risk of postnatal HIV transmission in HIV-
infected women.46 One study showed that if women had sore
nipples they felt less confident in their ability to breastfeed, and were
therefore less likely to choose breastfeeding.41,47
Other factors related to the individual are also reported. Women
who had increased exposure to media messages41 were more likely
to stop breastfeeding, and women who had completed schooling
16 6
were more likely not to breastfeed.40 Bland et al.41 reported on the
use of trained lay counsellors in their study, which was designed
20 IL
to improve breastfeeding practices in HIV-positive and -negative
women living in a high HIV-prevalent area with previously low EBF
rates. The study showed that women with better socio-economic
Y T
status were more likely to stop breastfeeding at 16 weeks, and
A N
single women were also more likely to stop breastfeeding.48 Prior
breastfeeding experience has also been found to impact on current
M U
practices; women who did not have a positive experience with their
first baby were less likely to breastfeed their second child.40
4 ED
The mental health of the mother also plays a part in breastfeeding.
Stress and anxiety can contribute to depression.49,50 Perinatal
depression is associated with infant under-nutrition, which may be
O
mediated through several separate or concurrent mechanisms.51
Depressive symptoms, such as poor concentration, lethargy, sleep
G
disturbance and low mood, can play a role in initiating and
maintaining EBF for the first six months.51 A study in Pakistan
R
demonstrated that depressed mothers were more likely to perceive
BA
their milk supply as being insufficient, despite this not objectively
N
being the case from quantity measurements; and depressed mothers
O
were more like to initiate early cessation of breastfeeding. These
findings are particularly pertinent for South Africa, given the high
EM
rates of perinatal depression, ranging from 35%–47%, reported in
diagnostic studies.52,53 Newborn weight loss has been associated
with milk-supply concern and maternal anxiety,54 and in India,
maternal anxiety was found to be an independent risk factor for
non-adherence to EBF at six months.55 Although there is a paucity
of data on maternal anxiety in South Africa,56 rates are likely to
be substantial given the co-morbidity between the two common
perinatal mental disorders57 and the high lifetime prevalence rate
(15.8%) for any anxiety disorder nationally.58
Mental health problems, together with the effects of poor maternal
nutrition, including obesity and under-nutrition, have been found
to contribute to unsuccessful breastfeeding.59 In contrast, a cluster
randomised-controlled trial showed that peer mentoring support for
HIV-positive mothers reduced depressive symptoms and increased
the likelihood of EBF for at least six months.60
Breastfeeding in public is not adequately supported in policy, the
media or in general society. The Normalise Public Breastfeeding
in South Africa (NPBSA) lobby group reports that women are
S A H R 20 1 6
Breastfeeding
reluctant to breastfeed in public because of fear of being mocked
and shamed. Breastfeeding in public is not seen as ‘normal’; this has
resulted in incidents where women have been escorted out of shops
for breastfeeding in public.61
The community dialogues conducted in 2013 revealed that there
was some confusion with regard to breastfeeding recommendations
for HIV-positive mothers.b Participants spoke about their difficulty
in determining the risks and rewards of practising breastfeeding if
they were HIV-positive. In Mpumalanga Province, all participants,
including women of childbearing age, men and family members,
reported that breastfeeding posed a dilemma for HIV-positive
mothers. They often adopted mixed feeding patterns, specifically
formula milk in private and breastfeeding in public, to avoid
embarrassment when people asked if they were not breastfeeding
PM
because they were HIV-positive.62 Furthermore, for women
regardless of HIV status, the practice of expressing breast milk and
storing it for the baby to feed on when the mother was absent was
uncommon, as grandmothers, mothers and nannies were assigned
to look after the babies.b,40,45 These caregivers determined their
own methods of formula feeding. Some of the participants also
reported mixed feeding and giving babies solid food earlier than
the recommended age.
Health systems and services
Human resources: numbers and capacity
Studies show that pregnant women are given advice on infant-
feeding choices mostly by healthcare staff, which emphasises the
important role that healthcare workers play in influencing mothers’
decisions.40–43 Fathers, mothers-in-law, aunts and other family
members are also mentioned as providing IYCF advice.40–43 In a
study by Davies that investigated how informed literate mothers were
about their infant-feeding options, 80% of mothers made decisions
based on information provided to them by healthcare workers.48
A notable obstacle hindering breastfeeding progress is the lack of
human resources to implement nutrition interventions. In the study by
Davies, 67% of healthcare workers indicated that insufficient staff
members were stationed at PMTCT sites, and only 53% had been
shown how to use feeding-option cards when counselling mothers.
Healthcare workers also reported that more educational materials
were needed. This staff shortage has been indicated in several
evaluations and reports, with accompanying recommendations for
the institution of a national human-resource strategy for public health,
as well as recommendations for a national audit of the nutrition and
nutrition-related workforce.37,63,64 These recommendations have not
been adequately addressed thus far.
Staff: knowledge, skills and attitudes
In 2013, Kassier and Veldman reported that some health workers
were still not convinced that breastfeeding is advantageous, even in
the case of HIV-negative mothers, and that staff lacked the necessary
lactation-management knowledge and skills.47 Davies48 found that
65% of the health worker respondents indicated that it was possible
to take a neutral stance in a counselling session, regardless of the
health worker’s personal preference for infant feeding, and 60% of
those who could not maintain neutrality in this regard nonetheless
believed that it was in the mother’s best interests to be counselled by
11 3
them. Ninety-eight per cent of these respondents agreed that mothers
had the right to make informed decisions, and 80% agreed that
mothers were able to make such decisions. Between 49% and 82%
of the healthcare workers knew the correct answers to knowledge
questions relating to breastfeeding, and between 37% and 56%
knew the correct answers to knowledge questions relating to formula
feeding. Not one healthcare worker participating in the study knew
all the steps involved in preparing a formula feed. In the same study,
14% of the healthcare workers indicated that what was expected
of them was not achievable in their working environment.47 These
findings underscore the need for ongoing training and retraining
of healthcare workers,43 including specific HIV and breastfeeding
training and supervision.65
Tuthill et al. offer qualitative evidence of health workers claiming
in South Africa; it also facilitates UNICEF-designed lactation-
management training workshops and a peer-counselling programme
for volunteers largely from disadvantaged communities to work as
breastfeeding counsellors.70 This organisation acts on step 10 of
the BFHI, which has been described as one of the most difficult and
neglected steps, namely: “to foster the establishment of breastfeeding
support groups and refer mothers to them on discharge from the
hospital or clinic”.70
Workplace and employment
Low-cost interventions in the workplace, including lactation rooms
and nursing breaks, have been shown to reduce absenteeism and
improve work performance, commitment and retention among
female staff, and paid maternity leave can increase EBF practice

that the transition from the prior policy of warning HIV-infected
mothers against breastfeeding and the subsequent promotion of
breastfeeding with ART coverage was difficult because of the
conflicting messages. They felt that as a result of these changes,
PM
substantially.1
Specific legislation in South Africa’s Constitution,71 Labour Relations
Act,72 Employment Equity Act,73 and Basic Conditions of Employment

16 6
patients no longer trusted the health workers’ guidance.62 Act74 protect women from discrimination related to pregnancy and
hazardous working circumstances, and regulate maternity leave.

20 IL
Insufficient and poor counselling by health professionals and lack
Women in South Africa are entitled to maternity leave of up to four
of health worker knowledge regarding the impact of HIV were also
months, but with the exception of government service and some
contributory factors for early cessation of breastfeeding.65 One study
Y T large companies this is mostly unpaid leave, making babies of
reported poor health worker knowledge and gaps in knowledge,
women working in other sectors vulnerable to suboptimal feeding
A N
which were evident because health workers recommended that
and care practices.
mothers feed their babies with water, formula and solids rather than
M U

encouraging the women to practise EBF.44 The Tshwane Declaration specifically resolved that legislation be
reviewed to protect and extend maternity leave for all workers,
4 ED

Baby-Friendly Hospital Initiative and to include an enabling workplace. This resolution is yet to be
The Baby-Friendly Hospital Initiative (BFHI) was launched by the addressed, leaving a void in the protection of economically active
World Health Organization and the United Nations Children’s Fund mothers and their babies.
O

(WHO/UNICEF) in 1991 as a 10-step model. This model should

be implemented in public birthing facilities to protect, promote and
Industry and marketing
G

support breastfeeding, thereby creating an enabling environment for

breastfeeding as the optimal infant-feeding choice.66,67 Globally, marketing strategies for infant formula are effective and
R

the retail value of the formula industry is growing. It is therefore

In South Africa, the BFHI has been renamed the ’Mother-Baby-
important to have inclusive national laws and regulations to
BA

Friendly Initiative’ (MBFI) to stress the importance of the initiative

restrain inappropriate marketing practices. Adequate monitoring
in reducing both infant and maternal morbidity and mortality, and
and meaningful penalties to protect breastfeeding should also be
O

also to shift the focus from the sole context of the hospital setting.68
put in place. The Code of Marketing of Breast-milk Substitutes and
EM

In Mpumalanga Province, early initiation of breastfeeding and

other foodstuffs for infants and young children, was legislated in
EBF were found more often in a sub-district where all public health
South Africa in December 2012.27 The impact of this legislation
maternity facilities were baby-friendly than in a sub-district where
on stakeholder compliance and on breastfeeding practices in South
none of the facilities was baby-friendly. The study concluded that
Africa should be assessed in the near future.
the MBFI appeared to be successful in improving infant-feeding
practices for at least the first six months of life.39 MBFI has received
much attention since the Tshwane Declaration, which called for all The media
public hospitals and health facilities to be accredited as ‘mother-
It has been noted that the South African government uses mass media
baby-friendly’ by 2015. Private birthing facilities are also targeted
infrequently for dissemination of nutrition policy messages, which is
to become MBFI-accredited and to implement the Ten Steps to
problematic in the light of intensive marketing of non-nutritious food
Successful Breastfeeding69 in the private medical care environment.
by food companies. A recommendation from an evaluation report
Although there has been progress in this regard, this process has not
on services to children under five was that the NDoH should create
yet been implemented and monitored optimally in all South African
a dedicated health-promotion strategy on nutrition for these children,
public and private birthing facilities.
as was done for HIV and AIDS. Television and radio should be used
A voluntary organisation, La Leche League South Africa, provides to educate pregnant women and mothers with children younger
information, encouragement and support to women who want to than five years about the importance of good nutrition. The use of
breastfeed, through their unique mother-to-mother support network. celebrities to promote breastfeeding has also been proposed to
La Leche League South Africa is active on governmental and NGO elevate the status of breastfeeding.36
bodies working for the promotion and protection of breastfeeding

11 4 S A H R 20 1 6

There is also considerable potential benefit in promoting and
supporting breastfeeding through social media. Examples are the
La Leche League Facebook page where mothers can pose questions
and be supported, and MomConnect.75
The State authority or local government in
charge of policies
Evidence from South African studies show that it is very difficult
for mothers to sustain EFB because of various factors, alone or
combined, that may obstruct this practice.
Less than 0.3% of the national health budget is allocated to nutrition,
including breastfeeding interventions. Priority nutrition interventions
are not necessarily receiving an appropriate proportion of the
nutrition budget; this has prompted a call to evaluate the proportion
of funds actually spent on high-priority interventions of this kind in
terms of returns on the nutrition-funding investment.28
16 6
Interventions targeting breastfeeding
20 IL
In this section we interrogate evidence on interventions to improve
breastfeeding and reflect on the extent to which interventions with
Y T
a strong evidence base are prioritised within local strategies,
A N
guidelines and policies. The section is structured to present findings
from studies that compiled evidence from systematic reviews drawn
M U
from an international literature base, plus findings from a review
that interrogated evidence drawn only from LMICs and that only
4 ED
included studies considered to be strong methodologically.
One of the Lancet 2016 Breastfeeding Series papers1 reported on
the effects of breastfeeding interventions in various settings.59,76
O
Findings were presented according to the following categories:
health systems and services; family and community; and workplace
G
and employment. In the health systems setting, several interventions
were included in the Baby-Friendly Hospital Initiative (BFHI), namely
R
individual counselling or group education, immediate breastfeeding
BA
support at delivery, and lactation management affecting
N
breastfeeding rates. These interventions increased EBF by 49%
O
(relative risk (RR)=1.49; 95% confidence interval (CI):1.33–1.68),
and any breastfeeding by 66% (RR=1.66; 95% CI:1.3–2.07).
EM
Counselling and education increased EBF by 66% (RR=1.66; 95%
CI:1.43–1.92), and any breastfeeding by 47% (RR=1.47, 95%
CI:1.29–1.68).1,59,76
In the family and community setting, the Lancet series presents a
meta-analysis of interventions providing both antenatal and postnatal
support to mothers, fathers and other family members at home; these
included community health workers and peer-to-peer counsellors. The
latter refers to counselling by a nurse, trained lactation counsellor, or
other health provider. This support was extended to post-discharge
telephone calls combined with home visits. Fathers were specifically
targeted individually and also in group counselling sessions. The
results showed that home and family-based interventions were
effective in improving EBF (RR=1.48; 95% CI:1.32–1.66), continued
breastfeeding (RR=1.26; 95% CI:1.05–1.50), any breastfeeding
(RR=1.16; 95% CI:1.07–1.25), and improved early initiation of
breastfeeding (RR=1.74; 95% CI:0.97–3.12).1,59,76
S A H R 20 1 6
Breastfeeding
Antenatal and postnatal combined counselling was more effective
than targeted counselling during one period only. Community-
based interventions consisting of counselling or education and
social mobilisation, with or without mass media, increased timely
breastfeeding initiation by 86% (95% CI:33–159) and EBF by 20%
(95% CI:3–39).1,59,76
In the workplace setting, the minimal data available suggest that
maternity leave policies are effective in increasing EBF by 52%
(RR=1.52; 95% CI:1.03–2.23). A global study did a multivariate
analysis on the relationship between national policies and EBF
rates.77 In multivariate models, national policies guaranteeing paid
breastfeeding breaks until the child was at least six months old were
associated with significantly higher rates of EBF. This guarantee
generated an increase of 8.9% in the rate of EBF of infants younger
PM
than six months (P<0.05) in the full model. Also, lactation rooms and
breaks to express breast milk increased breastfeeding until the child
was six months old by 25% (95% CI:9–43).1,59,76
What is clear from this and other related systematic reviews76,78 is
that multiple interventions are more effective than single interventions,
and that two or more actions (a mixture of interventions) were most
effective in improving any breastfeeding and EBF rates.
A literature review79 was done on public health interventions in
LMICs that improve maternal, neonatal and child morbidity and
mortality outcomes within the first 1 000 days of life in order to
identify a range of interventions. The objectives were to assess the
strength of the evidence supporting the effectiveness of the different
interventions, to assess their alignment with current South African
policies and guidelines, and to determine whether related gaps
exist. The group sought to confirm whether all these interventions
with a strong evidence base were used to inform local strategies,
policies and guidelines, and if so, to determine the degree to
which these interventions were incorporated into local documents
and promoted in practice. A systematic five-phased process was
followed, including an exhaustive search strategy covering a wide
range of databases, the application of rigorous quality-assessment
criteria, and assessment of applicability in South Africa through
studying key local strategies, policies and guidelines. With
regard to breastfeeding, the relevant LMIC interventions were: (1)
antenatal breastfeeding education; (2) breastfeeding support; (3)
breastfeeding promotion; and (4) Kangaroo Mother Care (KMC).
These are detailed in the following section.
While interrogating existing strategies, policies and guidelines, it
became clear that despite widespread commitment to promoting
appropriate breastfeeding practices, South Africa has failed to
incorporate specific evidence-based interventions in our strategies.
No document exists that lists the various options ‘in one place’,
presents the ‘how’ of implementation, or provides options that
enable multiple approaches to be adopted by nurses. Such failures
could exacerbate the incapacity of staff in terms of breastfeeding
promotion and support at the coalface. Furthermore, understanding
of local determinants, such as cultural and traditional practices, is
not explicitly incorporated into these guidelines.
11 5
Evidence from a review of breastfeeding
interventions in low- and middle-income
countries
Antenatal breastfeeding education
In 2011, Lumbiganon et al.80 did a systematic review to explore
the effectiveness of antenatal breastfeeding education in increasing
breastfeeding initiation and duration. One study in the review
compared peer counselling with routine care (that was not defined)
and showed a significant increase in the initiation of breastfeeding
in the intervention group (RR=1.82; 95% CI:1.13–2.93).
Another study compared a breastfeeding booklet–plus–video–plus–
lactation consultation versus a breastfeeding booklet–plus–video.
The results at six months showed a significant increase in EBF in the
group receiving a booklet–plus–video–plus–lactation consultation
compared with the other group (RR=2.23; 95% CI:1.01–4.92).
This study also measured a programme involving multiple methods
16 6
versus no formal education, namely a breastfeeding booklet–plus–
video–plus–lactation consultation versus no formal breastfeeding
20 IL
education. The results showed a significant increase in EBF at three
months in the group that received a breastfeeding booklet–plus–
(RR=2.02; 95% CI:1.16–3.49).
Y T
video–plus–lactation consultation compared with the other group
A N
M U
Breastfeeding support
A 2007 systematic review conducted by Britton et al.81 assessed the
4 ED
effectiveness of support for breastfeeding mothers. The target group
consisted of pregnant women who intended to breastfeed. The results
showed that all forms of extra support analysed together gave an
O
increase in duration of ‘any breastfeeding’ (RR=0.91 for cessation of
any breastfeeding before six months; 95% CI:0.86–0.96). All forms
G
of extra support had a greater effect on the duration of EBF than
on any other form of breastfeeding (RR=0.81; 95% CI:0.74–0.89).
R
Joint lay and professional support extended the duration of any form
of breastfeeding significantly (RR=0.65 for cessation before 4–6
BA
weeks; 95% CI:0.51–0.82; and RR=0.74 before two months; 95%
CI:0.66–0.83). Finally, EBF was significantly prolonged with use of
O
WHO/UNICEF training (RR=0.69; 95% CI:0.52–0.91).
EM
Breastfeeding promotion
A 2013 systematic review by Haroon et al.78 reported on
breastfeeding promotion interventions and breastfeeding practices
by comparing breastfeeding education or support with routine care.
The effect of interventions was observed for exclusive, predominant,
partial and no breastfeeding rates. Statistically significant increases
in EBF rates as a result of breastfeeding promotion interventions
were observed: 43% at day 1, 30% at <1 month, and 90% at 1–5
months. Rates of no breastfeeding reduced by 32% at day 1, by
30% at <1 month, and by 18% at 1–5 months.
Kangaroo Mother Care
The 2012 systematic review by Conde-Agudelo et al.82 covered
16 randomised controlled trials (RCTs) focused on low-birth-weight
neonates and demonstrated that kangaroo mother care (KMC) in
preterm neonates was associated with a 40% reduction in the risk
of mortality, a 58% reduction in nosocomial infection or sepsis, a
77% reduction in prevalence of hypothermia, and a reduced length
11 6 S A H R 20 1 6
of hospital stay. At follow-up, they found that KMC was associated
with a decreased risk of mortality and severe infection/sepsis.
Lastly, KMC was found to increase some measures of infant growth,
breastfeeding, and mother–infant attachment.
In 2012, Moore et al.83 did a systematic review of 34 RCTs and
showed that early skin-to-skin contact in KMC produced a significant
(27%) increase in breastfeeding at 1–4 months of age (RR=1.27;
95% CI:1.06–1.53), and increased duration of breastfeeding
(mean difference (MD) 42.55 days; 95% CI:−1.69–86.79), which
had borderline significance.
Evaluation of the nutrition interventions cited in this chapter showed
that KwaZulu-Natal and the Western Cape were the leading
provinces in terms of improved breastfeeding rates and nutritional
outcomes in South Africa.36 Central success factors were the
PM
interventions being province-led, and intentional key stakeholder
engagement. The success factors are presented in Table 2.
Table 2: Progress in improved breastfeeding rates and nutritional
outcomes in South Africa – central success factors for
KwaZulu-Natal and Western Cape Provinces
KwaZulu-Natal process – initiative for breastfeeding
support36,84
Strategic approach to improving breastfeeding and IYCN through
engaging in specific tasks in a defined time period
KwaZulu-Natal Province (KZN) has placed the Nutrition Department
at the highest level, and the Premier has launched Operation Sukuma
Sakhe (OSS), an inter-departmental co-ordination mechanism, with
nutrition as a key element. OSS task teams are extremely effective in
co-ordinating delivery. When compared with the other provinces, KZN
has a more balanced budget allocation for nutrition in proportion to the
province’s prevalence of child stunting.
Nutrition indicators
A monitoring and evaluation (M&E) reporting system has been
established in all departments, resulting in more nutrition indicators
being reported on than in other provinces. Two indicators were added
to the District Health Information System (DHIS) in April 2011: early
breastfeeding initiation (one hour of birth) and EBF at 14 weeks.
Nutrition advisors
The University of KwaZulu-Natal (UKZN) is currently training former
community caregivers (CCGs) in nutrition and skills to provide nutrition
support and non-clinical interventions at clinic level. KZN also has a
strong community-based service delivery model.
Progress in the province
District management advocacy has been facilitated for policy support
and training, and a communication strategy has been developed,
including an accelerated plan for implementation of MNCWH and
nutrition interventions at community level.
A breastfeeding culture has been created through the communication
strategy, including radio and print messaging and participation in the
annual World Breastfeeding Week.
Capacity-building for breastfeeding has been instituted at all levels
within the health care system, including community caregivers and
employment of nutrition advisors at all PHC facilities.
Results:
In 2012, the EBF rate was 34.3% at 14 weeks.
Early initiation of breastfeeding increased from 26% in 2011/12 to
81.60% in 2014/15.
The rate of ‘Infant exclusively breastfed at Hep B 3rd dose’ increased
from 34% to 49.8%.86
Ongoing strategies to improve IYCF include:
• Extension of the Mother-Baby-Friendly Initiative to community health
centres (CHCs) and PHC centres
• Establishment of breast-milk banks
• Media messaging (including social media)
• Expansion of health facility support, including lactation advisors
• Mentoring and support for healthcare workers
 Breastfeeding

Western Cape process85 – breastfeeding support, promotion assigned to recruit pregnant women at their sites to participate in
and programmes the study. Prevalence of EBF at 12 weeks in the intervention cluster
The Mother-Baby-Friendly Initiative (MBFI) has been implemented in was about twice that in the control cluster, whether based on a 24-
94% of the public birthing units in the Western Cape Province.
hour (PR=1.72; 95% CI:1.12–2.63) or seven-day (PR=1.98; 95%
Implementation of the MBFI requires that practices in the birthing
unit be reviewed to remove obstacles hindering the establishment CI:1.30–3.02) recall of feeding practices. The prevalence of EBF
of breastfeeding. This includes setting standards (the national was lower at 24 weeks of age than at 12 weeks, but the differences
standardised training package for clinical staff), educating mothers
(provincial infant-feeding education package), and standardising
(prevalence ratios) were higher for 24-hour (PR=5.70; 95%
practices (comprehensive infant-feeding policy available in all CI:1.33–24.26) and seven-day (PR=9.83; 95% CI:1.40–69.14)
accredited units).
recall of feeding practices.
The Western Cape Provincial DoH has created sentinel sites for the
breast-milk banks and drafted guidelines for the management of
expressed breast milk (to be submitted this year for approval). Lay counsellors trained to conduct home visits 41
Implementation of guidelines and policies:
Lay counsellors visited women to support EBF four times antenatally,
• Mother-Baby-Friendly Initiative implementation in public health
birthing facilities four times in the first two weeks postpartum, and then fortnightly
• Infant feeding counselling guidelines to guide counsellors (or up to six months. Daily feeding practices were recorded at weekly

healthcare workers) in supporting mothers to make informed infant-
feeding choices
• Infant formula on prescription according to set criteria. This has
worked to reduce the use of infant formula through strengthening the
criteria and supporting informed decision-making.
PM
intervals by separate field workers. Counsellors were trained on
the WHO/UNICEF HIV and Infant Feeding Counselling Course
and supervised for quality control. Using 24-hour recall, EBF rates
at three and five months were 83.1% and 76.5% respectively in

16 6
Breastfeeding Peer-Counselling Programme (BPCP) HIV-negative women and 72.5 and 66.7% respectively in HIV-
• Non-profit organisations are funded by sub-districts to place
positive women. Counselling visits were strongly associated with

20 IL
breastfeeding peer counsellors (BFPCs) at midwife obstetric units
and basic antenatal care sites in the Metropole district. BFPCs are adherence to cumulative EBF at four months. Women who had
capacitated to deliver peer-to-peer counselling and are trained in a received the scheduled number of visits were more than twice as
20-hour or updated national breastfeeding course.
Y T likely to maintain EBF than those who had not (HIV-negative women:
• The BFPCs are tasked with educating pregnant women on the infant-
feeding education package, supporting mothers without companions odds ratio (OR)=2.07; 95% CI:1.56–2.74), HIV-infected women:
A N
(when they can) and supporting (and educating) postnatal women on adjusted OR: 2.86; 95%; CI:2.13–3.83).
breastfeeding and its management.
M U

• Part of the BFPCs’ function is also to foster the establishment of

community support groups, but this has been difficult to implement Good Start 87 – integrated community-based package
and they are consequently facility-based counsellors. for maternal and newborn care
4 ED

Educating community health workers:

• Community health workers are trained in infant feeding as part of the
implementation of MBFI in order to foster support for mothers once
they have been discharged from the birthing unit.
O
CHWs were trained to provide counselling. In the intervention
cluster, CHWs were trained over 10 days and implemented the
intervention through a structured home-visiting programme consistent

• Messages around IYCF are standardised in both facility-based

programmes and community-based programmes.
with existing PMTCT, Integrated Management of Childhood Illness
G

Media messages: (IMCI), lactation counselling, and newborn care guidelines. Women
• The Western Cape has standardised key messages through in the intervention arm were scheduled to receive seven home-based
R

provincial documents, initiatives and policies. The First 1 000 Days visits: two during pregnancy and one within 48 hours of delivery,
campaign will incorporate a communication strategy.
during days 3–4 and 10–14, and during weeks 3–4 and 7–8. The
BA

Lactation consultants:
N

results showed that the EBF prevalence rate at 12 weeks increased in

• Some units are staffed with lactation consultants who volunteer in the
birthing units, but this is not uniform through the province. the intervention group compared with the control group (RR=1.92;
O

The Western Cape Department of Health’s breastfeeding policy has 95% CI:1.59–2.33). The intervention appeared to have a slightly
EM

been published and advocates for maternity legislation for women. more significant effect among HIV-negative mothers (RR=2.16; 95%
The policy is in the process of being implemented. Health facilities are
voluntarily establishing ‘comfort rooms’ for staff members that can be CI:1.71–2.73).
utilised as a space to express breast milk.85

Notable local studies
The following community-level projects providing various forms of
breastfeeding support have yielded promising results.
PROMISE-EBF86 – Individual home-based exclusive
breastfeeding peer counselling
Peer counsellors provided breastfeeding support in intervention
clusters. They provided one antenatal breastfeeding peer-counselling
visit and four post-delivery visits. The intervention involved mothers
receiving infant-feeding peer counselling, while in the control group,
peer counsellors assisted mothers with obtaining social grants. The
focus of the intervention was to provide community-level support.
Women from the respective communities were selected and trained
to provide counselling, and were supervised. Peer counsellors were
Key recommendations
The evidence presented in this chapter indicates that successful
protection, promotion and support of breastfeeding requires a
multi-layered, multipronged approach across the various levels
of government and society.1,2,12 In order to create an enabling
environment for breastfeeding in South Africa, the different strata in
society that influence breastfeeding practices should be considered
within the definition of an enabling environment for nutrition
interventions. Three linked elements of an enabling environment,
namely knowledge and evidence; politics and governance; and
capacity and resources,88 should be the main focus at all levels
of impact1 and should be addressed in South Africa as a matter
of urgency. This approach was also proposed in the Lancet Series
on Breastfeeding,1 and our recommendations are modelled to align
with the action points in the Series.

S A H R 20 1 6 117
Knowledge and evidence
Dissemination of evidence
Evidence on breastfeeding and its significant impact on national
health and development should be vigorously disseminated. There
is often a lack of understanding among programme managers,
policy-makers, scientists, healthcare workers and communities about
the significance of good national breastfeeding practices in the
achievement of the SDGs, as well as the benefits for both women
and children. Therefore, broad promulgation of such evidence is
necessary for the successful promotion, protection and support of
breastfeeding.
Promotion of a culture of breastfeeding
A positive attitude towards breastfeeding in society should be
engendered, with specific focus on addressing local beliefs and
practices that are contrary to the promotion of good practices. The
move to promote breastfeeding as a high-value practice should be
16 6
achievable in today’s milieu of mass social marketing and innovative
communication formats. Also, existing resources should be used and
20 IL
shared, for example the well-packaged information in the documents
developed for the launch of the Lancet Series on Breastfeeding.89
Y T
A N
Politics and governance
M U
Political will
Politicians working in all sectors (not only health) that affect IYCF
4 ED
need to understand and appreciate the role that breastfeeding plays
in reducing mortality and saving money on a national scale. National
commodity-based interventions such as the promotion and use of
O
drugs and vaccines tend to secure official support because they are
comparatively easy to monitor and evaluate, and they dovetail with
G
the interests of the commercial sector, whereas the promotion of
breastfeeding does not. However, breastfeeding has considerable
R
positive impact in economic terms, including increased intelligence
and thriving in children, which contributes to the country’s gross
BA
domestic product (GDP), reduction in healthcare costs associated
with reduction in non-communicable diseases in women and children,
O
reduced morbidity and mortality from childhood infections, and a
EM
beneficial impact on the environment. These advantages should
be entrenched in deliberations on the allocation of funding for the
promotion, protection and support of breastfeeding. Furthermore,
breastfeeding should feature prominently in health-related preventive
programmes such as the prevention of non-communicable disease in
women and children.
Removal of societal and structural barriers
Political institutions should strive for the removal of societal and
structural barriers to breastfeeding through application of their
authority and power base. This is an obligation of democratically
elected governments as custodians of the health and wellbeing
of communities. Furthermore, the countries that have ratified the
Convention of the Rights of the Child have a duty to promote, protect
and support breastfeeding as an explicit action towards the protection
of children and the promotion of their health.89 South Africa is also
obligated to uphold this right based on our Constitution. Societal
and structural barriers to the right of working mothers to breastfeed
11 8 S A H R 20 1 6
should be addressed through policy, legislation and systems of
accountability in order to support breastfeeding in the workplace
and to create an enabling environment for breastfeeding in general
(as workplace policies will not impact mothers who are informally
and self-employed). Furthermore, all maternity health services must
be compliant with Regulation 27 and the MBFI.
Regulation of the breast-milk substitute industry
Breast-milk substitutes are a multi-billion dollar industry, and without
stringent enforcement, the legislated regulations will continue to be
violated. Even ‘subtle’ marketing of breast-milk substitutes directly
subverts the promotion of breastfeeding as the best possible IYCF
practice. State commitment in enforcing regulations is a significant
way in which the government can fulfil its obligations to the
PM
International Convention on the Rights of the Child, particularly in
terms of ensuring “the survival and development of the child”.
Although breastfeeding is not expressly mentioned in the SDGs,
the improvement of breastfeeding interventions will contribute
extensively to the achievement of the health, food security, education,
equity, development and environmental SDG targets.91 However,
robust commitment and investment on a multi-sector scale, including
all relevant nutrition stakeholders, must be established.
Capacity and resources
Tailoring of interventions to local needs
Sufficient capacity and resources of the appropriate type and
level are crucial in considering what is needed to scale up efforts
for breastfeeding. Adequate numbers of trained breastfeeding
supporters (all healthcare staff, community health workers and
volunteers) should be strategically placed and supervised in health
facilities and communities for highest impact. The success stories from
at least two provinces in South Africa, reported earlier, should be
used as examples to build on. Existing policies and guidelines should
be reviewed to determine the extent to which the recommendations:
➢➢ are evidence-based;
➢➢ are explicit to service providers in terms of what needs to be
done to promote, protect and support breastfeeding;
➢➢ promote delivery of care by the most appropriate providers
(e.g. facility-based health worker versus community health
worker); and
➢➢ leverage existing resources such as community members and
leaders who have been shown to influence the choices of
breastfeeding women.
Lastly, there is a need for good-quality breastfeeding data to plan
effectively for targeted interventions and appropriate monitoring
and evaluation strategies. Standardised messages and explicit
guidelines on breastfeeding practices should be incorporated into
such interventions.68
 Breastfeeding

Conclusion
A review of the literature on breastfeeding in South Africa over the
past few decades suggests that EBF practices have stagnated at
around 8% for age six months. Since 2011, a display of high-level
political commitment to promote, protect and support breastfeeding
has resulted in important policy changes, including in the context
of HIV, as well as legislation of the Code of Marketing of Breast-
milk Substitutes in the form of Regulation 991. A number of policy
documents have highlighted breastfeeding as a key child-survival
strategy and also as an intervention that can substantially impact
future health. There are now indications that over the past four years
these commitments have had a positive effect on early (4–8 weeks)
EBF rates in the country.
Some progress has been made, albeit slow and fraught with
challenges. However, much still needs to be done to improve
exclusive and continued breastfeeding rates in the country. Three
linked elements of an enabling environment, namely knowledge and
evidence; politics and governance; and capacity and resources,88
should be the main focus at all levels of impact across society1 and
should be addressed in South Africa as a matter of urgency. Despite
the fact that almost two decades of democracy have passed, the
battle to attain good nutrition and breastfeeding outcomes continues.

PM
Multiple layers in society can impact IYCF and more specifically
breastfeeding; these include the mother, the family, the community,
hospitals, work-places, employers, business, industry, the media,
health services, and the State authority or local government in

16 6
charge of policies. Determinants of breastfeeding across these
layers, and interventions internationally, in LMICs and locally that

20 IL
have been proven to work, were reviewed in order to establish
which interventions with a strong evidence base are prioritised
Y T
within local strategies, guidelines and policies and in different
settings (i.e. the health systems and services, family and community,
A N
and workplace and employment). It is important to note that multiple
interventions are more effective than single interventions, with a
M U

combination of interventions shown to be most effective in improving

any breastfeeding and EBF rates. The range of interventions shown
4 ED

to have a robust evidence base included specific education of

mothers and health workers, use of lay health workers, peer-
counselling, provision of lactation support, involvement of the family,
O

and ongoing support within the community, specifically in LMICs.

However, not all these interventions have been implemented locally.
G

Importantly, two provinces (KwaZulu-Natal and the Western Cape)

are examples of high-level support; they have implemented specific
R

interventions known to be effective, and have recognised the value

of capacitating staff to deliver the interventions.
BA

In South Africa, numerous policies, strategies and guidelines have

O

been developed that show commitment to the promotion, protection

EM

and support of breastfeeding. However, what is clear is that to

move forward, South Africa cannot merely promote breastfeeding
as part of broader nutritional and PMTCT initiatives. Breastfeeding
should to receive sufficient prominence as a separate intervention
that warrants time, effort and attention. Effective and efficient
implementation of strategies and guidelines that have a strong
inter-sector focus is paramount. What is required is a demonstration
of concerted, co-ordinated effort to incorporate evidence into local
strategies, guidelines and policies, and active promotion of these in
practice. For South Africa to improve IYCN outcomes there has to be
widespread commitment:

➢➢ to move well beyond paying lip service to the concept of inter-

sector collaboration;

➢➢ to acknowledge that addressing service-related factors alone,

including operationalisation of resources and improved policy
and programme management, are not sufficient; and

➢➢ to agree that a better understanding of the local enabling

environment is required in order for breastfeeding to succeed.

S A H R 20 1 6 11 9
References
1 Rollins NC, Bhandari N, Hajeebhoy N, Horton S,
Lutter CK, Martines JC, et al. Why invest, and what it
will take to improve breastfeeding practices? Lancet.
2016;387(10017):491–504.
2 International Food Policy Research Institute. Global Nutrition
Report 2014: actions and accountability to accelerate the
world’s progress on nutrition. Washington, DC: International
Food Policy Research Institute, 2014.
3 Mhlanga RE. Maternal, newborn and child health: 30 years
on. In: Barron P, Roma-Reardon J, editors. South African
Health Review 2008. Durban: Health Systems Trust; 2008.
[Internet]. [cited 18 April 2016].
URL: http://www.hst.org.za/publications/841
4 South African National Department of Health; Medical
Research Council of South Africa; Demographic and Health
Survey;s Macro International Inc. South African Demographic
and Health Survey, 1998 Report. [Internet]. [cited 18 Aprilk
2016].
URL: http://www.mrc.ac.za/bod/dhsfin1.pdf.
16 6
5 Du Plessis LM, Kruger S, Sweet L. Complementary feeding: a
critical window of opportunity from six months onwards. S Afr
20 IL
J Clin Nutr. 2013;26(3)(Supplement):S129–S140.
6 Kramer MS, Kakuma R. Optimal duration of exclusive
Y T
breastfeeding. Cochrane Database Syst Rev. 2012 Aug
15;8:CD003517.
A N
7 Bhutta ZA, Ahmed T, Black RE, et al. What works?
Interventions for maternal and child undernutrition and
M U
survival. Lancet. 2008;371(9610):417–440.
8 Becker GE, Remmington S, Remmington T. Early additional
4 ED
food and fluids for healthy breastfed full-term infants.
Cochrane Database Syst Rev. 2011 Dec 7;(12):CD006462.
9 World Health Organization. Global strategy for infant and
young child feeding. Geneva: World Health Organization;
O
2003.
G
10 World Health Organization. Nutrition: Global Targets 2025.
[Internet]. [cited 11 April 2015].
URL: http://www.who.int/nutrition/topics/nutrition_
R
globaltargets2025/en/
BA
11 The World Bank Group. World Bank Development Report
2012: Gender Equality and Development. Washington, DC:
O
International Bank for Reconstruction and Development/The
World Bank; 2011.
EM
12 Victora CG, Aluísio J D Barros AJD, França GVA, et al.
Breastfeeding in the 21st century: epidemiology, mechanisms,
and lifelong effect. Lancet. 2016;(387):475–90.
13 South African National Department of Health. Pretoria South
Africa, Medical Research Council. South Africa Demographic
and Health Survey, 2002 Report. Available at: http://www.
mrc.ac.za/bod/sadhs.htm
14 Goga AE, Doherty T, Jackson DJ, Sanders D, Colvin M,
Chopra M, Kuhn L. – for the Good Start Study Group. Infant
feeding practices at routine PMTCT sites, South Africa: Results
of a prospective observational study amongst HIV exposed
and unexposed infants – birth to 9 months. Int Breastfeeding
J. 2012;7(4).
15 South African National Department of Health, South
African National AIDS Council, Clinical Guidelines: PMTCT
(Prevention of Mother-to-Child Transmission) 2010. [Internet].
[cited 18 April 2016].
URL: http://www.fidssa.co.za/Content/Documents/
PMTCT_Guidelines.pdf
120 S A H R 20 1 6
16 South African National Department of Health. The South
African Antiretroviral Treatment Guidelines, 2013. [Internet].
[cited 18 April 2016].
URL: http://www.hst.org.za/publications/pmtct-
guidelines-2013
17 South African National Department of Health. National
Consolidated Guidelines for the Prevention Of Mother-To-Child
Transmission of HIV (PMTCT) and the Management of HIV In
Children, Adolescents and Adults.(2015. [Internet]. [cited 18
April 2016].
URL: https://www.scribd.com/doc/268965647/National-
Consolidated-Guidelines-for-PMTCT-and-the-Management-of-
HIV-in-Children-Adolescents-and-Adults
18 Goga A, van Wyk EB, Doherty T, et al. – for the Good Start
Study Group. Operational effectiveness of guidelines on
PM
complete breast-feeding cessation to reduce mother-to-child
transmission of HIV: Results from a prospective observational
cohort study at routine prevention of mother-to-child
transmission sites, South Africa. J Acquir Immune Defic Syndr.
2009;(50):521–528.
19 Coutsoudis A, Goga AE, Rollins N, Coovadia HMC. Free
formula milk for infants of HIV-infected women: Blessings or
curse? Health Policy Plan. 2002 Jun;17 (2):154–60.
20 Goga A, van Wyk EB, Doherty T, et al., for the Good Start
Study team. Operational effectiveness of guidelines on
complete breast-feeding cessation to reduce mother-to-child
transmission of HIV: Results from a prospective observational
cohort study at routine prevention of mother-to-child
transmission sites, South Africa. J Acquir Immune Defic Syndr.
2009;(50):521–528.
21 Goga A. Review: Infant feeding and HIV. Towards a new
policy and implementation plan for minimising postnatal HIV
transmission and maximising infant HIV-free survival. South Afr
J HIV Med. 2009 December:20–30.
22 Bhutta ZA, Das JK, Rizvi A, Gaff MF, Walker N, Horton S, et
al. Evidence-based interventions for improvement of maternal
and child nutrition: What can be done and at what cost?
Lancet. 2013; 382(9890):452–477.
23 Coovadia AH, Goga AE, Schowalter L. Call to Action:
Prevention of Mother-to-Child Transmission of HIV. South Afr J
Med. 2009 Jul;4(4):319–24.
24 Tshwane Declaration for the Support of Breastfeeding in South
Africa. S Afr J Clin Nutr. 2011;24(4).
25 Participants of the National Breastfeeding Consultative
Meeting. The Tshwane Declaration for the Support
of Breastfeeding in South Africa. S Afr J Clin Nutr.
2011;24(4):214.
26 South African National Department of Health. Infant and
young child feeding policy. Pretoria: National Department of
Health; 2013. [Internet]. [cited 11 April 2016].
URL: http://www.health-e.org.za/wp-content/
uploads/2013/09/IYCF_Policy_2013.pdf
27 South African National Department of Health. Foodstuffs,
Cosmetics and Disinfectant Act 54 of 1972. 6 December
2012. Regulation 991. Government Gazette. 570(35941).
Government Notice No. 9868. Pretoria: Government Printer;
2012.
28 South African National Department of Health. Roadmap for
nutrition in South Africa for 2013–2017. Pretoria: National
Department of Health; 2013a. [Internet]. [cited 11 April
2016].
URL: http://www.health-e.org.za/2015/06/04/strategy-
roadmap-for-nutrition-in-south-africa-2013-2017/

29 South African National Department of Health. National
Strategic Plan for Maternal, Newborn, Child and Women’s
Health and Nutrition 2012–2016. Pretoria: National
Department of Health; 2012. [Internet]. [cited 11 April 2016].
URL: http://www.rmchsa.org/wp-content/resources/
resources_by_theme/MNCWH&NSystemsStrengthening/
MNCWH&NStrategicPlan_2012-2016.pdf
30 South African National Department of Health. National Health
Promotion Policy and Strategy 2015–2019. Pretoria: National
Department of Health; 2015. [Internet]. [cited 11 April 2016].
URL: http://www.health.gov.za/index.php/2014-03-17-09-
09-38/strategic-documents/category/229-2015str#
31 Office of the Presidency, South Africa: National Planning
Commission. National Development Plan 2030: Our future –
make it work. Pretoria: National Planning Commission; 2012.
[Internet]. [cited 11 April 2016].
URL: http://www.gov.za/issues/national-development-
plan-2030
32 Thornton L. Breastfeeding in South Africa: Social and
Cultural Aspects and Strategies for Promotion, Curationis.
1984;7(3):33–41.
16 6
33 Engesveen K, Nishida C, Prudhon C, Shrimpton R. Assessing
countries’ commitment to accelerate nutrition action
20 IL
demonstrated in PRSPs, UNDAFs and through nutrition
governance. Standing Committee on Nutrition News.
2009;37:10–16. Y T
34 Iversen PO, Du Plessis LM, Marais D, Morseth M, Adolfsen
A N
Høisæther E, Herselman MG. Review: Nutritional health
of young children in South Africa over the first 16 years of
M U
democracy. S Afr J Child Health. 2001;5(3):72–77.
35 Iversen PO, Marais D, Du Plessis LM, Herselman MG.
Assessing nutrition intervention programmes that addressed
4 ED
malnutrition among young children in South Africa between
1994–2010. Afr J Food Agric Nutr Dev. 2012;12(2).
36 South African National Departments of Health, Social
O
Development, and Performance Monitoring and Evaluation.
Evaluation of Nutrition Interventions for Children from
G
Conception to Age 5. Pretoria: The Presidency, Republic of
South Africa; 2014. [Internet]. [cited 11 April 2016].
URL: http://www.health-e.org.za/wp-content/
R
uploads/2015/04/Summary-Evaluation-of-Nutritional-
Interventions-for-Children-from-Conception-to-Age-5-.pdf
BA
37 Swart R, Sanders D, McLachlan MH. Nutrition: A primary
health care perspective. In: Barron P, Roma-Reardon J, editors.
O
South African Health Review. Durban: Health Systems Trust;
EM
2008. p.129–47. [Internet]. [cited 11 April 2016].
URL: http://www.hst.org.za/publications/841
38 World Health Organization. Landscape analysis on countries’
readiness to accelerate action to reduce maternal and child
undernutrition: Nationwide country assessment in South
Africa. Geneva: World Health Organization; 2010. [Internet].
[cited 11 April 2016].
URL: http://www.who.int/nutrition/landscape_analysis/
SouthAfrica/en/
39 Kent G. Nutrition rights: The human right to adequate food
and nutrition. In: Blau J, Gould K, Moncada A. Human Rights,
Environmental Justice and Popular Democracy. New York:
Rowman & Littlefield; 2007.
40 Sibeko S, Dhansay MA, Charlton KE, Johns T, Gray-Donald
K. Beliefs, Attitudes, and Practices of Breastfeeding Mothers
From a Periurban Community in South Africa. J Hum Lact.
2005;21(1):31–38.
41 Bland RM, Little KE, Coovadia HM, Coutsoudis A, Rollins NC,
Newella ML. Intervention to promote exclusive breast-feeding
for the first 6 months of life in a high HIV prevalence area.
AIDS. 2008;22(7):883–891.
S A H R 20 1 6
Breastfeeding
42 Van der Merwe M, Du Plessis LM, Jooste H. Comparison of
infant-feeding practices in two health sub-districts with different
baby-friendly status in Mpumalanga Province. S Afr J Clin
Nutr. 2015;28(3):121–127.
43 Goosen C, McLachlan MH, Schubl C. Factors impeding
exclusive breastfeeding in a low-income area of the Western
Cape province of South Africa. Africa Journal of Nursing and
Midwifery. 2014;16(1):13–31.
44 Shah S, Rollins NC, Bland R. Breastfeeding knowledge among
health workers in rural South Africa. J Trop Pediatr. 2005
Feb;51(1):33–8.
45 Mushaphi LF, Mbhenyane XG, Khoza LB, Amey AKA.
Infant-feeding practices of mothers and the nutritional status of
infants in the Vhembe District of Limpopo Province. S Afr J Clin
Nutr. 2008;21(2):36–41.
46 Doherty T, Sanders D, Jackson D, Swanevelder S, Lombard
PM
C, Zembe W et al. Early cessation of breastfeeding amongst
women in South Africa: an area needing urgent attention to
improve child health. BMC Pediatrics. 2012;(12):105.
47 Kassier SM, Veldman FJ. Cry, the beloved bottle: infant-
feeding knowledge and the practices of mothers and
caregivers in an urban township outside Bloemfontein, Free
State province. S Afr J Clin Nutr. 2013;26(1):17–22.
48 Davies A. PMTCT: How “informed” is the literate mother’s
decision regarding infant feeding options in the Gert Sibande
district, Mpumalanga province, South Africa? [dissertation].
Stellenbosch: Stellenbosch University; 2005.
49 Parsons CE, Young KS, Rochat T, Kringelbach L, Stein A.
Postnatal depression and its effects on child development: a
review of evidence from low- and middle-income countries. Br
Med Bull. 2012;101:57–79.
50 Honikman S, van Heyningen T, Field S, Baron E, Tomlinson
M. Stepped Care for Maternal Mental Health: A Case Study
of the Perinatal Mental Health Project in South Africa. PLOS.
2012;9(5):e1001222.
51 Rahman A, Hafeez A, Bilal R, Sikander S, Malik A, Minhas
F et al. The impact of perinatal depression on exclusive
breastfeeding: a cohort study. Matern Child Nutr. 2015.
doi: 10.1111/mcn.12170.
52 Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L,
Molteno C. Post-partum depression and the mother-infant
relationship in a South African peri-urban settlement. Br J
Psychiatry. 1999;175 (6):554–58.
53 Rochat TJ, Richter LM, Doll HA, Buthelezi NP, Tomkins A, Stein
A. Depression among pregnant rural South African women
undergoing HIV testing. JAMA. 2006;295(12):1373–78.
54 Flaherman VJ, Beiler JS, Cabana MD and Paul IM.
Relationship of newborn weight loss to milk supply concern
and anxiety: the impact on breastfeeding duration. Matern
Child Nutr. 2015 Mar 18. doi: 10.1111/mcn.1217.
55 Arifunhera JH, Srinivasaraghavan R, Sarkar S, Kattimani
S, Adhisivam B, Bhat BV. Is maternal anxiety a barrier to
exclusive breastfeeding? J Matern Fetal Neonatal Med. 2015;
(2):1–4.
56 Spies G, Stein GJ, Roos A, Faure SC, Mostert J, Seedat S,
Vythilingum B. Validity of the Kessler 10 (K–10) in detecting
DSM–IV defined mood and anxiety disorders among
pregnant women. Archives of Women’s Mental Health.
2009;(12):69–74.
57 Falah-Hassani K, Shiri R, Dennis C-L. Prevalence and risk
factors for comorbid postpartum depressive symptomatology
and anxiety. J Affect Disord. 2016;(198):142–147.
12 1
58 Herman AA, Stein DJ, Seedat S, Heeringa SG, Mooma H,
Williams DR. The South African Stress and Health (SASH)
study: 12-month and lifetime prevalence of common mental
disorders. S Afr Med J. [online]. 2009;(99)5.
59 Supplement to: Rollins NC, Bhandari N, Hajeebhoy N, et
al. on behalf of The Lancet Breastfeeding Series Group.
Why invest, and what it will take to improve breastfeeding
practices? Lancet. 2016;387:491–504.
60 Rotheram-Borus MJ, Richter LM, van Heerden A, van Rooyen
H, Tomlinson M, Harwood JM, et al. A Cluster Randomized
Controlled Trial Evaluating the Efficacy of Peer Mentors
to Support South African women living with HIV and their
infants. PLoS One. 2014 Jan 22;9(1):e84867.
61 Fokazi S. Call for law over breast feeding. Independent
OnLine (IOL), 10 July 2015. [Internet]. [cited: 5 April 2016].
URL: http://www.iol.co.za/news/south-africa/western-cape/
call-for-law-over-breast-feeding-1883338
62 Tuthill E, Mcgrath J, Young S. Commonalities and differences
in infant feeding attitudes and practices in the context of HIV
in sub-Saharan Africa: A metasynthesis. AIDS Care. 2014
16 6
February;26(2):214–25.
63 Academy of Science of South Africa. Scientific inquiry into
20 IL
the nutritional influences on human immunity with special
reference to HIV infection and active TB in South Africa.
Pretoria: Academy of Science of South Africa; 2007.
Y T
64 Labadarios D, Swart R, Maunder EMW, Kruger HS, Gericke
GJ, Kuzwayo PMN, et al. Executive summary of the National
A N
Food Consumption Survey Fortification Baseline (NFCS-FB-I):
South Africa, 2005. S Afr J Clin Nutr. 2008;21(3):245–300.
M U
65 Daniels K, Nor B, Jackson D, Ekström E, Doherty T.
Supervision of community peer counsellors for infant feeding
4 ED
in South Africa: an exploratory qualitative study. Human
Resources for Health. 2010;8:6.
66 United Nations Children’s Fund (UNICEF). Innocenti
O
Declaration on the Protection, Promotion and Support of
Breastfeeding. 1990. [Internet] [cited 11 April 2016].
URL: http://www.unicef.org/programme/breastfeeding/
G
innocenti.htm
R
67 World Health Organization. Baby-Friendly Hospital Initiative.
Revised, updated and expanded for integrated care. 2009.
[Internet] [cited 11 April 2016].
BA
URL: http://www.who.int/nutrition/topics/bfhi/en
O
68 Du Plessis L, Pereira C. Commitment and capacity for the
support of breastfeeding in South Africa. S Afr J Clin Nutr.
EM
2013;26(3)(Supplement):S120–S128.
69 World Health Organization, Division Of Child Health And
Development. Evidence for the Ten Steps to Successful
Breastfeeding. Geneva; World Health Organization; 1998.
[Internet]. [cited 18 April 2016].
URL: http://www.who.int/nutrition/publications/evidence_
ten_step_eng.pdf
70 La Leche League South Africa. [Internet]. [cited 14 April
2015].
URL: http://www.llli.org/southafrica.html
71 Republic of South Africa. Constitution of the Republic of South
Africa – Act 108 of 1996. [Internet]. [cited 11 April 2016].
URL: http://www.constitutionalcourt.org.za/site/
theconstitution/english-2013.pdf
72 South African National Department of Labour. Labour
Relations Act 66 of 1995. [Internet]. [cited 11 April 2016].
URL: http://www1.chr.up.ac.za/undp/domestic/docs/
legislation_30.pdf
73 Republic of South Africa. Employee Equity Act 55 of 1998.
Government Gazette. Vol. 400, No. 19370. Cape Town, 19
October 1998.
122 S A H R 20 1 6
74 Republic of South Africa. Basic Conditions of Employment Act
75 of 1997. Government Gazette. Vol. 390, No. 18491.
Cape Town, 5 December 2997.
75 La Leche League South Africa. [Internet]. [cited: 5 April
2016].
URL: https://www.facebook.com/groups/
lalecheleaguesouthafrica/
76 Sinha B, Chowdhury R, Jeeva Sankar M, Martines J, Tanjea
S, Mazumder S, et al. Interventions to improve breastfeeding
outcomes: a systematic review and meta-analysis. Acta
Paediatrica. 2015;104:114–35.
77 Heymann J, Raub A, Earle A. Breastfeeding policy: a
globally comparative analysis. Bull World Health Organ.
2013;91:398–406.
78 Haroon S, Das JK, Salam RA, Imdad A, Bhutta ZA.
Breastfeeding promotion interventions and breastfeeding
PM
practices: a systematic review. BMC Public Health.
2013;13(Suppl 3):S20. [Internet]. [cited 11 April 2016].
URL: http://www.biomedcentral.com/1471-2458/13/S3/
S20
79 English R, Peer N, du Plessis L, Honikman S, Tugenhaft A,
Hofman K. First 1 000 days – MNCH interventions in South
Africa: Is practice aligned with evidence? (Unpublished).
80 Lumbiganon P, Martic R, Laopaiboon, Festin MR, Ho JJ,
Hakimi M. Antenatal breastfeeding education for increasing
breastfeeding duration. Cochrane Database Syst Rev.
2011;(11): CD006425.
81 Britton C, McCormick FM, Renfrew MJ, Wade A, King SE.
Support for breastfeeding mothers. Cochrane Database Syst
Rev. 2007;1:CD001141.
82 Conde-Agudelo A, Belizan JM, Diaz-Rossello J. Kangaroo
mother care to reduce morbidity and mortality in low
birthweight infants. Cochrane Database Syst Rev.
2011;3:CD002771
83 Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-
to-skin contact for mothers and their healthy newborn infants.
Cochrane Database Syst Rev. 2012;5: CD003519.
84 Spies L. The Kwazulu-Natal experience. [unpublished].
Pretoria: The National Breastfeeding Summit, South African
National Department of Health; 2011.
85 Tylleskär T, Jackson D, Meda N, Engebretsen IM, Chopra M,
Diallo AH, Doherty T, et al. – PROMISE-EBF Study Group.
Exclusive breastfeeding promotion by peer counsellors in
sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial.
Lancet. 2011 Jul 30;378(9789):420–7.
86 Tomlinson M, Doherty T, Ijumba P, Jackson D, Lawn J, Persson
LÅ, Lombard C, et al. Goodstart: a cluster randomised
effectiveness trial of an integrated, community-based package
for maternal and newborn care, with prevention of mother-to-
child transmission of HIV in a South African township. Trop
Med Int Health. 2014;19(3):256–66.
87 Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N. The
politics of reducing malnutrition: Building commitment and
accelerating progress. Lancet. 2013;382(9891):552–569.
88 Lancet Breastfeeding Series. Key Messages and Findings.
[Internet]. [cited: 5 April 2016].
URL: http://www.who.int/pmnch/media/news/2016/
breastfeeding_lancet.pdf
89 United Nations, Office of the High Commissioner on Human
Rights, Convention on the Rights of the Child. 2 September
1990. [Internet] [cited: 14 April 2016].
URL: http://www.ohchr.org/Documents/ProfessionalInterest/
crc.pdf
 Breastfeeding

90 World Alliance for Breastfeeding Action (WABA).

Breastfeeding: A key to sustainable development. [Internet]
[cited: 5 April 2016].
URL: http://worldbreastfeedingweek.org/pdf/wbw2016-cal.

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 123
124
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
MomConnect: an exemplar implementation
of the Health Normative Standards Framework
11
in South Africa

Authors:
Christopher Seebregts i,ii Peter Barron iii
Gaurang Tanna iv Peter Benjamin v

PM
Thomas Fogwill vi

16 6
I 20 IL
n August 2014, the National Department of Health implemented MomConnect MomConnect has drawn
as a national digital maternal health program that implements the South African
Y T
mobile health (mHealth) strategy and the National Health Normative Standards global attention due to its
A N
Framework for Interoperability in electronic health (eHealth). As the first digital health innovative features and
program communicating with people at scale, MomConnect enrolled more than
its avoidance of many of
M U

half a million women from all regions of the country in the first year of operation,
representing approximately half the number of pregnancies in the public health sector. the common pitfalls when
4 ED

MomConnect uses a mobile phone application to support a pregnancy registration implementing digital
system in antenatal care facilities, allowing pregnant women to receive stage-based health projects at scale in
messages to help them improve their health and that of their babies. Women can
low-resource settings.
O

self-subscribe or be subscribed by community health workers to receive a limited set

of health-promotion messages. Registered users interact with the system by rating
G

the service received, asking questions, and submitting compliments or complaints.

R

The mobile system connects to a central health-information exchange that facilitates

interoperability between digital health applications and includes data validation, a
BA

national pregnancy registry and a monitoring and reporting system.

O

Used throughout the health system at facility level, MomConnect has generated a
national register of pregnant individuals and set up a national feedback system to
EM

clients. As such, it is an exemplar implementation of the Health Normative Standards

Framework enabling national-level innovation as a model for future health system
strengthening, enabling interoperability between digital health applications, and
achieving universal health coverage.

MomConnect has drawn global attention due to its innovative features and its
avoidance of many of the common pitfalls when implementing digital health projects
at scale in low-resource settings. This chapter focuses on the design and development
of the technical infrastructure supporting MomConnect.

i Jembi Health Systems

ii UKZN/Meraka Centre for Artificial Intelligence Research (CAIR) and Health Architecture Laboratory (HeAL),
School of Mathematics, Statistics and Computer Science, Universit y of KwaZulu- Natal
iii School of Public Health, Facult y of Health Sciences, Universit y of the Wit watersrand, Johannesburg
iv South African National Department of Health
v Health Enabled
vi Meraka Institute, Council for Scientific and Industrial Research

125
Introduction
Reduction in maternal and child mortality is a global health priority
that featured prominently in the Millennium Development Goals as
Goals 4 and 5, with targets given to each country.1 Like many other
middle- and low-income countries, South Africa is implementing
various programmes to improve maternal health.2–4 In 2014, the
Minister of Health, Dr Aaron Motsoaledi, launched an initiative
to use mobile phone technology as part of a suite of interventions
(e.g. increased access to contraception, improved coverage of
breastfeeding) to address the relatively high maternal mortality ratio
(MMR), child mortality rate and perinatal mortality rate (PNMR) in
South Africa.5,6 The Medical Research Council estimated the MMR
in South Africa to be 155 deaths per 100 000 live births in 2013,7
down from 281 deaths per 100 000 live births in 2008. South
➢➢ subscription to stage-appropriate SMS messaging from the
date of registration, through delivery, until the baby’s first
birthday;
➢➢ a virtual help-desk allowing pregnant women to ask additional
questions, and submit compliments and complaints; and
➢➢ a service to allow mothers to rate the quality of care received
at the facility.
Despite the existence of a number of mobile health applications
including websites, mobi-sites, social networks and smartphone
applications, these services were for the most part small in scale,
clustered mainly in urban areas, and required the use of smart
phones and internet access. This limited the usefulness of the

PM
Africa is targeting 100 deaths (or less) per 100 000 live births by technology in rural areas and in poorer communities, which were
2020.8 among the target populations identified by the NDoH in addressing
Mobile health (mHealth) is recognised as having significant potential maternal and child health.

16 6
to address health issues in developing countries, notably maternal
Policy framework
and child health.9–13

20 IL
In 2014, the NDoH published the HNSF,14 which augments previous
This chapter describes the development of the technical infrastructure
South African government policies dealing with interoperability,
for the MomConnect system, and the alignment of its information-
Y T
management component with the Health Normative Standards
Framework for Interoperability in electronic health (eHealth) in South
enterprise architecture and standards.19,20 The framework was
designed to address some of the issues and initiatives identified
A N
in the National eHealth Strategy17,21 and sub-outcome 10 of the
Africa (HNSF).14 The emphasis in this chapter is on describing the
Medium-term Strategic Framework 2014–2019 (under Outcome
M U

processes followed to implement a technical infrastructure using the

2: “A long and healthy life for all South Africans”).22 Additionally,
HNSF model, and its construction in a modular manner in order to
the South African mHealth Strategy23 was published in 2015 and
facilitate ongoing alignment with the evolving National Department
4 ED

complemented the eHealth Strategy published in 2012,21 which is a

of Health (NDoH) technical infrastructure. This initiative builds on
roadmap for achieving a well-functioning, patient-centred electronic
previous work conducted by South Africa’s NDoH and reported
national health information system. Processing of personally
on in the South African Health Review in respect of the eHealth
O

identifiable information is governed by the Protection of Personal

reference implementation.15–17
Information Act 4 of 2013.24
G

Understanding the technical infrastructure of the MomConnect

program is critical in achieving national scale, and it is an exemplar Preliminary processes and consultations
R

implementation of the HNSF that is relevant for digital health solution A mobile maternal health (mMH) task team comprising representatives
developers in South Africa and in other countries in low-resource
BA

from the NDoH, parastatal organisations, universities, non-

N

settings. governmental organisations and private sector organisations

O

In developing this chapter we have been guided by the recently was convened under the auspices of the NDoH. This task team
subsequently developed a concept proposal for using mobile
EM

published guidelines for reporting health interventions using mobile

phones.18
Development of MomConnect
The rationale for the MomConnect program was to capitalise on the
high mobile-phone coverage in South Africa in order to strengthen
antenatal care (ANC) services in the country. In particular,
MomConnect was designed to offer voluntary health-promotion
messaging to encourage pregnant women to attend an ANC
facility within the first trimester of pregnancy and to complete all
recommended ANC visits in a timely manner. MomConnect provides
the following basic services:a,4
➢➢ registration of pregnant women in public health ANC facilities
and enrolment into a national register of pregnant individuals;
➢➢ subscription to limited weekly messages essentially telling
pregnant women to attend a health facility via public or
Community Health Worker (CHW) enrolment;
technology to address some of the factors contributing to maternal
mortality in South Africa.3,5 Central elements of the proposal
included providing information and knowledge to pregnant women
by providing them with health-promotion messaging and enabling
them to interact with the system and provide feedback to health
providers on service quality.
Details of the MomConnect project in the context of other NDoH
projects have been published elsewhere.4,25,26
System design considerations
In designing a technical solution for MomConnect, a number
of considerations were taken into account, including maximum
coverage and reach to all areas of South Africa, including rural
settings. A South African National Identifier (SAID), or the mobile
phone number of the user in the case of the former not being
available, was chosen as the patient identifier. In order to ensure
the widest network coverage and mobile handset compatibility

a http://www.southafrica.info/services/health/momconnect.htm#.VsR-aBji7EE

126 S A H R 20 1 6
 MomConnect

for maximum access, Unstructured Supplementary Service Datab
(USSD) and Short Message Service (SMS) systems were chosen as
the protocols because they do not require sophisticated phones to be
operational, and every cell-phone in South Africa has the capacity
to support these two services.
Data elements
Table 1 provides a list of the data collected as part of the MomConnect
registration process at facilities as well as through self-subscriptions
and CHW enrolments. These data elements are collected for each
transaction; each mother can conduct multiple transactions of each
type and the system can capture a subset of these 16 elements per
transaction. Some transactions can be activated only once within a
System components
Edge devices
In the case of MomConnect, mobile phone handsets are used as
the edge devices. A constraint on the system is that it had to be
compatible with the majority of handsets, namely basic, low-end
handsets with support for only voice, USSD and SMS services. The
initial registration process in public health ANC facilities uses either
the client’s handset or a handset provided by the clinic.
Consumer application
For the purpose of the initial project, a single mobile health
application was selected to serve as the consumer application.
The application is an open-source, custom-made mobile messaging
platform, programmed to interact with individual mobile phone

specified period (to avoid duplicate entries for the same transaction),
while others can be activated a number of times.
These core data elements were later supplemented with additional
PM
handsets using USSD and to send messages via SMS. The USSD
application supports the collection of data from handsets using data-
collection screens as well as the messages sent back to the handsets

16 6
by SMS. The same toll-free USSD short-codes are made available
data elements relating to service ratings, a help-desk, and a system
on all four mobile networks in South Africa.27 SMS messages to the
for feedback on services received (compliments and complaints). A

20 IL
central system for opt-outs and help-desk questions are reverse-billed
separate but complementary program, NurseConnect, collects data
to the NDoH-funded MomConnect project. The cost was subsidised
elements from nurses in order to provide them with support and
Y T by all four mobile network operators in South Africa (Cell C, MTN,
clinical updates, and to facilitate interaction with managers.
Telkom Mobile and Vodacom). A separate system was integrated
A N
with the consumer application to provide help-desk functionality.
System architecture
M U

Health information exchange

The technical architecture of MomConnect was designed around
the HNSF health information exchange (HIE) framework that An open-source software application was used for the HIE component.
4 ED

connects consumer applications and edge devicesc (through an It was programmed to validate and orchestrate messages received
interoperability layer) to demographic registries and clinical in a standard format, as specified by the HNSF,14 also making it a
repositories complemented with security and audit services.14 reference implementation of the interoperability layer component as
O

prescribed by the HNSF, which promotes use of open standards to

achieve interoperability for health.
Table 1: Core data elements collected by MomConnect
G

Description Function
R

1 Mobile health application ID Unique identifier specifying the application provider. In the current version of
MomConnect, there is only one Application ID.
BA

2 Software type ID Unique identifier specifying the application software type. In the current version of
MomConnect, there are two types: (SMS) and (USSD).
O

3 Device telephone number Unique number of the SIM card interacting with the server by USSD or SMS
4 Client telephone number Unique mobile phone number of the client to which SMS messages will be sent
EM

5 Client identifier Unique client identifier – this is the South African National ID Number, if available;
alternatively the client mobile phone number is used.
6 Message type Unique code specifying the source of the data, viz. a public subscription, identification
by a community health worker, a clinic registration, an opt-out message, a message of
baby loss, service-rating data, help-desk data
7 Language Unique two-digit code indicating the preferred language for message correspondence in
one of the 11 official languages in South Africa
8 Event date Date of the event
9 Facility code Unique six-digit facility code
10 Date of birth Date of birth of the client (optional)
11 Opt-out reason code Unique code specifying the reason for opting out of the MomConnect service:
Miscarriage, Stillborn, Baby Loss, Not useful, Other, Unknown
12 Estimated due date The date of estimated delivery of the baby, validated by a nurse
13 Question-answer pairs Data containing the service rating and help-desk questions and answers
14 Reply date Date of the reply to the help-desk message
15 Class of help desk interaction Compliment, complaint or question
16 Help desk operator ID Unique code assigned to operators of the help-desk service

b USSD is used to send text between a mobile phone and an application

program in the network, much the same as requesting an air-time balance,
and is therefore largely familiar to users.
c An edge device typically exists at the edge of a health information network
where it is used by a human user to collect or display information.

S A H R 20 1 6 127
Demographic Registry and Clinical Repository
The Demographic Registry and Clinical Repository used by Mom-
Connect is a module of the open-source District Health Information
System (DHIS) – the official routine information system used to
monitor the performance of various health programmes in the
national health systems. It serves three main functions:
➢➢ The tracker module stores individual records in the form of a
national pregnancy registry and acts as a patient registry and
shared health record (SHR).
➢➢ The data warehousing capability facilitates aggregation
and therefore reports core indicators aggregated from the
individual records.
➢➢ The module stores an organisation unit hierarchy and thereby
maintains the list of unique facility codes, acting as a master
facility list and registry in the HNSF implementation.
In the early stages of the project, additional components, such as
16 6
a dedicated client registry with master patient index (MPI) and a
shared health record (SHR) were tested and although these were
20 IL
technically successful, they were removed because a significant
portion of records did not have personal identifier data (see Table 2)
and maintaining a separate system that was not serving a practical
Y T
function introduced additional and unnecessary overheads. In
A N
addition, the client registry system’s patient-matching algorithms
were not utilised, as the dataset captured would have been too
M U
small to de-duplicate client entries reliably. Finally, a substantial
amount of non-clinical event data were also collected, which could
4 ED
not be stored directly in the client registry. however, it is possible to
reinstate these components in the future if required.
Table 2: Identifier data captured in MomConnect (N,%)
O
Identity type Number Percentage
G
None 134 535 22%
SA national identifier 454 545 75%
R
Other identification 16 748 3%
BA
Source: South African National Department of Health, MomConnect Data,
19 February 2016.
O
Security and auditing
EM
All data transmission between various components is encrypted and
located in a secure data centre in South Africa and servers are
secured by firewalls and protected from unauthorised access. The
interoperability layer has a secure web-based console and alerting
system that is used to monitor the flow of transactions and ensures
that problems are identified and addressed timeously.
System application and implementation
Technical implementation of the MomConnect infrastructure
One of the important requirements for MomConnect was to adhere
to the principles and architecture elaborated in the HNSF. The
technical implementation team was able to meet this requirement
using existing software tools combined with the standards and
profiles listed in the HNSF specification.
The initial infrastructure was developed and deployed within the
first few months and then evolved iteratively over the course of the
project. Changes to the infrastructure were implemented without any
breaks in service.
128 S A H R 20 1 6
Standards and profiles
As specified in the HNSF, the connection between layers in the
health information exchange should be implemented using one or
more interoperability standards. The main interaction considered
for standardisation was that occurring between the consumer
application and the HIE.
The MomConnect implementation team initially chose the Clinical
Document Architectured (CDA) as the content standard. The Mobile
Access to Health Documente (MHD) profile was implemented from
the consumer application to the HIE for further processing. At the
same time, non-clinical data were captured in JavaScript Object
Notationf (a text-based data exchange format) (JSON). Due to the
limited clinical content captured in MomConnect and in the interests
of simplification, the JSON document became the primary source
PM
for transaction data populating the pregnancy registry. In future,
the team plans to replace the JSON document with a document
formatted using Fast Healthcare Interoperability Resourcesg (FHIR), a
relatively new lightweight Health Level Seven (HL7) standard. FIHR
is not mentioned explicitly in the HNSF as it did not exist at the time
of writing the HNSF, but it is an emerging standard that is expected
to be incorporated in future.
The selection, customisation and implementation of standards
prescribed by the HNSF is complex but achievable by a team with
knowledge of interoperability and international standards. In future,
the governance structures described in the HNSF, including the
appointment of an eHealth Standards Board under the leadership
of NDoH, plan to facilitate the process of standardisation and
localisation.
Sequence of events
A typical sequence of events in MomConnect is as follows:
➢➢ A user, alternatively a nurse or CHW, enters the client’s data,
on her behalf, into the MomConnect USSD application.
➢➢ During the USSD session, if a facility code is entered it is
validated against the central Facility Registry.
➢➢ These data are then sent through to the mobile platform, which
triggers the stage-based SMS message suite for the mother
and sends the data through to the HIE.
➢➢ The interoperability mediator validates the message and if
valid, places it into a queue.
➢➢ The message is then sent asynchronously to the generic DHIS2
tracker mediator that populates the MomConnect program
data in DHIS2 (the client registry and the tracker events, of
which the SHR is a subset).
Figure 1 shows a summarised sequence of events for capturing a
MomConnect registration.
The number of MomConnect registrations and subscriptions has
grown steadily over the 17-month period of the MomConnect
project, as shown in Figure 2.
d http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7
e http://wiki.ihe.net/index.php/Mobile_access_to_Health_
Documents_%28MHD%29
f JavaScript Object Notation is a lightweight data-interchange format that is
easy for humans to read and write.
g https://www.hl7.org/fhir/overview.html
 MomConnect

Figure 1: MomConnect registration: sequence of events

Handset Consumer application HIE DHIS

USSD/SMS

SMS

Validate facility code

Facility check

PM
Registration message

Message validation

16 6
20 IL
Accepted

Validate client
Y T
A N
Add event to tracker
M U
4 ED

Aggregate reporting

Handset Consumer application HIE DHIS

O
G

Key: USSD – Unstructured Supplementary Service Data

R

SMS –Short Message Service

HIE – Health Information Exchange
BA

DHIS – District Health Information System

N
O
EM

Figure 2: Cumulative total MomConnect registrations, subscriptions and enrolments (N)

613 791

550 000

500 000

450 000

400 000
Number of Individuals

350 000

300 000

250 000

200 000

150 000

100 000

50 000

8
06-09-2014 03-11-2014 31-12-2014 27-02-2015 26-04-2015 22-06-2015 19-08-2015 16-10-2015 13-12-2015 09-02-2016
Time

Facility registrations Public subscriptions Community health worker enrolments

S A H R 20 1 6 12 9
As a successful national mobile health application, MomConnect
is one of only a few known standards-based implementations in
Africa and serves as positive proof that South Africa can succeed in
implementing the HNSF and make health applications interoperable.
Discussion
In view of the operational success of the MomConnect technical
implementation, and ongoing challenges faced when attempting
to mainstream digital health technical solutions, it is useful to align
some of the key features of the technical architecture with factors that
have been found by others to be important to success. In this section,
we consider the MomConnect infrastructure in the context of two
digital health systems frameworks. The recently published guidelines
for reporting health interventions18 were also useful for guiding both
Technological systems
➢➢ Usability: The MomConnect technology platform was designed
to maximise usability at several levels. At an end-user level,
phones made use of simple USSD functionality that is familiar
to end-users and ubiquitously available across cell-phone
types throughout the country. The backend infrastructure was
optimised to use the fewest possible components and simplest
possible standards, and user-friendly administration tools were
developed to assist with long-term maintenance.
➢➢ Interoperability: MomConnect’s technical infrastructure
makes use of the architecture provided by the HNSF, which
implements interoperability standards and profiles across
different applications that may also be extended to support
additional health services.

the content of this chapter and the recommendations for future work.
The MomConnect program and its technical features are reviewed
from four health system dimensions as recommended by Leon et
PM
➢➢ Privacy and security: The MomConnect technical infrastructure
makes use of industry-standard methods for ensuring privacy
and implementing security.

16 6
al.28 Financial systems

20 IL
Government stewardship ➢➢ Sustainable funding: The MomConnect technical infrastructure
uses entirely open-source systems and software that minimises
➢➢ Strategic leadership: This is arguably the single most important
Y T licensing and support costs and is consistent with South African
criterion for success, and the MomConnect infrastructure scores
government policy.29 As such, it is relatively more sustainable
highly in this dimension in that it was launched and supported
A N
and less reliant on ongoing funding than other commercial
by the Minister of Health and led by senior officials in the
systems. The system is being improved continuously and the
M U

NDoH. The project was personally launched by the Minister

operating costs are being made more economical, e.g. by
in every province in South Africa, ensuring buy-in at the level
integrating with other established government systems and
where implementation occurs. The technical infrastructure itself
4 ED

developing data-driven alternatives that have lower line costs.

is closely aligned with government policy as an instantiation of
the NDoH HNSF architecture and implementation roadmap. ➢➢ Cost-effectiveness: This criterion can only be evaluated fully
once the impact of MomConnect has been assessed; however,
➢➢ Learning environment: A more formal evaluation of the impact
O

early indications are that the infrastructure component

of the MomConnect program is currently being conducted
is as low-cost as it can be, with the exception of line costs
G

by the NDoH. Learnings from the infrastructure component

that are still being optimised. Based on initial results from
have contributed significantly to our understanding of the
a similar intervention in Bangladesh,30 we anticipate that
R

implementation of systems at scale and the larger task of

MomConnect will be found to be cost-effective for such a
implementing the HNSF. These learnings are iteratively built
BA

public health intervention. Additionally, improvements in cost-

N

into incremental improvements to the system.

effectiveness may be realised if the USSD and SMS services
O

Organisational systems are supplemented with data services.

EM

➢➢ Capacity for implementation: The MomConnect infrastructure
development was undertaken by the NDoH in collaboration
with private sector partners mobilised through the mMH Task
Team. This proved to be an effective mechanism for ensuring
that the MomConnect infrastructure contributes directly to the
development of the public health system, while leveraging
some of the innovation and implementation skills available in
the private and academic sectors.
Another framework for evaluating the MomConnect technical
architecture is the Principles for Digital Development (PDD),31
generally considered by many donors and implementing partners to
represent best practice in the development of digital health solutions.
Evaluation of the MomConnect technical implementation against the
PDD is detailed in Table 3.

➢➢ Culture of information use: The MomConnect infrastructure

was designed to integrate directly with the DHIS, which is used
for monitoring and evaluation (M&E) of the various NDoH
programmes. Integration of the registry system with the M&E
platform ensures that MomConnect data are readily available
to NDoH officials in near-real time. In this way, the data can be
used effectively to monitor and intervene as necessary.

130 S A H R 20 1 6
 MomConnect

Table 3: Evaluation of MomConnect technical implementation against the Principles for Digital Development (PDD) framework

Design with the • This was adapted using the input of local experts to make it compatible with the local South African context, ensuring that the
user system was accessible to and equitable for marginalised populations where the need is greatest (rather than where technical
access is easiest). The South African Mobile Alliance for Maternal Actionh (MAMA) project had extensively tested the system
used by MomConnect and its initial messages with South African women.
• The messaging system used has been found to be effective in other low-resource settings.
• The task team comprised people with varied backgrounds and experience, from which the project benefited.
• Technical infrastructure made use of general, pre-developed eHealth and mHealth system components that had been
successfully implemented in low-resource settings and shown to be effective and reliable. This meant that the focus could
be on satisfying the end-user’s requirements. The task of developing the MomConnect infrastructure was largely one of
configuring the systems for the mobile maternal use case and integrating the working systems using the NDoH standards-
based framework, rather than attempting to develop new systems.
Understand the • The process followed in the development of the technical infrastructure was initiated and led at the highest level by the NDoH
ecosystem and made use of an mMH Task team that included experienced private sector mHealth practitioners.
• A survey of all mHealth services and projects was conducted at the start of the initiative, and all active partners were invited to
the first meeting that led to the establishment of the Task Team.
• Technical implementation was aligned with technological, legal and regulatory policies, both in South Africa and internationally.

PM
Design for scale • A systems approach was followed in the development of the technical infrastructure to ensure that the system fitted into the
wider NDoH architecture.
• Open standards were selected and implemented to ensure that the application could be scaled to include other mHealth
applications and extended to include additional services.
• The system was designed to be used in thousands of facilities, with training and support designed accordingly.

16 6
Build for • The technical infrastructure was designed around considerations of long-term sustainability, including the use of open-source
sustainability software and alignment with NDoH systems.

20 IL
• Use of the program has been institutionalised through the operating practices of clinical staff, ensuring a level of organisational
sustainability.
• MomConnect was designed to be a zero-cost service for the client.
Y T
Be data-driven • Technical infrastructure was largely developed to manage data, including the data for registering and subscribing clients,
messages sent to clients to promote antenatal care, and data for monitoring and evaluating the program.
A N
• A simpler minimal solution would have been merely to register women and provide messages. However, the technical backend
infrastructure provides much more data for effective management of the program.
M U

• Usage data from MomConnect are collated weekly and circulated to the MomConnect Task Team and other stakeholders
ensuring that management decisions are informed by data on the development of the system.
Use open data, • Technical infrastructure has a number of features illustrating the principles of an open mHealth architecture32 and open eHealth
4 ED

open standards, architectures in general:

open source and - Open data: The principles of making data open are relative in this context and the use of personally identifiable data cannot
open innovation. be made open. However, the de-identified, aggregate reporting data are made available within the NDoH and used for routine
monitoring and evaluation of the program and to compare outcomes with performance indicators, such as the expected rate
O

of enrolment based on previous maternal booking rates.

- Open standards: By adopting the HNSF architecture and design, the MomConnect technical infrastructure implements open
G

standards. Both the IHE profiles and the HL7 CDA specification used by the MomConnect technical infrastructure are openly
available to users from low- and middle-income countries. The standards were also adapted to the specific requirements of
MomConnect. The standards will be used to define a common means of connecting mHealth consumer applications to the
R

HIE.
- Open source: All applications used by the MomConnect technical infrastructure are open source.
BA

- Open innovation: Development of the technical infrastructure was conducted in an open environment and with transparency,
allowing open innovation to occur.
O

Re-use and • The NDoH and mMH Task Team elected to use open-source software that had already been implemented in South Africa
improve and other countries. In this way, the MomConnect technical infrastructure was built based on existing initiatives, and its
EM

development has benefited from the considerable software development effort and investment that has generated existing
software tools and standards. This has certainly lowered the costs and risk associated with software systems development.
In addition, by using existing tools, MomConnect has contributed to the continued growth and development of these tools as a
global good of open architecture health informatics tools that can be deployed in other low-resource settings.33
• The message structure and the content of many of the messages were adapted from the MAMA South Africa project. While the
NDoH took full ownership of the MomConnect project, the existing building blocks were used rather than re-invented.
• The South African MomConnect technical infrastructure has now become a model for other initiatives, such as FamilyConnect
in Uganda.
Address privacy • MomConnect is one of the first projects in South Africa collecting individual-level data using a unique patient identifier. Privacy
and security and security are of primary concern. The MomConnect HIE and monitoring systems protect client data at several levels,
including physical access to the hardware, encryption of data and the use of certificates. A security policy has been developed
and implemented by the NDoH
Be collaborative • The MomConnect technical infrastructure project has been collaborative on several different levels. The mMH Task Team was
initiated as a collaborative forum with representatives from a range of South African organisations. As the system develops,
additional partners may be included to contribute to the integrated system. The development of the technical architecture was
a productive collaboration between public health professionals and software engineers. The use of open-source software
components and communities has the potential to contribute to the notion of a “broader commons of resource, action and
knowledge” through the development of similar projects and initiative in Africa.33,34

Key: MAMA – Mobile Alliance for Maternal Action mMH – mobile Maternal Health
NDoH – National Department of Health HNSF – Health Normative Standards Framework
IHE – Integrating the Healthcare Enterprise HL7 – Health Level Seven
CDA – Clinical Document Architecture HIE – health information exchange

h MAMA South Africa provides access to information on pregnancy using different channels and a variety of formats and protocols (see http://www.askmama.
co.za/)

S A H R 20 1 6 131
Conclusion
Aligning MomConnect with international best practices resulted in a
number of conclusions:
➢➢ Ensure government stewardship: Government stewardship is the
most fundamental precondition for building health information
technology infrastructure at national level. MomConnect has
also shown that projects with strong government leadership
can effectively leverage private sector innovation to best
advantage and have the strongest chance of creating systems
that are sustainable beyond the initial development phase.
➢➢ Adopt an open architecture approach: The open architecture
approach adopted in the HNSF14 has significant advantages
for large-scale systems development, allowing multiple
applications to be integrated into a single system through
loosely coupled components. Open standards and open
application programming interfaces (APIs) are fundamental
enablers of the open architecture approach. Combining a
16 6
flexible front-end consumer application with a standardised
platform proved to be a powerful platform for MomConnect.
20 IL
➢➢ Adopt the Principles for Digital Development:31 These principles
can assist system developers in avoiding common pitfalls and
Y T
help them to develop systems that contribute to strengthening
A N
public health systems rather than consuming scarce resources
with limited outcome.
M U
➢➢ Re-use and integrate: Software and system development is
expensive and risky, with a high failure rate. Within this context
4 ED
many working components can be re-used and integrated into
a working system. This effectively lowers the cost and risk
associated with system development. However, it is necessary
O
to avoid the hazards of fitting the requirement to a particular
software tool.
G
➢➢ Design a roadmap: Restricting scope and creating a roadmap
for implementation are critical to the success of system
R
development projects. It is important to understand which
BA
functionality is important at which stage of development of the
N
project. In the case of MomConnect, it was possible to limit
O
functionality, e.g. the number of data elements, in order to
focus on the elements essential to its success.
EM
Recommendations and future directions
Based on our experience in implementing the technical infrastructure
for MomConnect, we offer the following recommendations for the
future development of the MomConnect technical infrastructure and
related projects as part of the HNSF implementation, several of
which are already being investigated or developed by the NDoH:
➢➢ Include data options: Despite generous discounts afforded
by Mobile Network Operators (MNOs), USSD and SMS
are expensive protocols to implement. Significant cost
savings could be achieved by supplementing MomConnect
with applications that use data services while retaining the
reach afforded by USSD and SMS. Interaction with the HPRS
application could also help to reduce the cost of collecting
MomConnect data in facilities where it has been implemented.
1 32 S A H R 20 1 6
➢➢ Extend to other health services: An opportunity exists to
extend the MomConnect implementation to other health
services where digital data are collected. The NDoH plans
to expand the program to include additional maternal,
newborn and child health (MNCH) services and mobile health
applications. The application currently being considered is
the mobile health application implemented by CHWs as part
of the primary health care stream of Ward-based Outreach
Teams (WBOTs). MomConnect can be developed to include
and integrate with other services, such as child health and
immunisation programmes supporting a continuum of care
through pregnancy and early childhood and linking to the
requirements for universal health coverage.35
PM
➢➢ Include other mobile health applications: A particular advantage
of the HNSF architecture is that it enables interoperability
between different applications using the same interoperability
standard. This opens up the possibility of leveraging digital
health applications used in other programmes to contribute
to data collection and potentially interact with MomConnect
to create more extended data sets. The ability to facilitate
interoperability between different mHealth applications will
solve the vexing problem of the proliferation of small pilot
projects (‘pilotitis’) in mHealth that has plagued many low- and
middle-income countries, including South Africa, struggling
to use information and communication technologies (ICTs) to
improve efficiencies.13,36 The NDoH is already working with
other mobile health application providers to explore such
incorporation into the MomConnect technical infrastructure.
➢➢ Extend the national architecture based on the HNSF: The South
African HNSF is an advanced legislative framework for
digital health that can be used effectively to realise digital
health benefits such as interoperability, standardisation and
re-use of existing infrastructure. The architecture itself could
be used effectively by the NDoH to guide the implementation
of other digital health programs in South Africa in the
interests of strengthening the public health information system
more generally. There are many advantages in integrating
MomConnect into the eHealth reference implementation
project, including integration with the HPRS to reduce duplicate
registration and unnecessary data capture. As the application
and data integration occurs, additional opportunities will
open up for integrated data to support public health services
in South Africa.
➢➢ Assess the effectiveness of the MomConnect messages: The
MomConnect interoperability architecture is a powerful
platform for data integration. In future, triangulation of data
from within MomConnect and other programs collecting
maternal health data could be used to test the delivery
of messages and their effectiveness in improving ANC
attendance. The NDoH has already initiated an action to
integrate related applications, which can catalyse integration
of data elements and enable more powerful analyses. This
will also serve as a model for other health services within the
HNSRF implementation project.
 MomConnect

Acknowledgments
The authors acknowledge the leadership of the South African Minister
of Health who initiated and leads the MomConnect project, as well
as the direction and contribution of the South African National
Department of Health, especially Dr Yogan Pillay who convened and
led the mMH Task Team, and the MomConnect project managers.
The mobile phone and mobile health application components were
implemented and managed by a group from Praekelt Foundation.
The interoperability components were implemented and managed
by a group from Jembi Health Systems. The registry and data
warehouse components were implemented and managed by a group
from the Health Information Systems Programme, South Africa (HISP-
SA). Additional inputs for the technical design and implementation
of MomConnect were provided by the Council for Scientific and

PM
Industrial Research (CSIR) Meraka Institute and Inner City Fund
(ICF) International. Regular inputs and feedback were provided
by all members of the mMH Task Team. Local and international
funders, including the United States President’s Emergency Plan for

16 6
AIDS Relief (PEPFAR), the Johnson & Johnson Foundation and Elma

20 IL
Philanthropies, support MomConnect. The mobile operators in South
Africa – Cell C, MTN, Telkom Mobile and Vodacom – afforded
generous discounts on the commercial cost of SMS messages.
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 1 33
References
1 United Nations. United Nations Millennium Development
Goals. New York: United Nations; 2002. [Internet]. [cited 5
April 2016].
URL: http://www.un.org/millenniumgoals/
2 South African National Department of Health. Guidelines
for Maternity Care in South Africa. A manual for clinics,
community health centres and district hospitals. 2015.
[Internet]. [cited 5 April 216].
URL: http://www.health-e.org.za/wp-content/
uploads/2015/11/Maternal-Care-Guidelines-2015_
FINAL-21.7.15.pdf
3 Chola L, Pillay Y, Barron P, Tugendhaft A, Kerber K, Hofman
K. Cost and impact of scaling up interventions to save lives
of mothers and children: taking South Africa closer to MDGs
4 and 5. Glob Health Action. 2015 Apr 21;8(0). [Internet].
13 Praekelt G. The Role of mHealth in South Africa. Stanford Soc
Innov Rev. 2013 Feb. [Internet]. [cited 6 April 2016].
URL: http://ssir.org/articles/entry/the_role_of_mhealth_in_
south_africa
14 South African National Department of Health. Health
Normative Standards Framework for Interoperability in
eHealth in South Africa. Version 2.0. Pretoria: National
Department of Health; 2014. [Internet]. [cited 6 April 2016].
URL: http://www.gov.za/documents/national-health-act-
national-health-normative-standards-framework-interoperability-
ehealth
15 Wolmarans M, Solomon W, Tanna G, Chetty M, Dombo M,
Venter J, et al. eHealth Programme reference implementation
in primary health care facilities. In: Padarath A, King J,
English R, editors. South African Health Review 2014/15.

[cited 5 April 2016].
URL: http://dx.doi.org/10.3402/gha.v8.27265
4 Peter JE, Barron P, Pillay Y. Using mobile technology to
improve maternal, child and youth health and treatment of
PM
Durban: Health Systems Trust; 2015. p. 35–44. [Internet].
[cited 6 April 2016].
URL: http://www.health-e.org.za/wp-content/
uploads/2015/10/HST-SAHR-2014-15-Complete.pdf

16 6
HIV patients. S Afr Med J. 2015 Nov 16;106(1):3. [Internet]. 16 English R, Masilela T, Barron P, Schonfeldt A. Health
[cited 7 February 2016]. information systems in South Africa. In: Padarath A, English R,

20 IL
URL: http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10209 editors. South African Health Review 2011. Durban: Health
Systems Trust; 2011. p. 81–9. [Internet]. [cited 6 April 2016].
5 National Committee for Confidential Enquiry into Maternal
URL: http://www.hst.org.za/sites/default/files/Chap 7
Deaths. Saving Mothers 2011–2013: Sixth report on the
Y T Information Systemspgs 81-90.pdf
Confidential Enquiries into Maternal Deaths in South Africa.
2014. [Internet]. [cited 7 February 2016]. 17 Masilela TC, Foster R, Chetty M. The eHealth Strategy for
A N
URL: http://www.kznhealth.gov.za/mcwh/Maternal/Saving- South Africa 2012–2016: how far are we? In: Padarath A,
Mothers-2011-2013-short-report.pdf English R, editors. South African Health Review 2013/14.
M U

Durban: Health Systems Trust; 2014. p. 15–24. [Internet].

6 Victora CG, Requejo JH, Barros AJD, Berman P, Bhutta Z,
[cited 6 April 2016].
Boerma T, et al. Countdown to 2015: a decade of tracking
URL: http://www.hst.org.za/sites/default/files/eHealth_
4 ED

progress for maternal, newborn, and child survival. Lancet.

Strategy.pdf
15 October 2015. [Internet]. [cited 7 February 2016].
URL: http://dx.doi.org/10.1016/s0140-6736(15)00519-x 18 Agarwal S, LeFevre AE, Lee J, L’Engle K, Mehl G, Sinha
C, et al. Guidelines for reporting of health interventions
7 Dorrington RE, Bradshaw D, Laubscher R, Nannan N. Rapid
O

using mobile phones: mobile health (mHealth) evidence

mortality surveillance report 2014. Cape Town; 2015.
reporting and assessment (mERA) checklist. BMJ. 2016 Mar
[Internet]. [cited 7 February 2016].
17;352:i1174. [Internet]. [cited 5 April 2016].
G

URL: http://www.worldcat.org/isbn/978-1-928340
URL: http://dx.doi.org/10.1136/bmj.i1174
8 South African National Department of Health. Strategic Plan
R

19 South African Government. Minimum Interoperability

2015/162019/20. 2015;1–60. [Internet]. [cited 5 April
Standards (MIOS) for Information Systems in Government.
2016].
BA

MIOS v4.1. 2007;4.1:1–25. [Internet]. [cited 6 April 2016].

N

URL: http://www.health.gov.za/index.php/2014-03-17-09-
URL: http://www.sita.co.za/standard/MIOSv4.12007.pdf
09-38/strategic-documents/category/229-2015str
O

20 Government Information Technology Officer’s Council of South

9 Mechael PN. The Case for mHealth in Developing Countries.
Africa. Government-Wide Enterprise Architecture (GWEA)
EM

Innovations. 2009:103–18. [Internet]. [cited 6 April 2016].

Framework [Internet]. 1.2 edition, 2010. p. 1–62. [Internet].
URL: http://www.uio.no/studier/emner/matnat/ifi/
[cited 6 April 2016].
INF5761/v12/undervisningsmateriale/Mechael - 2009 - The
URL: http://gissa.org.za/special-interest-groups/open-source/
case for mHealth in developing countries(1).pdf
foss-documents/GWEA Framework Implementation Guide
10 Free C, Phillips G, Galli L, Watson L, Felix L, Edwards P, et al. v1.2 Jun 2010.pdf/at_download/file
The Effectiveness of Mobile-Health Technology-Based Health
21 South African National Department of Health. National
Behaviour Change or Disease Management Interventions for
eHealth Strategy, South Africa 2012–2017. June 2012.
Health Care Consumers: A Systematic Review. PLoS Med.
[Internet]. [cited 6 April 2016].
2013; 10(1):e1001362. [Internet]. [cited 5 April 2016].
URL: https://ndoh.dhmis.org/owncloud/index.php/s/
URL: http://dx.doi.org/10.1371/journal.pmed.1001362
R5cmdp0gY4Fa43Z?path=/eHealth
11 Free C, Phillips G, Watson L, Galli L, Felix L, Edwards P, et al.
22 The Presidency, Republic of South Africa. Department of
The Effectiveness of Mobile-Health Technologies to Improve
Planning, Monitoring and Evaluation. Medium-term Strategic
Health Care Service Delivery Processes: A Systematic Review
Framework (MTSF) 2014–2019. Pretoria: Department of
and Meta-Analysis. PLoS Med. 2013; 10(1):e1001363.
Planning, Monitoring and Evaluation; 2014. [Internet]. [cited
[Internet]. [cited 5 April 2016].
6 April 2016].
URL: http://dx.doi.org/10.1371/journal.pmed.1001363
URL: http://www.dpme.gov.za/news/MTSF/MTSF 2014-
12 Noordam AC, Kuepper BM, Stekelenburg J, Milen A. 2019.pdf
Improvement of maternal health services through the use of
23 South African National Department of Health. mHealth
mobile phones. Trop Med Int Health. 2011 May;16(5):622–
Strategy 2015–2019, South Africa. Pretoria: National
6. [Internet]. [cited 6 April 2016].
Department of Health; 2015. [Internet]. [cited 6 April 2016].
URL: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-
URL: https://ndoh.dhmis.org/owncloud/index.php/s/
3156.2011.02747.x/epdf
R5cmdp0gY4Fa43Z?path=/M Health Strategy

134 S A H R 20 1 6
 MomConnect

24 South African Government. Act No. 4 of 2013: Protection of
Personal Information Act, 2013. [Internet]. 2013. Available
from:
URL: http://www.justice.gov.za/legislation/acts/2013-004.
pdf
25 Bateman C. Using basic technology – and corporate
social responsibility – to save lives. S Afr Med J. 2014 Oct
13;104(12):839. [Internet]. [cited 7 February 2016].
URL: http://www.ajol.info/index.php/samj/article/
view/113893
26 South African National Department of Health. MomConnect.
One Year of Operation: A Case Study. August 2014 – August
2015. Pretoria: National Department of Health; 2015. p.
1–16. [Internet]. [cited 6 April 2016].
URL: http://www.healthenabled.org/resources/momconnect_
case_study.pdf
34 Moodley D, Pillay AW, Seebregts CJ. Position Paper:
Researching and Developing Open Architectures for National
Health Information Systems in Developing African Countries.
In: Liu Z, Wassyng A, editors. Lecture Notes in Computer
Science (including subseries Lecture Notes in Artificial
Intelligence and Lecture Notes in Bioinformatics). Berlin:
Springer; Heidelberg; 2012. p. 129–39. [Internet]. [cited 6
April 2016].
URL: http://researchspace.csir.co.za/dspace/
bitstream/10204/6369/1/Moodley2_2012.pdf
35 Mehl G, Labrique A. Prioritizing integrated mHealth
strategies for universal health coverage. Science. 2014;
345(6202):1284–7. [Internet]. [cited 6 April 2016].
URL: http://dx.doi.org/10.1126/science.1258926
36 Wilson K, Gertz B, Arenth B, Salisbury N. The Journey to
Scale. Moving together past digital health pilots. December
2014. [Internet]. [cited 6 April 2016].

PM
27 South African National Department of Health. Momconnect: URL: http://www.path.org/publications/files/TS_dhs_
What number do you dial? Pretoria: National Department of journey_to_scale.pdf
Health; 2015. [Internet]. [cited 6 April 2016].
URL: http://www.kznhealth.gov.za/Momconnect/Lines.pdf

16 6
28 Leon N, Schneider H, Daviaud E. Applying a framework for
assessing the health system challenges to scaling up mHealth
in South Africa. BMC Med Inform Decis Mak. 2012 Nov

20 IL
5;12(1):123. [Internet]. [cited 6 April 2016].
URL: http://www.biomedcentral.com/1472-6947/12/123
Y T
29 South African National Department of Public Service and
Administration. Policy on Free and Open Source Software Use
A N
for South African Government. August 2006. [Internet]. [cited
6 April 2016].
M U

URL: http://www.gov.za/documents/policy-free-and-open-
source-software-use-south-african-government
30 Chowdhury ME. Evaluating accessibility, acceptability
4 ED

and effectiveness of Aponjon mobile health messaging for

improved maternal and newborn health behaviors and
practices in Bangladesh. September 2015. [Internet]. [cited
6 April 2016].
O

URL: http://www.tractionproject.org/resources/key-findings-
mama-study-traction-supprted-study-conducted-international-
G

center-diarrheal
31 Digital Development Principles Working Group. Principles for
R

Digital Development. [Internet]. [cited 6 April 2016].

URL: http://digitalprinciples.org/
BA

32 Estrin D, Sim I. Open mHealth Architecture: An Engine for

Health Care Innovation. Science. 2010; 330(6005):759–60.
O

[Internet]. [cited 5 July 2014].

EM

URL: http://dx.doi.org/10.1126/science.1196187
33 Crichton R, Moodley D, Pillay A, Gakuba R, Seebregts CJ.
An Architecture and Reference Implementation of an Open
Health Information Mediator: Enabling Interoperability in the
Rwandan Health Information Exchange. In: Weber J, Perseil
I, editors. Lecture Notes in Computer Science (including
subseries Lecture Notes in Artificial Intelligence and Lecture
Notes in Bioinformatics). Berlin: Springer; Heidelberg; 2013.
p. 87–104. [Internet]. [cited 6 April 2016].
URL: https://www.researchgate.net/profile/
Deshendran_Moodley/publication/262912516_An_
Architecture_and_Reference_Implementation_of_an_Open_
Health_Information_Mediator_Enabling_Interoperability_
in_the_Rwandan_Health_Information_Exchange/
links/5412d89d0cf2bb7347

S A H R 20 1 6 1 35
136
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
The contribution of congenital disorders to
child mortality in South Africa
12

Authors:
Helen L. Malherbe i
Colleen Aldous ii

PM
David Woods iii
Arnold Christianson iv

16 6
R 20 IL
eduction in child mortality has been a priority issue in South Africa leading up In South Africa many
to the Millennium Development Goals. However, the contribution of congenital
Y T
disorders (CDs) to child mortality is yet to be recognised and acted upon. congenital disorders
A N
Rapid reductions in child mortality have resulted largely from comprehensive HIV and
go undiagnosed or are
misdiagnosed resulting in
M U

AIDS programmes and interventions such as the childhood Expanded Programme of

Immunisation. However, the Rapid Mortality Surveillance System reports that since the incorrect cause of
2011, reductions in child mortality rates “stopped abruptly”. This indicates that health
4 ED

issues other than those currently being addressed may require long-term prioritisation. death being reported and
In 2013, congenital anomalies (excluding many CDs) overtook infection as the third in an underestimation
leading cause of early neonatal deaths, which account for one-third of all under-five
of the true burden of
O

deaths.
congenital disorders
G

As South Africa transitions epidemiologically, the proportion of deaths caused by

CDs is increasing, as mortality from communicable diseases drops, revealing the in the country.
R

previously hidden disease burden of CDs. In South Africa, many CDs go undiagnosed
or are misdiagnosed, resulting in the incorrect cause of death being reported. These
BA

inaccurate data result in an underestimation of the true disease burden of CDs in the
O

country.
EM

As up to 70% of CDs can be prevented or ameliorated, it is essential that they

be prioritised and that relevant, accessible services for prevention and care be
implemented. A good legislative and regulatory framework exists in South Africa for
the provision of services, but implementation has been poor and fragmented. Current
services are available at a lower base than in 2001.

This chapter argues for recognition of the role of CDs in child mortality and morbidity
and the potential advantages of medical and genetic services for the prevention and
care of CDs.

i Genetic Alliance South Africa; School of Clinical Medicine, College of Health Sciences, Universit y of KwaZulu- Natal
ii School of Clinical Medicine, College of Health Sciences, Universit y of KwaZulu- Natal
iii Newborn Care, School of Child and Adolescent Health, Universit y of Cape Town
iv Wits Centre for Ethics (WiCE), Universit y of the Wit watersrand, Johannesburg

137
Introduction
Since the Millennium Development Goals (MDGs) were set in
2000, there has been a global drive to reduce child mortality.1 In
order to achieve the MDG 4 target of cutting under-five mortality
by two-thirds by the end of 2015, countries rapidly incorporated
measures relevant to their specific healthcare challenges. As the
MDG deadline loomed, South Africa focused on responding to
the HIV and AIDS and concomitant tuberculosis (TB) epidemics, re-
engineering primary health care and developing a strategic plan for
Maternal, Newborn, Child and Women’s Health (MNCWH) and
Nutrition. Several ministerial committees were established to address
underlying issues, including the National Perinatal Mortality and
Morbidity Committee (NaPeMMCo) and the Committee on Mortality
and Morbidity in Children (CoMMiC). The topic of newborn and
child mortality and survival has also been examined in detail in
previous editions of the South African Health Review.2,3
None of these policies or initiatives has comprehensively recognised
16 6
the contribution of congenital disorders (CDs) to neonatal, infant
and child mortality and morbidity. This is despite the fact that in
20 IL
industrialised countries around the world, CDs are the leading
cause of death in infants and children, contributing up to 28% of
Y T
under-five deaths in high-income countries.4 Like many other middle-
and low-income countries (MLICs), South Africa is following this
A N
epidemiological trend and the proportion of deaths and disability
resulting from CDs is rising, especially as communicable diseases
M U
are better controlled.5
This chapter provides an overview of the health issue of CDs and
4 ED
their unappreciated role in child mortality and morbidity in South
Africa. Epidemiological transition is described in relation to CDs
and an outline is given of the growing role of CDs in the burden
O
of disease in South Africa and why it has remained hidden. The
chapter also identifies the benefits of recognising the contribution
G
of CDs in the burden of disease, including potential reductions in
R
mortality and morbidity through medical genetic services for the
prevention and care of CDs. The current status of these services
BA
is reviewed and compared with what is required to address this
growing health need. Where relevant, secondary data have been
O
sourced from peer-reviewed literature and globally recognised data
EM
sources.
Millennium Development Goal 4
The adoption of the United Nations Millennium Development
Declaration in 20001 and the time-based targets set for the
following 15 years has resulted in varying degrees of achievement
among participating nations. MDG 4 focused on improving child
survival, and significant progress towards this two-thirds reduction
in under-five mortality was achieved globally. By 2015, the global
under-five mortality rate (U5MR) had been reduced by 53%, halving
the number of children dying annually from 12.7 million in 1990 to
5.9 million in 2015.6 Many regions achieved or came close to the
targeted two-thirds (66%) reduction in U5MR. In sub-Saharan Africa,
the U5MR decreased by 54%.6 One in every 12 children still dies
before his or her fifth birthday in South Africa compared with one in
147 in high-income countries.6
South Africa’s progress towards MDG 4 has been varied. In 2005,
South Africa was one of only four countries where the U5MR
138 S A H R 20 1 6
was higher than the 1990 MDG baseline due to the negative
epidemiological impact of HIV and AIDS and concomitant TB.7
Significant reductions were then seen in child mortality until 2011
due to a number of factors. These included scaled-up prevention of
mother-to-child transmission of HIV, expanded roll-out of antiretroviral
therapy, and the addition of the rotavirus and pneumococcal
conjugate vaccines to the childhood Expanded Programme of
Immunisation (EPI).7–9 Despite the rate of reduction tripling since
2000, the U5MR decreased by one-third only, to 39 per1 000
live births,8 falling short of the South African MDG 4 target of 2
per1 000 live births.
However, according to the Rapid Mortality Surveillance Report there
PM
has been no further decrease in infant and child mortality in South
Africa since 2011.8 This stagnation indicates the need to address
other health issues contributing to infant and child mortality, whilst
continuing with ongoing efforts.5,7,8 Many issues related to social
determinants of health and childhood illnesses are already being
addressed, including malnutrition and infectious diseases associated
with poverty such as measles, diarrhoea and malaria. A 2013 study
identified 15 key interventions that were scaled up in South Africa
for maximum impact on maternal and child mortality during the
final two years of the MGDs.10 Preliminary measures to target non-
communicable diseases (NCDs), now a component of South Africa’s
quadruple burden of disease, are also under way.11 However, CDs,
which are the first NCD experienced by infants and children,5,12 are
yet to be recognised for their contribution to stillbirths, and neonatal,
infant and child mortality in South Africa. This is despite the global
call to action by the World Health Assembly (WHA) in 2010 through
Resolution 63.17,13 which recognised the importance of CDs as
a cause of stillbirths and neonatal mortality. To attain MDG 4,
WHA 63.17 called for “accelerated progress in reducing neonatal
mortality including the prevention and management of CDs”.13
CDs are a common, costly and critical health issue. According to
the 2006 March of Dimes report,14 serious CDs result in the death
of 3.3 million children under the age of five globally every year.
Although CDs are found in all populations throughout the world,
over 90% occur in MLICs where 95% of CD-related deaths occur.14
Reasons for this unequal distribution of CDs include less-developed
health services and a variety of poverty-related reasons that increase
the risk of CDs occurring, such as a higher percentage of older
mothers and consanguineous marriages, and the survival advantage
against malaria for carriers of some single gene disorders.14 Despite
this higher incidence of CDs in MLICs, the contribution of CDs to
the burden of disease is yet to be recognised by many of these
countries.
Definitions and terminology
CDs are defined as “any potential pathological condition arising
before birth, including disorders caused by environmental, genetic
and unknown factors, whether they are evident at birth or become
manifest later in life”.15 CDs that are caused before conception are
genetic and the result of chromosomal abnormalities or single gene
defects, or are multifactorial in origin. Post-conception CDs are the
result of teratogens (alcohol, prescribed and recreational drugs,
maternal infections and illnesses, exposure to environmental toxins
 Congenital disorders

and radiation) or abnormalities of the fetal environment that deform transition of countries has been described extensively using
or disrupt the developing fetus (e.g. constraint and amniotic band Omran’s model,18 which defines three stages of disease. As
disorder). Teratogens – fetal environmental factors that cause CDs – mortality rates decrease and longevity increases, countries move
may be chemical substances, physical agents or infections, and are from Stage 1 ‘the age of pestilence and famine’ to Stage 2, ‘the
more common in MLICs where the potential for exposure is higher age of receding pandemics’ and into the third stage, ‘the age
and there are fewer preventative measures in place.14 of degenerative and man-made diseases’ characterised by low
mortality rates and high life expectancy at birth (over 50 years). It
The global lack of consensus on terminology related to CDs has
is in this third stage that communicable diseases are well controlled
plagued the medical genetics sector and resulted in lower priority
or eradicated, and NCDs and degenerative diseases emerge.18
being given to this healthcare issue. In 2006, after decades of
uncertainty, agreement was reached by international experts on Like many MLICs, South Africa is not following Omran’s classic
the use of basic terminology at a joint World Health Organization model18 of epidemiological transition that was completed by
(WHO) and March of Dimes meeting.15 Participants recommended industrialised, high-income nations decades ago.19 From 1960 to
that the terms ‘CDs’ and ‘birth defects’a be used synonymously. Use the early 1990s, infant and child mortality in South Africa declined
of the term ‘congenital anomaly’ was not advised, since it excludes steadily and longevity increased.5 Figure 1 plots the U5MR,20 infant

PM
around 40% of functional CDs including non-syndromic congenital mortality rate (IMR)20 and life expectancy at birth (longevity) data,21
disabilities, common single gene disorders and inborn errors of and the HIV epidemic (indicated by the percentage of HIV-positive
metabolism.b,12,15 pregnant women)22 for South Africa for the last 25 years. Life
expectancy at birth peaked at 62.33 years in 1992, and in 1993

16 6
The limited uptake of this agreed terminology and the copious use of
both the U5MR and the IMR were at an all-time low of 58.2 per
non-equivalent terms has led to confusion, fragmentation of effort and
1 000 live births and 45.1 per 1 000 live births respectively.20,21 All

20 IL
an inability to compare data sets.b This has diluted the visibility of the
indications were that South Africa was approaching the early phases
significant contribution of CDs to neonatal, infant and child mortality,
of transition from Stage 2 (the ‘age of receding pandemics’) to Stage
and prevented CD data from being evaluated comprehensively. CDs Y T 3, the ‘age of degenerative and man-made diseases’ and was set to
are often undiagnosed or misdiagnosed and the cause of death
follow the classical model of epidemiological transition.5,18
A N
is wrongly attributed, contributing to under-reporting.16 The lack of
accurate data on CDs has led to an underestimation of the true However, in the mid-1990s, epidemiological transition was
M U

contribution of CDs to the disease burden.14,16,17 interrupted and reversed by the HIV and AIDS and concomitant TB
epidemics (Figure 1). As a result of these epidemics, South Africa
4 ED

has seen a counter-transition.7 HIV prevalence rates, indicated by

Epidemiological transition the infection rate in pregnant women, climbed over the following
Epidemiological transition occurs when there is a change in decade from 7.6% in 1994 to 30.2% in 2005.22 The U5MR rose
O

population health statistics and pattern of disease in a region or dramatically in response, peaking at 80.8 per 1 000 live births
country, resulting from changes in socio-economic, educational, in 2003 and the IMR at 53.2 per 1 000 live births in 2002.20
G

infrastructural and healthcare development.14 The epidemiological In 2005, longevity dropped to its lowest level since the 1960s at
R

Figure 1: Epidemiological transition in South Africa over the past 25 years, as demonstrated by data for childhood mortality,20 longevity,21
BA

and the HIV epidemic22

O

90 35
EM

80
30
Total number of deaths per 1 000 live births

70
Percentage of HIV infected women

25
60

20
50

40 15

30
10
20
5
10

0 0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year

MDG set U5MR IMR Longevity HIV prevalence (% pregnant women infected) ARV roll-out

Source: Malherbe, 2015.5

a Birth defects are defined as abnormalities of structure or function, including

disorders of the metabolism, which are present from birth.15
b Personal communication: B. Modell, 19 January 2016.

S A H R 20 1 6 1 39
51.56 years.21 The combination of a newly emerged communicable
disease (HIV and AIDS) and the re-emergence of an old infection
(TB) with an increasing burden of NCDs has resulted in an additional
stage being added to Omran’s original concept, called the ‘age of
emergent and re-emergent infections’.19,23,24
these CDs became proportionately greater in overall neonatal,
infant and child mortality as deaths from communicable diseases
reduced. As industrialised countries completed the second stage
of epidemiological transition, CDs emerged and have remained a
leading cause of child death in these nations today.29,30

Following the roll-out of comprehensive HIV and AIDS interventions
in 2004, the HIV and AIDS prevalence rate plateaued at around
30% in the early part of the current decade (see Figure 1).22 The
rapid reductions achieved in infant and child mortality between
2005 and 2011 have resulted in both the IMR and U5MR being
lower today than prior to the HIV and AIDS epidemic, at 28
per1 000 and 39 per1 000 live births respectively.8 South Africa
is now back in positive epidemiological transition. However, both
the IMR and U5MR have stagnated since 2011, and the neonatal
CDs attained public health significance in these industrialised
nations in the early 1960s when they moved into the third stage
of epidemiological transition.14,18 This was demonstrated in a
comparative study undertaken by McKeown30 of death rates in
England and Wales for 1901 and 1971, shown in Table 1. An
overall reduction of 68% was seen in the death rate for all diseases
over the 70-year study, including a 90% reduction in infectious
diseases. Death rates for NCDs decreased by 45% overall, but the
number of CD deaths remained the same.30 This was due to the

PM
mortality rate (NMR) has stagnated since 2009 despite the continued mainly genetic cause of CDs, which cannot be changed, resulting in
implementation of HIV and AIDS interventions.8 CDs contributing a greater proportion of deaths as overall mortality
decreased.
A significant contributor to ongoing high mortality in children are

16 6
deaths from unnatural causes, causing just over a third (18.5%) of
Table 1: Standardised death rates (per million of population) for
deaths in children aged 1–4 years in 2014.25 Natural deaths in England and Wales in 1901 and 1971

20 IL
the same age-group were attributed to intestinal infectious diseases
(17.2%), influenza and pneumonia (9.1%) and malnutrition (8.6%), %
1901 1971 Reduction
with TB and HIV ranked fourth and fifth.25
Some neonatal deaths,
Y T Infectious Diseases
which contribute the bulk of under-five deaths, are preventable
Airborne Diseases
A N
through addressing modifiable factors that are intertwined with
Respiratory infection 2 747 603 78
social determinants of health. CoMMiC reports that modifiable
Pulmonary TB 1 268 13 99
M U

factors are 30% home-based, including seeking medical attention Whooping cough 312 1 100
earlier, failure to recognise severity of illness, and inadequate Measles 278 0 100
4 ED

nutrition.26 The majority of health system-modifiable factors (80%) Scarlet fever and Diphtheria 407 0 100
relate to health personnel.26 Smallpox 10 0 100
Upper respiratory tract infections 100 2 98
The total contribution of CDs to stillbirthsc
in South Africa is unknown.
O

Sub-total 5 122 619 88

Data from the Perinatal Problem Identification Programme (PPIP)
Food and Water-borne Diseases
2012/13 attributed 2.5% of stillbirths in non-tertiary settings and
G

Cholera, Diarrhoea and 1 232 33 97

7.7% of stillbirths in tertiary settings to CDs.27,28 These data are likely Dysentery
to be an underestimate, especially in primary health care settings Non-respiratory TB 544 2 100
R

due to restricted diagnostics and unavailability of screening. The Typhus, Typhoid 155 0 100
BA

Lancet Ending Preventable Stillbirths Series Study Group estimates a Sub-total 1 931 35 98
N

global median of 7.4% stillbirths attributed to CDs based on reliable Other Infections
O

data from 18 countries.28 Sub-total 1 415 60 96

90% Overall Reduction for Infectious Diseases
EM

However, the role and contribution of CDs to the ongoing high level Non-communicable diseases
of mortality is not visible in the available data. Birth defects 126 127 0
Perinatal problems 1 249 192 85
Heart disease 1 186 1 688 - 42
Congenital disorders and epidemiological Rheumatic heart disease 487 88 92
transition Cancer 844 1 169 - 39
Other diseases 4 598 1 406 69
During the process of epidemiological transition, CD deaths remained
Sub-total 8 490 4 670 45
invisible, essentially ‘buried’ among deaths due to communicable
Overall reduction for non-communicable diseases 45%
diseases, and only emerging as these diseases were adequately
Total 16 958 5 384 68
controlled.16 As industrialised countries moved through the second
68% Overall Reduction in Death Rate of All Diseases
stage of epidemiological transition, there was a slight decrease in
CD birth prevalence and deaths due to fetal environmental factors, Source: McKeown, 1976.30
essentially teratogens.14 This was because of improved care and
prevention strategies for these disorders. However, since 85–90% A further example of the increasing proportion of child deaths
of CDs have a genetic or partially genetic aetiology, their birth from CDs is shown in Figure 2, which shows the percentage of
prevalence and resulting mortality remained high.14 Deaths from deaths due to congenital anomalies using the World Bank Country
Classificationsd according to Gross National Income (GNI) per
c In South Africa, a stillbirth is defined as a fetus of at least 26 weeks’ capita.4 As GNI increases, the percentage of child deaths from CDs
gestation and born with no signs of life after complete birth. This definition
varies between countries, making data compilation and comparison
complex. d South Africa is classified as an upper middle-income country.

1 40 S A H R 20 1 6
 Congenital disorders

(congenital anomalies only) increases, contributing a greater portion Congenital disorders in South Africa
in the higher GNI classification. An increase can be seen in all
groups between 2010 and 2013. Today, CDs account for 28% of Prior to the HIV and AIDS epidemic in the early 1990s, CDs began
child deaths in high-income countries and they are the leading cause to emerge as a healthcare issue in South Africa due to falling child
of death in infants and children younger than five years. mortality and increasing longevity. A national task force of experts
was established in collaboration with the WHO to investigate the
Figure 2: Percentage of under-five deaths resulting from congenital need for, and implementation of, services for the care and prevention
anomalies using World Bank Country Classifications of CDs. Following wide consultation, the National Policy Guidelines
for the Management and Prevention of Genetic Disorders, Birth
30
28 Defects and Disabilities were published in 2001.31
26
25 The 2001 National Policy Guidelines31 outlined goals, objectives,
strategies and delivery of clinical and laboratory services
20 appropriate for the care and prevention of CDs in South Africa.
Priority disorders were designated, which included Down syndrome,

PM
15 14 neural tube defects, fetal alcohol syndrome (FAS), albinism, cleft-lip
and palate, and club feet. The financial cost to society and to the
10 9 State resulting from burden of disease was estimated at several billion
6 Rand annually at the time. Personnel requirements to implement

16 6
5 5
5 3 these services were specified in the 2001 Guidelines, based on UK
criteria, and were later revised using more relevant criteria for South

20 IL
0 Low Income Lower middle Income Upper middle Income High Income Africa in the Strategic Framework for the Modernisation of Tertiary
2010 2013
Hospital Services.32

Source: WHO, 2015.4

Y T In 2004, the National Guidelines for the Care and Prevention of the
A N
Most Common Genetic Disorders, Birth Defects and Disabilities33
Figure 3 plots global IMRs for countries against the percentage were published, targeting Primary Health Care Providers (PHCPs),
M U

of infant deaths resulting from CDs, demonstrating that as infant and describing common CDs and strategies for their care and
mortality drops, the contribution (proportion) of CDs relative to infant prevention.
4 ED

mortality increases. This is particularly noticeable as the IMR drops After this surge of policy generation, the HIV and AIDS and TB
to between 40 and 50 per 1 000 live births.
epidemics obscured the issue of CDs once more.5 As a result, the
It is clear from the literature and mounting evidence that the growing commitment and momentum towards CDs as a healthcare
O

contribution of CDs to child mortality increases as countries issue was redirected to these competing healthcare priorities along
develop, and that MLICs, including South Africa, are following this with the associated resources.
G

epidemiological trend.5,14 The proportion of deaths resulting from

CDs in South Africa will rise as overall infant and child mortality
R

decreases.
BA

Figure 3: Relationship between infant mortality and percentage of infants dying from CDs based on global country figures
O

80
EM

70

60
% of infant deaths due to CDs

50

40

30

20

10

0
0 10 20 30 40 50 60 70 80 90 100 110 120 130

Infant deaths /1 000 live births (IMR)

Source: Modell, 2015.e

e Personal communication: B. Modell, 20 August 2015.

S A H R 20 1 6 141
Data modelling of CDs
There is a lack of birth prevalence data for CDs in South Africa,
as is the case for many MLICs.14,16 The overriding factors for this
are the limited facilities available and the lack of skilled clinicians
to identify and diagnose CDs.14,16,17 This is exacerbated by the
incompleteness of vital registration data and inadequacies of other
mortality and morbidity data sources, especially for infants and
children.3,8 To fill this gap, country-specific prevalence estimates are
generated using a combination of local data for specific indicators
combined with known prevalence rates from more well-resourced
countries.14,16 These modelled data14 of genetic causes and an
estimate of teratogenic causesf indicate that a minimum of 6.8%
of South African births are affected by CDs.g Of these, 80.5% are
caused by genetic factors and 19.5% by teratogens. This translates
to one in every 15 live births in South Africa being affected by a
CD.5 The proportion of teratogenic CDs is more than the 10–15%
expected in MLICs and is one of the highest documented prevalence
rates in the world due to the high prevalence of FAS, which is
16 6
entirely preventable.14
20 IL
Reliable surveillance data provide a vital information tool for policy-
makers to plan, implement, monitor and evaluate policy accordingly
Y T
to prevent adverse health conditions and improve public health.
With 6.8% of live births affected by a CD in South Africa, a total
A N
of 83 118 live births would have been affected in 2012, based
on vital registration data.34 However, only 2 174 cases were
M U
reported via the Birth Defects Collection Tool (BDCT) administered
by the Department of Health in 2012.35 With only 2.6% of the
4 ED
expected CDs being reported, this indicates under-reporting by
97.4% for 2012. When taking into account that only 26% of CDs
are diagnosable during the early neonatal period,36 under-reporting
O
of 90% is still unacceptably high. This is hampering the recognition
of CDs as a key contributor to the burden of disease.
G
The lack of empirical data as evidence for CDs in South Africa
prevents policy-makers from accurately assessing the contribution of
R
CDs to the disease burden.37,38 Figure 4 outlines the cycle caused
BA
as a result of this underestimation. Underestimation leads to a lack of
prioritisation of CDs, and to CD prevention and care services being
O
neglected. The lack of CD diagnosis due to poor services leads to
EM
under-reporting and poor data. Under-reporting contributes to an
underestimate of CD deaths and disability. CDs are not considered
to be a healthcare priority and the cycle resumes. Modelling is used
as a tool to highlight the gap between the expected health need and
current services available.
f Personal communication: A Christianson, 15 August 2013.
g These modelled estimates are based on national figures published in
Appendix B of the 2006 March of Dimes Report.14 These figures are
currently under revision.
1 42
Figure 4: The cycle caused by the underestimation of CDs
Underestimate
Lack of
of CD burden
prioritisation
Under- Neglected
reporting services
Inadequate Non-diagnosis
data & misdiagnosis
PM
Emerging data
Despite the lack of evidence-based data, available mortality data
are beginning to reveal the hidden disease burden of CDs. Under-
reporting of births and deaths leading to incomplete vital registration
data, especially for children, makes it an unsuitable source for
monitoring and evaluating child mortality. District Health Information
System (DHIS) data, which record deaths in public sector hospitals,
also tend to be inadequate, as outlined by McKerrow in 2010.3 The
PPIP is the most detailed source of information on factors contributing
to perinatal death and hence child mortality.3 The 2012/13 PPIP
data,27 representing 75.6% of all DHIS-recorded births in South
Africa, indicated that congenital abnormalitiesh have overtaken
infection as the third leading cause of death during the first week of
life in neonates after deaths from immaturity and hypoxia. Congenital
abnormalities accounted for 11.24% and 8.20% of early neonatal
deaths in infants weighing >1 000g and >500g compared with
8.84% and 7.44% of deaths respectively from infection.27 This shift,
combined with the stagnation of neonatal mortality since 2009,
and of infant and under-five mortality since 2011,8 speaks to the
epidemiological transition in South Africa.
This trend continued in the Western Cape Province (WC) in 2014,
with congenital abnormalities ranked as the third cause of early
neonatal death in infants weighing >500g and >1 000g.i At
10%, deaths in the under-fives from congenital abnormalities
in the province are double that recorded in other provinces and
nationally.4,39 The WC neonatal mortality rate is also half the
national rate of 11 per1 000 live births,40 making the province a
good example of what will occur in other provinces in the coming
decade as healthcare services improve and CDs are revealed.
Following on from the PPIP programme is the Child Healthcare
Problem Identification Program (CHILD PIP), which audits child
mortality from 28 days to 18 years. In 2005, deaths from congenital
abnormalitiesj were mentioned in only 0.3% of cases from the 15
hospitals across six provinces participating in CHILD PIP.41 CHILD
PIP acknowledged this as an underestimate due to the lack of access
h No formal definition is given by the PPIP programme for congenital
abnormalities; however, it is understood to refer to obvious structural
abnormalities only.
i Personal communication: N. Rhoda, 25 February 2016.
j Although no formal definition of congenital abnormalities is given, the
diagnoses made include single gene, chromosomal and multifactorial
disorders and post-conception disorders.
S A H R 20 1 6

to post-mortems and lack of paediatricians to assess (diagnose) the
cases.41 Between 2005 and 2014, mortality data were submitted
to CHILD PIP by 198 hospitals across 49 districts. Of the 44 854
deaths recorded,k 2.2% cited congenital abnormalities as either
the main cause or underlying cause of death. Although higher than
the 2005 figure, this too was reported as an underestimate due
to the lack of identification of CDs by health workers conducting
the audit, and limitations in the cause-of-death categorisation in the
current CHILD PIP programme, which is now being rectified by the
development of a new data form.l
As the U5MR has decreased, the proportion of deaths in the
perinatal period has risen.42 In South Africa, just over 40% of deaths
among under-fives occur during the neonatal period.43 Globally, the
contribution of neonatal deaths to under-five mortality is projected
to rise from 45% to 52% by 2030.6 The contribution of CDs to
these deaths should be recognised and addressed if child mortality,
particularly neonatal mortality, is to be reduced further.
16 6
Since available data sets reported only include sub-groups of CDs,
the true contribution of CDs to the burden of disease is likely to be
20 IL
higher than estimated.
Y T
Congenital disorders and disability
A N
CDs are not merely a cause of child mortality but also of morbidity.
For every child who dies as a result of a CD, many survive serious CDs
M U
and sustain lifelong mental, physical, auditory or visual disability.14
The economic cost as a result of this morbidity is considerable. In
4 ED
2012, 116 000 beneficiaries – caregivers of children older than
one year with severe disabilities or disabling chronic illnesses
requiring permanent home-based care, including those affected by
O
CDs, acquired conditions and injuries – received means-tested care
dependency grants of R1 200 per month.44 This totals R1.6 billion
G
annually, excluding inflation, adult disability grants and other costs.
R
In lower-resourced countries, the majority of children born with
serious CDs (3.3 million annually) die due to a lack of appropriate
BA
N
care, and a further 3.2 million who survive are disabled for life.14
Early intervention and relevant care can save the life of the child from
O
a life-threatening serious CD, and cure or ameliorate the degree of
EM
long-term disability. Many of these interventions, including one-off
surgeries for congenital malformations, are relatively inexpensive
compared with the cost of ongoing chronic care for untreated CDs.
Many community-based preventative measures are both inexpensive
and ‘low-tech’.14 Where appropriate services for the care and
prevention of CDs are available, 30% of CD deaths in the first year
cannot be prevented. However, 40% of the cases can be cured,
mainly by surgery, and 30% survive with disability.45,46 In South
Africa, specialised surgery capacity is limited and unavailable in
some provinces, preventing widespread access to such intervention.
Strengthening surgical capacity in all areas is required, as both
general and specialised surgery could help to alleviate this shortfall.
Interventions must incorporate both prevention and care. As outlined
in the 2006 March of Dimes Report,14 there are three types of
prevention: primary prevention, in which CDs are avoided prior to
conception through basic reproductive health approaches, including
folic acid supplementation; secondary prevention, which aims to
k 87.6% of these deaths occurred in children aged five and younger. Personal
Communication: M. Patrick, 17 March 2016.
l Personal Communication: M. Patrick, 17 March 2016.
S A H R 20 1 6
Congenital disorders
reduce the number of babies born with CDs through screening,
prenatal diagnosis, avoidance of potentially teratogenic substances
during pregnancy and the option of termination of pregnancy;
and tertiary prevention, being the early detection, diagnosis, cure
and mitigation of CDs after the child is born, including surgical
interventions and palliative care. Tertiary prevention is equivalent
to care that constitutes diagnosis, treatment, counselling and
psychosocial support of those affected by CDs.
In lower-resourced countries, prevention tends to be overemphasised
to the detriment of care due to the misplaced myth that care
is expensive.14,16 This may cause those affected by CDs and
consequently living with a disability to be marginalised, which
undermines their human dignity and human rights. Christianson’s
mantra, “Care is an absolute. Prevention is the ideal” was coined in
PM
2000.47 This emphasises both care and prevention (at all levels) as
integral components of medical genetic services, and one cannot be
neglected at the expense of the other.
In many MLICs, comprehensive services for the care and prevention
of CDs are not implemented. In addition to the immense loss of
life and suffering of those affected, there is a significant economic
cost. Implementation of key interventions can reduce this cost and
save lives, as outlined in Table 2. Congenital malformationsm are the
most common type of CD and also the most treatable. Almost half
of the congenital malformations such as cleft lip and/or palate and
congenital heart defects can be cured through paediatric surgery, but
without this intervention, the result is death or permanent disability.
To date, the folate fortification of staple food (maize meal and
bread) to reduce neural tube defects (NTDs) – an example of
primary prevention – is the only preventative intervention being
comprehensively implemented in South Africa. Since fortification
began in 2003, a 30.5% reduction in NTDs has been seen.48 In
addition to the obvious reductions in mortality and morbidity, there
is also a considerable cost benefit. According to Sayed et al.,48 with
the average estimated cost of treatment being R100 000 per NTD
case for the first three years of life, averting 406 cases every year
would render a minimum annual saving of R40.6m, offset by the
minimal cost of R1.4m per year for the 2% fortification.
If all other interventions were implemented as outlined in Table 2,
the burden of genetically determined CDs could be reduced by
almost 70% and would generate sizable economic benefits due
to the gain of almost three years of healthy life per head of the
population.14,16,46 However, the current static child mortality rates
in South Africa are an indication that current interventions being
implemented fall far below this level of potential.
m A malformation due to multifactorial inheritance.
1 43
Table 2: Summary of estimated potential effects of interventions for preventing genetically determined CDs

Estimated
Maximum average increase
Birth prevalence postnatal lives in longevity
per 1 000 live saved (per 1 000 Maximum per head of
Type of CD births Intervention live births) reduction (%) population (years)
Congenital 36.5 Paediatric surgery 17.70 48.5 1.24
malformationsn (Tertiary Prevention/care)
Folic Acid Supplement 11.50 31.5 0.81
(Primary Prevention)
Prenatal diagnosis 3.50 9.6 0.25
(Secondary Prevention)
Total congenital malformations 32.70 89.6 2.30
Chromosomal 3.8 Family planning 0.75 19.7 0.05
disorderso (Primary Prevention)
Prenatal diagnosis 0.5 13.2 0.04
(Secondary Prevention)

PM
Total Chromosomal disorders 1.25 32.9 0.09
Genetic risk 2.4 Routine antenatal & neonatal care 2.40 100 0.17
factorsp (Tertiary Prevention/care)
Inherited 11.5 Genetic counselling 1.73 15 0.12
disorders (Primary Prevention)

16 6
(severe, early Neonatal screening 0.7 6.1 0.05
onset)q (Tertiary Prevention/care)

20 IL
Prenatal diagnosis 1.15 10 0.08
(Secondary Prevention)
Total inherited disorders
Y T 3.60 31.1 0.25
Total 54.2   39.90 73.7 2.80
A N
Source: Christianson and Modell, 2004;16 Christianson et al., 2006.14
M U

Medical genetic services Medical genetic services in South Africa

4 ED

Interventions to prevent, detect and care for CDs are collectively Since the early 1970s, the mainstay of medical genetic services
known as medical genetic services. The aim of genetic services in South Africa has been the work of human genetics departments
O

is two-fold: to reduce suffering by offering care to those affected, at major academic centres and medical schools in urban areas,
and to improve health by preventing CDs.14 These services are starting in Johannesburg and Cape Town.51 Access to these services
G

key in reducing the contribution of CDs to the burden of disease. was limited mainly to urban areas, with some outreach into rural
By providing the ‘best possible patient care’ in the prevailing areas being conducted by the academic centres.
R

circumstances for those affected by or at risk of CDs, medical genetic

Services improved following the publication of the Policy Guidelines
services ensure that people with CDs, or those at reproductive risk
BA

for the Management and Prevention of Genetic Disorders, Birth

of having children with CDs, ‘can live and reproduce as normally
Defects and Disabilities in 2001.31 The number of posts supported
O

as possible’.17,49,50
by the National Health Laboratory Service increased in response
EM

In many lower-resourced countries, the development of medical
genetic services has been driven by epidemiological transition.
Governments begin to see CDs as an important public health issue
when the IMR falls below 40–50 per 1 000 live births and only limited
reductions in child mortality can be achieved by addressing other
health issues.12,16,17,50 With an IMR of 28 per1 000 live births in
2014,8 South Africa is well past this threshold when medical genetic
services should be comprehensively implemented. CDs should be
prioritised alongside other NCDs and ongoing interventions against
communicable diseases in order to further reduce child mortality
and to provide better care for those who are disabled as a result of
CDs.5 When the IMR reaches 20 per 1 000 live births (the MDG
4 target for South Africa), CDs will emerge as a leading cause of
death in infants.12
n Obvious structural abnormalities/malformations due to multifactorial
inheritance.
o A structural or numerical abnormality of the chromosomes.
p G6PD deficiency and Rhesus haemolytic disease of the newborn.14
q Single gene disorders, including autosomal-dominant, autosomal-recessive,
sex-linked inheritance and mitochondrial disorders.
to the policy.51 However, implementation continued through the
established framework of academic centres, rather than through the
integration of services into primary health care and the extension of
clinical genetic services beyond urban areas, as was recommended
in the 2001 Guidelines.
As services for HIV and AIDS developed over the past decade
to combat the epidemic, tertiary medical genetic services were
neglected.5 By severely limiting the implementation of the 2001
policy guidelines, the lack of investment in medical genetic services
has resulted in insufficient trained personnel, inadequate capacity
at all levels, and severely compromised laboratory services.5,51
In 2013, South Africa was reported as the only country of eight
emerging economies evaluated where positive development in
improving medical genetic service structures had ceased, and
indeed retrogressed.37

144 S A H R 20 1 6
 Congenital disorders

The framework of medical genetic services across the continuum of

health care in South Africa is shown in Table 3. This demonstrates
how interventions to prevent and care for CDs may be integrated
into maternal and child care (e.g. comprehensive antenatal care)
and highlights current gaps in implementation.

Table 3: Overview of medical genetic services across health care in South Africa
(X=service in place in SA; S= service required in SA)

1° Health Care 2° Health Care 3° Health Care

Type of Clinic Community District Regional Provincial Academic
Prevention/ Health Hospital Hospital Tertiary Hospital
Care Intervention Centre Hospital
Family planning X X X Xr Xr Xr
Primary Prevention:
Pre-conception care ensuring
individuals born free of CDs and
not damaged in early embryonic period

Optimising women’s diet:s

• Folic acid supplementation (5mg
daily)t

PM
X X X X X X
• Iron (200mg daily)
• Alcohol/Smoking (education)
Pre-conception screening Su Su Su X X X
Maternal infections:v

16 6
Detection and treatment X X X X X X
(primarily syphilis)

20 IL
Treating health conditions:
• Diabetes mellitus X X X X X
• Epilepsy Y T X X X X X
• DVT or cardiac conditions (Wafarin) X X X X
A N
Genetic counselling
Sw Sw X X X
(if required)
M U

Screening:
Secondary Prevention:
Reducing the number of children
born with CDs

Ultrasound S S X X X
Advanced maternal age screening S S S S X X
4 ED

Pre-natal diagnosis (amniocentesis,

chorionic villus sampling, X X X
cordocentesis)
Genetic counselling and psychosocial
O

Sw Sw Sw X X
support
Options:
G

• Therapeutic S X X X X
• Termination of pregnancy
R

Early diagnosis:
Tertiary Prevention/Care:
Early detection, cure,
amelioration and care once
a child is born with a CD

• Examination of every newborn by

BA

S S X X X
N

trained observer (top to toe)

• Biochemical screening
S S S S S
O

(Hypothyroidism)
Care interventions:
EM

• Medical/therapeutic X X X X X
• Surgery Xx Xx Xx Xx
• Habilitationy X X X X
• Palliative care X X X X
• Genetic counselling and psychosocial
Sw Sw Xw X X
support

r Family planning is associated with specialist services in these secondary and
tertiary hospitals although it is not listed as an official service.
s Mandatory iodisation of table salt (40–60ppm) was introduced in South
Africa in 1995 to prevent iodine-deficiency disorders.
t Mealie meal and wheat flour have been fortified with folic acid in South
Africa since 2003.
u Pre-conception screening at the level of community health centres and district
hospitals should include screening for advanced maternal age, taking a
family history and relevant referral.
v The rubella (German measles) vaccine is available only in the private
sector in South Africa.
w Genetic counselling for common disorders such as Down syndrome
and spina bifida.
x This may be limited to general surgery in some provinces where
specialised surgery (e.g. cardiac, cranofacial, etc.) is currently
unavailable. Some CDs may require only general surgery (e.g.
Meckel’s diverticulum), whilst others require more specialised surgical
intervention (e.g. cleft lip and/or palate).
y For example, occupational, speech and physiotherapies.

S A H R 20 1 6 1 45
Table 4: A comparison of medical genetics services capacity in 2001 and 2015

Recommended 2003 32 200131 2015

Ratio Ratio Ratio
Category Number (Pop=46 13m)52 Number2 (Pop=44 82m)52 Number (Pop=54 96m)34
Medical geneticists 20 1 per 2m 4 1 per 11.2m 12z 1 per 4.9m
Genetic counsellors 80 1 per 580 000 <20 1 per 2.2m 8aa 1 per 8.4m
Medical scientists/technologists 100 1 per 450 000 50 1 per 900 000 26ab 1 per 2.1m

Medical genetic services are now at a lower base than in 2001, trained labour ward nurses, together with midwives, obstetricians
as outlined in Table 4. The 2003 recommended human capacity and paediatricians, are the frontline healthcare professionals
requirements32 to be trained and in-post by 2010 remain unfulfilled. encountering CDs in the continuum of care.
Today there are 12 medical geneticists, compared with four in 2001
and the 20 recommended by 2010.
Legislative and regulatory framework
Of the 14 genetic counsellors practising today, only eight practise in

PM
The World Health Assembly (WHA) call in 201013 to prioritise CDs
State services, compared with 20 in 2001 and the 80 recommended.
as a healthcare issue through Resolution 63.17 was fundamental
Since existing posts were frozen and no new posts were created
for medical genetic services worldwide. WHA 63.1713 recognised
to accommodate newly qualifying genetic counsellors, many have
the importance of CDs as a cause of stillbirths and neonatal deaths,
been forced to leave the service or the country, or to work in

16 6
and their contribution to under-five mortality, and it is recognised
private practice. No provision was made for genetic counsellors
that for MDG 4 to be achieved, “accelerated progress in reducing

20 IL
in the Occupational Specific Dispensation (OSD), a government
neonatal mortality including the prevention and management
initiative aimed at attracting and retaining skilled employees through
of birth defects” was required. Although South Africa is yet to
improved remuneration. Budget cuts have also reduced diagnostic
Y T respond to WHA63.17,13 a number of other international treaties
laboratory personnel numbers to unsustainable levels and equipment
and protocols of relevance to CDs have led to the development of
A N
has not been upgraded or maintained.5,51 Many practitioners have
equivalent national legislation. Table 5 lists international treaties
left, retired or emigrated due to a high service workload, limited
M U

and conventions that included content of relevance to CDs, many of

opportunity to undertake research, and the inability to perform their
which are foundational for national legislation.
tasks satisfactorily due to inadequate medical genetic laboratory
4 ED

services. To reverse this, adequate staffing and modern equipment
are required along with the necessary training to ensure the
translation of this technology is appropriate to the country’s needs
and circumstances.
O
South Africa is well placed to respond to WHA 63.1713 since a
comprehensive, national legislative framework already exists for the
provision of medical genetic services for the care and prevention

of CDs. Relevant national legislation is outlined in Table 5.

The lack of access to health workers is possibly the greatest constraint The Constitution of the Republic of South Africa53 provides for
G

across the health system in terms of South Africa achieving health fundamental rights to life, equality, dignity, freedom and security
goals,26 including the MDGs. Rectifying the shortfalls in specialist of the person, and education. The socio-economic right for all to
R

healthcare professionals in the medical genetic services sector is access healthcare services, including reproductive health care, is
critical. provided subject to the concept of progressive realisation.ad Every
BA

child – including those with CDs and disabled as a result – has

The Medical Genetics Education Programme (MGEP) is a distance- the right to ‘basic nutrition, shelter, basic healthcare services and
O

education postgraduate training course for nurses and rural medical social services’ (section 28, 1c), but these rights are not subject to
EM

officers. This equips in-post healthcare professionals with basic progressive realisation.
knowledge and skills to identify and diagnose common disorders,
counsel patients and to refer those affected by CDs appropriately, The provision of medical genetic services is specified in the National
providing an additional supporting capacity for medical geneticists Health Act (NHA) 61 of 2003 through a clear directive in Chapter
and genetic counsellors. Between 2004 and 2013, over 1 000 3, under “Main functions of the National Department” in section 21
healthcare providers, mainly labour ward nurses, were trained (2) (b) (vii) as follows:
through the MGEP course held countrywide.ac Today, fewer than
The Director-General must, in accordance with national health
100 remain in services for the care and prevention of CDs. The
policy, issue and promote adherence to, and norms and
lack of continued government support for this training, including
standards on health matters including genetic services.54
financial, trainee contact and uptake of these skills by facility
management, has forced trainees to discontinue their genetic nursing Also of relevance to CDs in the NHA are epidemiological
role and move to other fields. This has had a direct negative impact surveillance, management, prevention and control of NCDs, and
on the national surveillance of CDs via the BDCT, as many MGEP- the health needs of vulnerable groups including children and the
disabled.54 Other key national legislative instruments of relevance
z No medical geneticists are employed by the State in Gauteng. Personal
communication: A. Krause, 11 February 2016. to CDs are outlined in Table 6.
aa Of these eight genetic counsellors, three are employed full-time directly
by the State, three full-time by tertiary institutions, and four are employed
part-time, plus six in private practice. Personal communication: T. Wessels,
25 February 2016.
ab NHLS academic medical scientists only. Personal communication: H.
Soodyall, 27 July 2015.
ad Defined as recognising that economic and social rights can only be
ac Personal communication: D. Tshikedi, 2 October 2013. achieved over time, subject to the availability of resources.

146 S A H R 20 1 6
 Congenital disorders

Table 5: International treaties, conventions, declarations and protocols of relevance to medical genetic services

Document Article/ Rule/Overview

World Programme of Action Concerning the Disabled (1982) Prevention, rehabilitation and equalisation of opportunities
Standard Rules on the Equalization of Opportunities for Persons with Disabilities 1 Awareness-raising
(1993) 2 Medical care
3 Rehabilitation
4 Support service
5 Accessibility
United Nations Convention on the Rights of the Child (signed 1993 and ratified 2 No discrimination
1995) 6 Right to life
23 Disabled child
24 Healthcare
26 Social Security
International Covenant on Economic, Social and Cultural Rights (1966) (signed 12 Physical and Mental Health
1994 and ratified 2015)

PM
United Nations Millennium Declaration (signed 2000)1 Goal 4: Reducing under-five mortality by two-thirds by 2015
United Nations Convention on the Rights of Persons with Disabilities (signed and 5 Equality/non-discrimination
ratified 2007) 6 Women with disabilities
7 Children with disabilities

16 6
8 Awareness-raising
9 Accessibility

20 IL
10 Right to life
19 Living independently

Y T 20 Personal mobility
23 Respect for home and family
A N
25 Health
26 Habilitation and Rehabilitation
M U

African Charter on the Rights and Welfare of the Child (‘Children’s Charter’) (signed 5 Right to life
1997 and ratified 2000) 13 Protection of physically/mentally disabled to ensure dignity
14 Physical/ mental health and healthcare
4 ED

The New Partnership for Africa’s Development (2001) Healthcare provision and delivery
African Youth Charter (signed and ratified 2009) 16 Health
23 Girls and young women
O

24 Mentally/physically challenged youth

World Health Assembly Resolution 63.17 (signed and ratified 2010)11 Urges member states to address CDs as a healthcare issue
G

through specific actions

R
BA

N
O
EM

S A H R 20 1 6 1 47
Table 6: Key national legislation of relevance to medical genetic services

Title Overview Sections relevant to CD

Constitution of the Republic of South
Africa (108 of 1996)53
Health Professions Act (56 of 1974)
National Health Act (61 of 2003)54
Chapter 2 – Bill of Rights
Regulates the health professions
through the Health Professions
Council of South Africa
Framework for a structured and
quality uniform health system
• 9 Equality
• 10 Human dignity
• 11 Life
• 27(1)(a) Access to healthcare services, including reproductive
healthcare
• 28 (1)(c) Every child has the right to basic healthcare services
• 4(3)(a) Free healthcare to pregnant/breastfeeding women, children
under six not members/beneficiaries of medical aid schemes
(c) free termination of pregnancy
• 21(2)(b)(vii) Genetic services
• 21(2)(k) and 25(2)(w) Management, prevention and control of
communicable and non-communicable diseases

PM
• 23(1)(a)(ix) and 27(1)(a)(ix) Epidemiological surveillance and
monitoring of national and provincial trends
• 21, 23, 25, 27 Implementation of national/provincial policy and
compliance 

16 6
• 39(2)(a)&(d), 70(2)(d) Health needs of vulnerable groups including
children and people with disabilities

20 IL
• 48 Development and provision of human resources in national
health system
• 52 Regulations relating to human resources

Choice on Termination of Pregnancy

Y T
Law related to abortion
• 70 Identification of health research priorities
• 2(b)(ii) and minors 5(5)(a)(ii) Termination of pregnancy (ToP)
A N
Act (92 of 1996) between 13–20 weeks inclusive if substantial risk that the fetus
would suffer from a severe physical or mental abnormality
M U

• 2(c)(ii) and minors 5(5)(b)(ii)ToP after the 20th week if the continued

pregnancy would result in a severe malformation of the fetus
The National Health Laboratories Laboratory services for the public • 4 and 5(1) Cost-effective and efficient health laboratory services
4 ED

Service Act (37 of 2000) health sector including training

Mental Health Care Act (17 of 2002) A legal framework for mental health
in South Africa with an emphasis on
human rights
O

The Nursing Act (33 of 2005) Regulates the nursing profession

through the South African Nursing
Council
G

Children’s Act (38 of 2005) Protection of children and their rights • 11 Children with disability or chronic illness
• 156 (1)(G) Care and protection
R

Social Assistance Act (13 of 2004) Rendering of social assistance • 7 Care dependency grants
BA

• 9 Disability grants
N
O

National policy
EM

The National Policy Guidelines for the Management and Prevention
of Genetic Disorders, Birth Defects and Disabilities31 and the
National Guidelines for the Care and Prevention of the Most
Common Genetic Disorders, Birth Defects and Disabilities33 are the
only two policy documents that focus solely on CDs. In 2014, a
process of revision of the 2001 Policy Guidelines was initiated and
is due for completion in 2016.
A new edition of the Guidelines for Maternity Care in South
Africa was published in 2015,55 replacing the 2007 edition. This
contains relevant content on the identification of mothers at high
risk of having babies with a CD, as well as essential information for
primary prevention of CDs and referral to genetic services.
Implementation of the 2001 Policy Guidelines,31 and therefore of
the underpinning legislation, has been fragmented, especially in the
past decade. The lack of recognition for the contribution of CDs to
the disease burden has resulted in the exclusion of comprehensive
interventions from national strategies. The lack of integration of key
interventions is noticeable in the National Department of Health’s
Strategic Plan for Maternal, Newborn, Child and Women’s Health
and Nutrition in South Africa 2012–2016.56 While CDs are
mentioned as a cause of neonatal death and as contributing to
15–20% of children affected by long-term/chronic health conditions
“not receiving the care they require”, no responding interventions
are outlined.56 In other documents, individual CDs or categories
such as mental health disorders are recognised in the National
Department of Health’s Strategic Plan 2014/15–2018/19,57 but
with no acknowledgement of the genetic predisposition of such
conditions.
CDs are the first NCDs experienced by people – infants and
children.12 However, they are not contextualised as such in national
strategies and interventions to address the growing NCD disease
burden. In the 2nd Triennial Report of the Committee on Mortality
and Morbidity in Children (CoMMiC),26 CDs are included under
long-term health conditions in children together with acquired
childhood conditions resulting from infections. This precludes the use
of the term ‘NCD’, effectively burying CDs beneath communicable
disease once again.

148 S A H R 20 1 6
 Congenital disorders

Conclusions and recommendations
CDs are currently not recognised as a healthcare issue in South
Africa. Thus, their contribution to the disease burden is currently
underestimated, and the impact of interventions for their prevention
and care is not considered. Instead, those born with and dying from
CDs are largely overlooked and those surviving with disability are
largely ignored, as care is not being provided to this most vulnerable
group. Despite the lack of data due to poor national surveillance,
CDs are beginning to emerge as a significant cause of mortality in
children. Data from child mortality audit programmes indicate the
growing contribution of CDs to neonatal death and to deaths in
children under five years of age. Following the epidemiological trend
of industrialised countries, the contribution of CDs to the disease
burden will continue to increase in South Africa as the country
uphold the dignity and constitutionally and legally enshrined rights
of those affected by CDs.5,60
Priority actions include:
➢➢ Increased political will and financial commitment – This
should be accompanied by appropriate CD-related expertise
on ministerial and government committees dealing with the
neonatal/infant/child mortality and the development of
women, maternal and child health services.
➢➢ Improvement of national surveillance, patient registries and
monitoring of CDs – Linked to existing systems for sustainability,
these should be accompanied by ongoing training to increase
coverage and accuracy of CD data identification and
documentation.

PM
develops, until they eventually constitute the leading cause of child
➢➢ Capacity-building – The education and training of healthcare
death and disability. By not addressing this issue comprehensively
professionals and the creation of related posts is required at
now, many lives will be lost unnecessarily and others will survive
all levels, especially for staff in primary health care facilities.
with lifelong disability as the result of serious CDs. There is also

16 6
a significant economic cost associated with CDs. Up to 70% of ➢➢ Increased community education and awareness – Such pro-
the deaths and the disability caused by CDs can be prevented or grammes are required to ensure awareness, understanding

20 IL
mitigated through relevant interventions.45,46 and knowledge of available services and how to use them.

South Africa has already passed the point at which other nations
Y T ➢➢ Role of lay advocacy/patient support groups – These need to
have identified the need to develop comprehensive medical genetic be recognised, supported and strengthened to partner with
A N
services in order to reduce child mortality further. This is largely government and the medical genetics community.
a consequence of the abating HIV and AIDS and TB epidemics
M U

which have buried CDs as a health issue. While the control of these
epidemics must continue, it cannot be at the expense of other child
4 ED

healthcare needs if child mortality, including neonatal deaths, is to

be further reduced.5,7

While a good legislative framework provides for genetic services

O

in South Africa, the significant shortfall in implementation indicates

that this intention has been lost in translation. Medical genetic
G

services currently available are inadequate in terms of capacity and

infrastructure at all levels and far from the seamless continuum of
R

care required. While the implementation of accessible and relevant

BA

medical genetic services for the care and prevention of CDs is

N

essential to contribute to reducing static mortality rates further in

O

South Africa, such interventions must also plan for morbidity and
ongoing treatment of those affected. Such interventions have major
EM

economic implications for South Africa, and the CD contribution to

the burden of disease should be addressed holistically.

If South Africa is to meet the Sustainable Development Goal (SDG)

358 target to end preventable deaths in newborns and children,
and to reduce the U5MR to at least 25 per 1 000 by 2030, CDs
must be comprehensively addressed. Reducing premature mortality
from NCDs by 2030 will require CDs to be contextualised as a
NCD in South Africa, in alignment with the international definition
of NCDs. The SDG goal for universal health coverage and access to
quality essential healthcare services can only be achieved if relevant
medical genetic services for the care and prevention of CDs are
made available for all South Africans.58

The re-engineering of the healthcare service and the NHI initiative59

provide opportunities for the rebirth of medical genetic services, and
for rectification of their currently compromised state. Their integration
as part of services for women’s, maternal and child health would
allow medical genetic services to develop throughout the continuum
of care in all appropriate stages of life. Such services are vital to

S A H R 20 1 6 1 49
References
1 United Nations General Assembly. Resolution 55/2. United
Nations Millennium Declaration, A/RES/55/2 18 September
2000.[Internet]. [cited 13 January 2016].
URL: http://www.un.org/millennium/declaration/ares552e.
htm
2 Bamford L. Maternal, newborn and child health. In: Padarath
A, English R, editors. South African Health Review 2012/13.
Durban: Health Systems Trust; 2013. p.49–66. [Internet].
[cited 13 January 2016].
URL: http://www.hst.org.za/sites/default/files/Chapter4_
Maternal,%20Newborn_and%20Child_Health.pdf
3 McKerrow N, Mulaudzi M. Child mortality in South Africa:
Using existing data. In: Fonn S, Padarath A, editors. South
African Health Review 2010. Durban: Health Systems Trust;
2010. p.59–71. [Internet]. [cited 13 January 2016].
URL: http://www.hst.org.za/sites/default/files/Chap5.pdf
4 World Health Organization. World Health Statistics 2015.
Geneva: World Health Organization; 2015. [Internet]. [cited
24 February 2016].
16 6
URL: http://www.who.int/gho/publications/world_health_
statistics/2015/en/
20 IL
5 Malherbe HL, Christianson AL, Aldous C. Need for services
for the care and prevention of congenital disorders in South
Africa as the country’s epidemiological transition evolves. S
Y T
Afr Med J. 2015;105(3):186–88.
A N
6 You D, Hug L, Ejdemyr S, Beise J. Levels and Trends in Child
Mortality 2015. Estimates Developed by the United Nations
M U
Inter-agency for child mortality estimation. New York: United
Nations Children’s Fund; 2015. [Internet]. [cited 24 February
2016].
4 ED
URL: http://www.who.int/maternal_child_adolescent/
documents/levels_trends_child_mortality_2015/en/
7 Kerber KJ, Lawn JE, Johnson LF, et al. South African child
deaths 1990–2011: Have HIV services reversed the trend
O
enough to meet Millennium Development Goal 4? AIDS.
2013;27(16):2637–48.
G
8 Dorrington R, Bradshaw D, Laubscher, R, Nannan N. Rapid
mortality surveillance report 2014. Cape Town, South Africa:
R
Burden of Disease Research Unit, South African Medical
Research Council; 2015. [Internet]. [cited 14 December
BA
2015].
URL: http://www.mrc.ac.za/bod/
O
RapidMortalitySurveillanceReport2014.pdf
EM
9 Madhi SA, Bamford L, Ngcobo N. Effectiveness of
pneumococcal conjugate vaccine and rotavirus vaccine
introduction into the South African public immunisation
programme. S Afr Med J. 2014;104(3 Suppl 1):228–34.
10 Chola L, Pillay Y, Barron P, Tugendhaft A, Kerber K, Hofman
K. Cost and impact of scaling up interventions to save lives of
mothers and children: taking South Africa closer to MDGs 4
and 5. Glob Health Action. 2015;8:27265. [Internet]. [cited
23 March 2016].
URL: http://dx.doi.org/10.3402/gha.v8.27265
11 Bradshaw D, Groenewald P, Laubscher R, et al. Initial burden
of disease estimates for South Africa, 2000. S Afr Med J.
2003;93:682–88.
12 World Health Organization, Hereditary Diseases Programme.
Guidelines for the development of national programmes for
monitoring birth defects. Rome, Italy: The International Centre
for Birth Defects of the International Clearing House for Birth
Defects Monitoring Systems; 1993.
13 World Health Assembly. Resolution 63.17. Birth Defects,
WHA63.17. [Internet]. [cited 13 January 2016].
URL: http://apps.who.int/gb/ebwha/pdf_files/WHA63/
A63_R17-en.pdf
150 S A H R 20 1 6
14 Christianson A, Howson CP, Modell B. March of Dimes:
Global Report on Birth Defects, the Hidden Toll of Dying
and Disabled Children. White Plains, NY: March of Dimes
Birth Defects Foundation; 2006. [Internet]. [cited 15 January
2016].
URL: http://www.marchofdimes.org/materials/global-report-
on-birth-defects-the-hidden-toll-of-dying-and-disabled-children-
full-report.pdf
15 World Health Organization. Management of birth defects
and haemoglobin disorders. Report of a joint WHO–March
of Dimes meeting in Geneva, Switzerland, 17–19 May 2006.
Geneva: World Health Organization; 2006. [Internet]. [cited
13 January 2016].
URL: http://www.who.int/genomics/publications/WHO-
MODreport-final.pdf?ua=1
PM
16 Christianson A, Modell B. Medical Genetics in Developing
Countries. Annu Rev Genomics Hum Genet. 2004;
5:219–65.
17 World Health Organization. Prevention and Management of
Genetic Disorders and Birth Defects in Developing Countries.
Report of a joint WHO/WAOPBD meeting, The Hague, 5–7
January 1999. Geneva: World Health Organization;1999.
[Internet]. [cited 27 February 2016].
URL: http://www.who.int/genomics/publications/reports/
en/
18 Omran AR. The epidemiologic transition: A theory of the
epidemiology of population change. Milbank Mem Fund.
1971;49(4):509–38.
19 Kahn K, Garenne ML, Collinson MA, Tollman SM. Mortality
trends in a new South Africa: Hard to make a fresh start.
Scand J Public Health Suppl. 2007;35(69):26–34.
20 United Nations Inter-agency Group for Child Mortality
Estimation (IGME). Child mortality estimates. [Internet]. [cited
3 November 2014).
URL:http://www.childmortality.org
21 World Bank. Life expectancy at birth total (years). [Internet].
[cited 2 November 2014).
URL: http://data.worldbank.org/indicator/SP.DYN.LE00.IN
22 Health Systems Trust. 2012 National Antenatal Sentinel HIV &
Herpes Simplex Type-2 Prevalence Survey. [Internet]. [cited 4
November 2014].
URL: http://www.hst.org.za/publications/2012-national-
antenatal-sentinel-hiv-herpes-simplex-type-2-prevalence-survey
23 Agyei-Mensah S, de-Graft Aikins A. Epidemiological transition
and the double burden of disease in Accra, Ghana. J Urban
Health. 2010;87(5):879–97.
24 Smallman-Raynor M, Phillips D. Late stages of epidemiological
transition: Health status in the developed world. Health Place.
1999;5(3):209–22.
25 Statistics South Africa. Mortality and causes of death in South
Africa 2014: Findings from death notification. P0309.3.
Pretoria: Stats South Africa; 2015. [Internet]. [cited 15 March
2016].
URL: http://www.statssa.gov.za/publications/P03093/
P030932014.pdf
26 Committee on Morbidity and Mortality in Children. 2nd
Triennial Report of the Committee on Morbidity and Mortality
in Children under 5 Years (CoMMiC);2014. Pretoria:
National Department of Health; 2014.
27 Pattison R, Rhoda N. Saving Babies 2012–2013: Ninth
Report on perinatal care in South Africa. Pretoria: Tshepesa
Press; 2014:35. [Internet]. [cited 18 February 2016].
URL: http://www.ppip.co.za/wp-content/uploads/Saving-
Babies-2012-2013.pdf

28 Lawn J, Blencowe H, Waiswa P, et al. Ending preventable
stillbirths 2: Stillbirths: rates, risk factors, and acceleration
towards 2030. Lancet. 2016;387:587–603.[Internet]. [cited
23 March 2016].
URL: http://dx.doi.org/10.1016/S0140–6736(15)00837–5
29 US Centres for Disease Control and Prevention. D10 leading
causes of death by age group, United States 2013. [Internet].
[cited 28 February 2016].
URL: http://www.cdc.gov/injury/images/lc-charts/
leading_causes_of_death_by_age_group_2013-a.gif
30 McKeown T. The modern rise of population. London: Edward
Arnold; 1976.
31 South African National Department of Health. Policy
Guidelines for the Management and Prevention of Genetic
Disorders, Birth Defects and Disabilities. Pretoria: National
Department of Health; 2001.
32 South African National Department of Health. Strategic
Framework for the Modernisation of Tertiary Hospital
Services. Discussion Document. Pretoria: National Department
of Health; 2003.
16 6
33 South African National Department of Health. National
Guidelines for the Care and Prevention of the Most Common
20 IL
Genetic Disorders, Birth Defects and Disabilities. Pretoria:
National Department of Health; 2004.
34 Statistics South Africa. Mid-year population estimates 2015.
Y T
Pretoria: Stats South Africa; 2015. [Internet]. [cited 10 August
2015].
A N
URL: http://www.statssa.gov.za/publications/P0302/
P03022015.pdf
M U
35 Mtyongwe V. National birth defects data: 2006–2012.
Presentation at: 15th Southern African Human Genetics
4 ED
Congress, Sandton, Johannesburg, 6–9 October 2013.
36 Venter P, Christianson A, Hutamo C, Makhura M, Gericke G.
Congenital anomalies in rural black South African neonates –
O
a silent epidemic? S Afr Med J. 1995;85(1):15–20.
37 Nippert I, Christianson A, Gribaldo L, et al. Genetic Testing in
G
Emerging Economies (GenTEE) Summary Report. Ispra, Italy:
Joint Research Centre, European Commission; 2013. p.176.
R
38 World Health Organization/World Alliance of Organizations
for the Prevention of Birth Defects. Services for the prevention
BA
and management of genetic disorders and birth defects in
developing countries – report of a joint WHO/WAOPBD
O
meeting, The Hague 5–7 January 1999. Geneva: World
Health Organization;1999. [Internet]. [cited 7 November
EM
2014].
URL: http://apps.who.int/iris/bitstream/10665/66501/1/
WHO_HGN_GL_WAOPBD_99.1.pdf
39 Groenewald P, Msemburi W, Morden E, Zinyakatira N,
Neethling I, Daniels J, et al. Western Cape Mortality Profile
2011. Cape Town: South African Medical Research Council;
2014.
40 National Perinatal Mortality and Morbidity Committee. Short
Report (2010–2013). Pretoria: National Department of
Health; 2014.
41 Patrick ME, Stephen CR. Saving children:2005. A survey of
child healthcare in South Africa. Child Healthcare Problem
Identification Programme and Medical Research Council.
[Internet]. [cited 23 March 2016].
URL: http://www.childpip.org.za/documents/report_saving_
children_2005.pdf
42 Dorrington R, Bradshaw D, Laubscher, R, Nannan N. Rapid
mortality surveillance report 2013. Cape Town, South Africa:
South African Medical Research Council, Burden of Disease
Research Unit; 2014.
S A H R 20 1 6
Congenital disorders
43 Velaphi S, Rhoda N. Reducing neonatal deaths in South
Africa – are we there yet, and what can be done? S Afr J
Child Health. 2012;6:67–71.
44 South African Department of Women, Children and People
with Disabilities. The United Nations Convention on the Rights
of the Child. South Africa’s combined second, third and fourth
periodic state party report to the Committee on the Rights
of the Child (Reporting period: January 1998–April 2013).
Pretoria: Department of Women, Children and People with
Disabilities; 2013. [Internet]. [cited 10 August 2015].
URL: http://www.unicef.org/southafrica/South Africa
F_resources_uncrcreport16.pdf
45 World Health Organization. WHO technical report series
865: Control of hereditary diseases – report of a WHO
scientific group, 1993, Geneva, Switzerland. Geneva: World
Health Organization; 1996. [Internet]. [cited 27 February
2016].
PM
URL: http://www.who.int/genomics/publications/reports/
en/
46 Czeizel AE, Intôdy Z, Modell B. What proportion of
congenital abnormalities can be prevented? BMJ.
1993;306:499–503.
47 Christianson AL, Venter PA, Modiba JH, Nelson MM.
Development of a primary health care clinical genetic service
in rural South Africa – The Northern Province experience,
1990–1996. Community Genetics. 2000; 3(2):77–84.
48 Sayed A, Bourne D, Pattison R, Nixon J, Henderson B. Decline
in the Prevalence of Neural Tube Defects Following Folic Acid
Fortification and Its Cost-Benefit in South Africa. Birth Defects
Research (Part A). 2008;82:211–16.
49 World Health Organization, Human Genetics, Chronic
Diseases and Health Promotion. Community Approaches
to the Control of Hereditary Diseases. Report of a WHO
Advisory Group, Geneva, 3–5 October 1985. Geneva:
World Health Organization; 2005.p.34. [Internet]. [cited 10
August 2015].
URL: http://www.who.int/genomics/publications/
WHOHGNWG85.10.pdf?ua=1
50 Modell B, Kuliev A. The history of community genetics: the
contribution of the haemoglobin disorders. Community Genet.
1998;1:3–11.
51 Kromberg J, Sizer EB, Christianson A. Genetic services
and testing in South Africa. J Community Genet. 2013
Jul;4(3):413–23.
52 Statistics South Africa. South African Statistics 2014. Pretoria:
Stats South Africa; 2014.
53 Republic of South Africa. Constitution of the Republic of South
Africa Act 108 of 1996. Government Gazette No 17678.
Pretoria: Government Printer; 1996.
54 South African National Department of Health. National Health
Act 61 of 2003. Government Gazette Vol. 469, No. 26595.
Pretoria: Government Printer. 2004.
55 South African National Department of Health. Guidelines for
Maternity Care in South Africa. Pretoria: National Department
of Health; 2015.
56 South African National Department of Health. Strategic
Plan for Maternal, Newborn, Child and Women’s Health
(MNCWH) and Nutrition in South Africa 2012–2016.
Pretoria: National Department of Health; 2012.
57 South African National Department of Health. Strategic Plan
2014/15–2018/9. Pretoria: National Department of Health;
2014.
151
58 United Nations. Sustainable Development Goals. Goal 3:
Ensure healthy lives and promote well-being for all at all ages.
[Internet]. [cited 13 January 2016].
URL: http://www.un.org/sustainabledevelopment/health/
59 South African National Department of Health. National Health
Insurance in South Africa Policy Paper. Pretoria: National
Department of Health; 2011.
60 Christianson AL. Attaining human dignity for people
with birth defects: A historical perspective. S Afr Med J.
2013;103(12):1014–19.

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

1 52 S A H R 20 1 6
Integrating mental health into South Africa’s
health system: current status and way forward
13

Authors:
Marguerite Schneider i Emily Baron i Erica Breuer i
Sumaiyah Docrat i Simone Honikman i Ashraf Kagee ii

PM
Michael Onah i Sarah Skeen ii Katherine Sorsdahl i
Mark Tomlinson ii Claire van der Westhuizen i Crick Lund i

16 6
A 20 IL
s implied by the World Health Organization’s statement, “There is no health Integration of mental health
without mental health”, it is essential to think of mental health as an integral
Y T
part of health. As such, it should be integrated into health policy and practice requires a vision, high-level
A N
in order to improve global health and address the significant treatment gap for commitment, allocation of
mental, neurological and substance use (MNS) disorders.
resources, as well as oversight
M U

Efforts to address this in South Africa have included policy responses as well as and support of the provinces
research and service innovations integrating mental health into general health care.
4 ED

This chapter provides an overview of the current policies and services in place for in the implementation of
mental health care in South Africa; it also describes current research on effective mental health services.
strategies for providing such services, and identifies key barriers and facilitators in
O

implementing these policies and scaling up mental health services.

G

The examples of research projects and service initiatives described reflect strategies
of integration into Primary Health Care, such as using task-sharing together with a
R

strong support structure for supervision and referral. Once effectiveness is established,
the challenge of how to scale up these interventions remains. Further research will be
BA

required to evaluate both the outcomes of scaled-up mental health care and the best
O

practices to achieve this.

EM

Integration of mental health requires a vision, high-level commitment, allocation of

resources, as well as oversight and support of the provinces in the implementation
of mental health services. The vision is apparent in the South African Mental Health
Policy and Strategy Plan – the implementation of this policy is the challenge that now
lies ahead.

i Alan J Flisher Centre for Public Mental Health, Psychiatry and Mental Health, Universit y of Cape Town
ii Alan J Flisher Centre for Public Mental Health, Psychology, Universit y of Stellenbosch

1 53
Introduction
The prevalence of mental disorders is relatively high in South Africa,
as reported in the 2003 South African Stress and Health (SASH)
study.1,2 The SASH study reported a 12-month prevalence of 16.5%
and a lifetime prevalence of 30.3% for depression and anxiety
disorder in the adult South African population. Although anxiety
disorders were most common, high rates of substance abuse were
also reported.
Yet, in South Africa, it is estimated that 75% of people with a mental
disorder do not receive mental health services.3 This is commonly
referred to as ‘the mental health treatment gap’. Addressing this
treatment gap is key to ensuring equitable access to health care for
people with mental disorder. This was clearly set out in Daar et al.’s
Declaration on Mental Health in Africa: Moving to Implementation,4
which noted that people with mental disorders have psychosocial
disabilities arising from their mental disorder, as well as from the
stigma, discrimination and social exclusion that they, their families
16 6
and their caregivers experience on a recurring basis. These
psychosocial disabilities lead to difficulty with accessing health
20 IL
services, finding and keeping employment, obtaining adequate
schooling, and engaging in social activities and development
programmes.5 Y T
Mental disorders result in lower life expectancy and increased risk
A N
of co-morbid physical illnesses, and often result in limited access
M U
to appropriate general healthcare services.6–8 Furthermore, people
with physical health conditions have increased risk of common
mental disorders.9,10 In South Africa, mental disorder often co-
4 ED
occurs with and exacerbates what is known as the quadruple
burden of disease,11,12 namely: maternal and child illnesses;
infectious diseases such as HIV and TB; non-communicable diseases
O
(NCDs) such as cardiovascular disease and diabetes; and injury.
The following sections review existing data on the prevalence of
G
mental and substance use disorders and their association with this
quadruple burden of disease.
R
Maternal depression is common in South Africa, with prevalence
BA
ranging from 18% to 47% for antenatal depression13–16 and
from 32% to 35% for postnatal depression.17 The consequences
O
of maternal depression on maternal and child outcomes are well
EM
documented and include premature delivery and other birth
complications, and delayed milestones for the children,17–19 as well
as increased risk of suicide, substance and alcohol abuse and non-
adherence to medical treatment regimens in mothers.13,20,21
Research suggests a high prevalence of mental disorders among
people living with HIV,22,23 as well as those diagnosed with TB.23–25
This is particularly important given the high prevalence of both TB
and HIV in South Africa.26 There is growing evidence of increased
risk of HIV infection for people with mental disorders as well as
an increased prevalence of mental illness in people living with
HIV. There is also substantial evidence showing that mental and
substance use disorders are associated with poor adherence to HIV
and TB treatment.20,27–29
In recent years there has been increasing acknowledgement of
the growing prevalence of NCDs, such as cardiovascular disease,
cancer, diabetes and chronic respiratory disorders, in low- and
middle-income countries (LMICs).11,30 While there may be genetic
antecedents of these conditions, there is growing evidence that
behavioural factors such as diet, physical inactivity, smoking and
154
S A H R 20 1 6
alcohol use play an important role in determining their onset and
severity.10,31 Also, the comorbidity of mental health, neurological,
and substance use (MNS) disorders and NCDs has adverse
implications for the prognosis of both conditions, and affects mood-
related quality of life, family relationships, adherence to medical
treatment and the potential for suicidal ideation.32
Finally, non-fatal injuries as a victim, perpetrator/protagonist or
witness have serious mental health implications.33 This is especially
relevant in South Africa, where the South African Medical Research
Council’s Burden of Disease Unit found that interpersonal violence
was the second leading risk factor for healthy years of life lost
in South Africa, associated with an increased burden of mental
disorders such as major depression and anxiety disorders, and
PM
also increasing harmful alcohol use.34 The SASH study noted that
having suffered an accident (20%) or physical violence (21%),
having witnessed atrocities (4%) and having witnessed a death or
someone else being injured (20%) accounted for the majority of the
traumatic events experienced in the sample.35 In addition, over half
of the relative post-traumatic distress burden was accounted for by
witnessing an injury event or death.35
These issues are exacerbated in the context of elevated levels of
poverty. Over one fifth of South Africa’s population lives below the
‘food poverty line’, and with a Gini co-efficient of 0.65, South Africa
has one of the highest rates of inequality globally.36 Population
mental health is shaped by the social and economic environment of
a country,37 and common mental disorders have been linked with a
number of indicators of poverty in low- and middle-income countries,
including low education level, food insecurity, inadequate housing,
social class, socio-economic status and financial stress.38
The relationship between poverty and mental health has often been
conceptualised as a vicious cycle, with people living in poverty at
increased risk of developing mental health problems due to factors
such as increased levels of stress, exclusion, and reduced access
to social capital, as well as physical factors such as malnutrition,
obstetric risks, and exposure to violence.39 Simultaneously, those
with mental disorders are more likely to slide into poverty due to
stigma and exclusion from social and economic opportunities,39 the
high cost of accessing treatment, or the loss of employment due to
diminished productivity.40 Up until recently, mental health was often
omitted from national health and development policies.41
However, the National Development Plan, intended to guide
development in South Africa until 2030, identified the need to
bolster the network of professionals to treat and support people
experiencing psychosocial problems.42 The recent national Mental
Health Policy Framework and Strategic Plan adopted in 2013 also
showed that the government was ready to integrate mental health
in the South African health system, and reduce the mental health
treatment gap and health burden.43 Concerns remain, however,
as to whether this plan is feasible and sustainable, and whether
other activities and policies should be put in place for full integration
of mental health into the health system. The aims of this chapter
are therefore to provide an overview of the current policies and
examples of health services research and implementation for mental
health care in South Africa; to identify gaps; and to propose a way
forward for policy, research and practice to facilitate the integration
of mental health in South Africa’s health system.
 Mental health

National policy development

In the post-apartheid era, significant strides have been made in
national policy with respect to mental health. In 1997, the White
Paper on the Transformation of the Health System included a chapter
on Mental Health (Chapter 12), which stated:
A comprehensive and community-based mental health service
should be planned and coordinated at the national, provincial,
district and community levels, and integrated with other health
services.44
This signified a major departure from apartheid-era mental health
policy and practice, which was focused largely on institutional and
custodial care, with racial segregation of facilities. In the same year,
the Department of Health issued Mental Health Policy Guidelines,45
➢➢ To promote the mental health of the South African population,
through collaboration between the Department of Health and
other sectors
➢➢ To empower local communities, especially mental health
service users and carers, to participate in promoting mental
wellbeing and recovery within their community
➢➢ To promote and protect the human rights of people living with
mental disorder
➢➢ To adopt a multi-sectoral approach to tackling the vicious cycle
of poverty and mental ill-health
➢➢ To establish a monitoring and evaluation system for mental

PM
health care
which provided a framework for provinces to develop their own
mental health policies and plans. In 1997/1998, the Department ➢➢ To ensure that the planning and provision of mental health
of Health commissioned a study on mental health service norms services is evidence-based.41
and standards for South Africa.46 This initially focused on severe

16 6
Prior to this policy, the mental health services context was
psychiatric conditions, and was followed by further studies on norms
characterised by the treatment gap for mental disorders previously

20 IL
for community mental health services,47 and child and adolescent
described. A situational analysis of public mental health services
mental health services.48 The Mental Health Care Act of 200249 was
and policies in South Africa and its nine provinces undertaken in
promulgated in 2004, and was a major piece of legislation reform
Y T
in line with international human rights instruments and World Health
Organization (WHO) guidelines. The 1997 Mental Health Policy
200551 showed weak policy implementation at provincial level,
marked inequality between provinces in terms of available resources
A N
for mental health care, lack of routine data collection for monitoring,
Guidelines were reviewed a decade later50 and showed limited
and reliance on mental hospitals rather than more decentralised
M U

implementation in provincial health services. This was attributed to

services. At the time of drafting the SA MH Policy, mental health
the low priority given to mental health, scarcity of human resource
care services primarily involved dispensing medication for severe
factors, and reluctance on the part of provinces to be active in the
4 ED

mental disorders, with little effort to detect and treat other mental
implementation of guidelines.
disorders such as depression and anxiety. However, there were
In 2012, the Minister of Health convened a series of provincial some changes noted, such as endorsement of the integration of
O

Mental Health Summits (February–March 2012), attended by over mental health into primary health care with training of some PHC
4 000 mental health stakeholders around the country. The purpose nurses, and integration within emergency management and ongoing
G

of these summits was to generate national consensus around policy psychopharmalogical care for those patients with stabilised chronic
priorities for mental health in South Africa. This culminated in a mental disorders.43
R

national mental health summit, held in Pretoria in April 2012 and

To meet the objectives of the SA MH Policy, the National Department
attended by over 400 stakeholders. It was convened by the Minister
BA

of Health proposed the establishment of multidisciplinary mental

of Health, and marked a substantial new policy commitment to the
health teams in health districts, starting with the National Health
neglected area of mental health. Subsequently, a task team was
O

Insurance (NHI) pilot sites, with the inclusion of non-specialised

convened by the Deputy Minister to draw up a national Mental
EM

mental health counsellors as part of the team. Challenges to the

Health Policy Framework and Strategic Plan, based on previous
mental health research in the country, and the recommendations
from the summits. This new policy was adopted by the National
Health Council in July 2013.43
Policy Framework and Strategic Plan
The South African Mental Health Policy Framework and Strategic
Plan (referred to hereafter as the SA MH Policy) aimed to realise
the integration of mental health care into a comprehensive primary
health care (PHC) approach enshrined in the Mental Health Care
Act of 2002.49 The SA MH Policy sets out the key aims of integrating
mental health care into PHC as follows:
➢➢ To scale up decentralised integrated primary mental health
services, which include community-based care, PHC clinic
care, and district hospital-level care
➢➢ To increase public awareness regarding mental health and
reduce stigma and discrimination associated with mental
disorder
implementation of this policy remain the lack of financial and
human resources, the limited number of evidence-based treatment
protocols (other than medication) for disorders such as depression
and anxiety, beyond medication, limited awareness of and negative
attitudes towards mental disorders (which may limit health-seeking
behaviours by people with mental disorders), and a low level of
health-system readiness to integrate mental health care.52,53 The
financing challenges to integration are discussed further under the
heading ‘Financing barriers’, as any health system improvement will
be premised on the availability of adequate financing.
International trends
The new South African policy reflects the response seen globally,
especially since the 2007 landmark Lancet series on Global Mental
Health, culminating in the final “Call to Action” paper, which urged
governments to scale up mental health care and provided the
targets, indicators and costs required to do so.54 In 2013, the World
Health Assembly adopted the WHO Global Mental Health Action

1 55
S A H R 20 1 6
Plan,55 which set clear targets and indicators for increasing policy
commitment to mental health and scaling up mental health services
globally between 2013 and 2020. Every two years, the WHO Atlas
survey collects data for these indicators to assess the extent to which
countries are making progress towards these targets.55 The four
major objectives of the action plan are to:
out-of-pocket payments are not part of the public service financing
mix.44,61–63 For example, South African households with illness
(including mental disorders) often spend over 10% of their household
income on public health-related needs, much of this being for costs
such as transport, care arrangements and management of complex
healthcare needs.64

➢➢ strengthen effective leadership and governance for mental
health;
➢➢ provide comprehensive, integrated and responsive mental
health and social care services in community-based settings;
➢➢ implement strategies for promotion and prevention in mental
health; and
➢➢ strengthen information systems, evidence and research for
With the recent release of the NHI White Paper, the South African
NHI scheme has recognised the quadruple burden of disease in the
country, with NCDs including mental illness playing a contributory
role.65 The proposals set out in the NHI White Paper already
face major financing and implementation constraints because of
low growth rates, prevailing drought and power shortages. The
consequences of this are that health insurance for neglected health
problems like mental health are likely to be relegated to the ‘back-

mental health.
In 2015, mental health was also included in the United Nations
(UN) Sustainable Development Goals. In the Health Goal of the
PM
burner’, making the National Mental Health Policy Framework difficult
to implement. Aside from the financing structure of the proposed
NHI, the content of the comprehensive package for insurance-
holders should also be redefined to incorporate mental health, as

16 6
declaration, the UN points out the importance of mental health for
well as substance abuse. Indeed, although the White Paper includes
overall health and global development. It states that by 2030, the
mental health services and health counselling services as part of

20 IL
aim of all countries is to “reduce by one third premature mortality
the comprehensive package, it does not acknowledge the wide-
from non-communicable diseases through prevention and treatment
ranging nature of mental disorders, from depression and anxiety
to promote mental health and well-being” (target 3.4); “strengthen
Y T through to psychosis and mood disorders. Therefore, while the NHI
the prevention and treatment of substance abuse” (target 3.5), and
implementation is likely to improve mental health systems through
A N
implement “universal health coverage” (target 3.8). This is a major
enhanced infrastructure and augmented investment in primary and
departure from the WHO Millennium Developmental Goals56,57
M U

community care, it is still unclear whether access to mental health

which largely ignored mental health, and represents a significant
services will improve substantially. Without clarity on and explicit
move forward in linking mental health with social and economic
objectives for mental health service provision, it is unlikely that the
4 ED

development.56,57
mental health needs of South Africa will be adequately addressed.

Financing barriers The research consortium EMERALD (Emerging mental health systems
in low- and middle-income countries) is currently attempting to
O

While the policy initiatives by the South African National Department

address this gap.a The project, which started in November 2012,
of Health are promising, the general fiscal constraints in the country
G

seeks to improve mental health outcomes by enhancing health

may affect the roll-out of mental health services. From an economic
system performance. Specifically, the Project aims to identify key
point of view, it costs South African society more not to treat mental
R

health system barriers to, and solutions for, the scaled-up delivery
disorder than to treat it.58 Bearing this in mind, together with the
of mental health services in LMICs, and by doing so to improve
recognised lack of financial resources in South Africa and other
BA

mental health outcomes in a fair and efficient way. With respect to

LMICs, this section introduces the need and potential options for
sustainable financing options for South Africa, the Project has three
O

sustainable financing.
primary objectives in the South African context:
EM

Some of the most significant barriers to the delivery of mental health

services in South Africa and other LMICs emerge in part as a result
of insufficient resourcing.59 The resulting treatment gap also has
an economic and social impact that is far-reaching and critical to
countries, both at the micro-economic and macro-economic levels.
While there is a lack of data available for mental health financing
in South Africa – particularly for care delivered at the community,
primary care and district hospital level(s) – available budget reports
have indicated that Government is the main source of funding for
care of severe mental disorders in the country, where an estimated
US$ 59 million of annual government spending flows to tertiary and
specialised care facilities providing mental health services.59,60 In
contrast to this, the total annual cost in lost income for people living
with mental disorder amounts to US$ 3.6 billion – dwarfing the
annual government spending on mental health services.58 Where
treatments are accessed by patients, they are often inappropriate
and involve indirect costs that are economically catastrophic for
affected individuals and their families – even in contexts where
➢➢ to estimate the resource needs associated with an adequate
and appropriate health systems response to the current burden
of mental disorders;
➢➢ to quantify the resource distribution and household impacts of
addressed and unaddressed mental disorders; and
➢➢ to provide sustainable options for how best to finance the
estimated ‘price tag’ in a way that is feasible but also fair.
Efforts to integrate mental health into primary
health care
Many factors have plagued the provision of mental health services in
South Africa. The lack of human and financial resources to address
the treatment gap remains evident.46,66,67 Despite the formulation
of national policy and provision of guidelines, the limited resources
that exist remain concentrated in large psychiatric hospitals with a
predominantly vertical model of care. Given the global focus on the

a http://www.EMERALD-project.eu

156
S A H R 20 1 6
 Mental health

integration of mental health into existing health platforms to address

the lack of human resources, task-shifting or task-sharing has been
proposed as a strategy to manage this shortfall.68
The chapter by Spedding, Stein and Sorsdahl in the 2014/15
South African Health Review69 provides an overview of task-shifting
interventions for the management of mental disorders such as
depression, anxiety and substance abuse. The emerging evidence
suggests that this strategy has been successful in some instances.
Box 1 contains examples of research initiatives and services which
have focused on integrating mental health care into PHC and health
programmes in South Africa.
Box 1: Research on integration of mental health into primary health
care
The Africa Focus on Intervention research for Mental health (AFFIRM)
The AFFIRM project funded by the National Institute of Mental Health
(USA) comprises a randomised controlled trial (RCT) which tests the
effectiveness of a manual-based counselling intervention by trained lay
counsellors for depressed pregnant women attending one of two Midwife
Obstetric Units (MOUs) in Khayelitsha.72 Pregnant women were screened
for depression and recruited into the trial if they scored 13 or higher on
the Edinburgh Postnatal Depression Scale (EPDS). The intervention arm
received six sessions of basic counselling by trained counsellors supervised
and supported by a Master’s-level mental health counsellor. The women
allocated to the control arm received brief phone calls once a month for
three months to assess basic health. The final results will be available
towards the end of 2016, but anecdotal evidence suggests that women
appreciated the contact and felt better able to cope with their pregnancy.
Of note is the changing awareness of the midwives and the clinic psychiatric
nurse on the extent of prenatal depression and the need for counselling
services. If the RCT shows an effect from the counselling, then the RCT

Programme for Improving Mental Health Care (PRIME)
PRIME is a research consortium working in five LMICs (Ethiopia, India,
Nepal, South Africa and Uganda) funded by the United Kingdom’s
Department for International Development (DFID).70 In each country,
PM
implementation provides a model for scaling up the implementation of this
type of service. This piece of research addresses the need to develop task-
sharing interventions for maternal depression that are feasible to scale up
at all antenatal care services.

16 6
a district demonstration site has been established to consult with local
stakeholders and develop and implement a district mental healthcare plan.

20 IL
The South African site is a NHI pilot site recommended by the national Integration of mental health services into chronic
Department of Health: Dr Kenneth Kaunda District in the North West disease care
Province. PRIME team members have been working with the Department
Y T
of Health and local stakeholders to develop and implement the district
mental health care plan. The South African plan is integrated with the
In South Africa, the integration of chronic disease and mental
health services delivery has been slow due to limited knowledge of
A N
Department of Health’s chronic disease management approach, and feasible, acceptable and effective collaborative care models.
includes core intervention packages at the healthcare organisation, facility
M U

and community levels, providing care for individuals with psychosis, The project entitled ‘Strengthening South Africa’s health system
depression and alcohol use disorder.52 PRIME-SA has worked to strengthen through integrating treatment for mental disorder into chronic
the mental health components of the Primary Care 101 (PC101) clinical
4 ED

disease care’ (Project MIND) is presently investigating the feasibility,

guidelines, based on the WHO mhGAP Intervention Guide, as well as to
acceptability, effectiveness and cost-effectiveness of two collaborative
provide counselling services for people with depression, and psychosocial
rehabilitation groups for people living with severe mental disorder. The care models for patients receiving chronic disease care (specifically
implementation of the plan is being evaluated through repeat facility HIV and diabetes) in the Western Cape: a vertical and horizontal
O

detection surveys (to discern changes in the capacity of primary care model of care. In the horizontal model, within the chronic disease
staff to detect people with depression, and alcohol use disorders), cohort team, one or more healthcare providers are designated to provide
G

studies (to assess changes in clinical, functioning and economic outcomes),

mental health care. The mental health services are provided by
and a case study methodology (to assess the process of implementation).
R

In addition, the PRIME team is working with the Department of Health to designated personnel who are responsible for their usual chronic
scale up the PRIME packages for depression in a large cluster-randomised disease duties as well as mental health care. In the vertical model,
BA

controlled trial for people living with HIV and hypertension.b This initiative services are provided by separate cadres of health providers, where
addresses the need to integrate mental health care services within PHC mental health services are provided by dedicated personnel whose
O

through training and support of PHC nurses, primarily, and by identifying

only responsibility is to deliver mental health care. This is a project
key steps in scaling up these services.
EM

currently under way and no results are published yet. However,

The Substance use and TRauma InterVEntion (STRIVE) model in the Western Project MIND constitutes research that addresses not only the
Cape integration of mental health services within chronic care, but also the
The treatment of substance use disorders is a public health priority, services and systems requirements for this to be achieved effectively.
particularly in South Africa where the prevalence of these disorders is high.
Efforts have been made to find ways to integrate the identification and
treatment of individuals with these disorders into the emergency department
services. In a recent randomised controlled trial, the effectiveness of a
blended motivational interviewing–problem-solving therapy (MI-PST)
was tested among patients presenting to emergency departments in the
Western Cape.71 Results indicated that a blended MI-PST intervention
was feasible to implement among patients presenting for emergency
department services in South Africa. The preliminary findings also
suggested promising outcomes for substance use and depression, although
study design limitations reduced the interpretability and generalisability
of the results. Should the intervention prove to be effective in subsequent
research, the Western Cape Department of Health may consider rolling
out this intervention to other emergency departments in the province. This
initiative focuses on development of evidence-based treatment approaches
that can be scaled up within emergency departments at all hospitals to
address substance use disorders.

b The protocol for this COBALT RCT is registered at https://clinicaltrials.gov/

ct2/show/NCT02407691

1 57
S A H R 20 1 6
Integration of mental health into primary care and effective task-sharing interventions67,80,81 and the AFFIRM trial
should provide further evidence on this nature.
Two current services where mental health care is fully integrated in
the health system are described in Box 2. Limitations

Box 2: Examples of integration of mental health into primary care
The Perinatal Mental Health Project
The Perinatal Mental Health Projectc (PMHP) provides a stepped-care,
collaborative model for delivering a mental health service at three MOUs
in Cape Town.75 Given that 99% of pregnant women attend antenatal
care facilities for an average of 3.7 visits,76 this provides an important
opportunity to screen for common perinatal mental health problems, and
provide integrated care. All women are offered psychosocial risk and
depression screening at their first antenatal visit, and those who meet the
criteria for being at risk are offered on-site, free-of-charge counselling
with one of the trained PMHP counsellors. Two counsellors are nurses
Although there are a number of effective evidence-based treatment
interventions available in the South African and broader LMIC
context, such as those described, these remain largely at the testing
phase and need to be scaled up more broadly and their feasibility
assessed. Many of the models are research-led, with access to
resources that might otherwise not be available in primary care
settings. Indeed, effective services, especially task-sharing models of
services, require strong training, supervision and support structures
to ensure high-quality services and retention of human resources.
Stigmatisation of patients with mental or substance use disorders by

who were trained in counselling and the third counsellor has a BPsych
degree; all three are supervised by a clinical psychologist. The counsellors
conduct a detailed assessment and tailor their intervention according
to the needs of the patient. This may include couple or family therapy,
PM
healthcare workers may directly affect health-seeking behaviours of
patients, and must also be addressed on an ongoing basis during
training and supervision.73

16 6
motivational interviewing, problem-solving therapy, psycho-education, Furthermore, research shows that mental disorders can be detected
and interpersonal and cognitive behavioural therapy. The counsellor is through effective screening by trained non-professionals; however,

20 IL
also responsible for co-ordinating referrals, as required, to a wide range of we need more definitive evidence on optimal detection methods,
social support services. A small minority of women with severe symptoms
including when and for whom screening might be appropriate.74
are eligible for and accept referral to psychiatric services.
Y T
Several years of service delivery, with embedded monitoring and This should be provided together with a well-functioning referral
evaluation procedures, have resulted in the development of several design mechanism to ensure that those who require more specialised
A N
features that address access to care, stigma and mental health awareness. services are able to access these. Indeed, system strengthening is
For example, the PMHP has conducted participatory capacity-building and important to ensure continuity of care across primary, secondary
M U

training activities with all maternity care staff at the three MOUs to improve
and tertiary care, and access to medication and psychosocial care.
mental health literacy, empathic skills and self-care practices. This training
has created an enabling environment for the sustained integration of the Given the financial, systemic and human resources challenges that
4 ED

mental health services. The number of women screened has increased, the South African health system faces, the scaling-up of research-
as has the rate of uptake with a reduction in the loss to follow-up. While related programmes is complex.
the programme is currently self-funded, the model of care developed by
PMHP provides an example of the feasibility of integrating the content into
O

existing maternal health care services. Challenges remain as to the funding Conclusion
model and the support structures required to ensure that the counsellors are
G

effective and avoid burnout. Progress has been made in South Africa with regard to integrating
mental health into health systems. Recent South African policy
R

Thuthuzela Care Centres

The 24-hour Thuthuzela Care Centresd offer services at primary- and developments show a high level of commitment by the National
Department of Health, with the formation of the Ministerial Mental
BA

secondary-level health facilities for the care of adults and children who
N

have been sexually assaulted. These Centres were established under Health Advisory Committee in 2015. However, despite compelling
the mandate of the Sexual Offences and Community Affairs Unit of
O

evidence supporting the case for investment in mental health

South Africa’s National Prosecuting Authority, and a number of partners
systems,55 there exists a lack of understanding as to how investments
EM

are involved in service provision. The Centres provide psychological

support in the acute phase and beyond, while also providing access
to physical care, forensic examinations and legal support.77 To our
knowledge, the psychosocial interventions provided have not been
formally evaluated, and it is not clear whether these interventions are
standardised or evidence-based. This is an example of a mental health
care service provided within the healthcare system. However, the extent
of its integration as a health services component remains to be seen.
It does nevertheless show the possibilities of providing intersectoral
services, in this instance between the justice and health systems.
in scaled-up mental health services can best be paid for in a way
that is feasible, fair and appropriate within the fiscal constraints
and structures of different countries.59 Decision-makers should weigh
up a number of additional, complementary financing mechanisms
or strategies, in particular how to increase access at a cost that is
affordable, not only for the South African economy as a whole, but
also for the households or individuals who make use of services that
are available.

The distal determinants of mental disorder such as unemployment,

HIV Counsellors
Additionally, a number of HIV counsellors have been trained and
deployed in the South African health system as an integrated service
within PHC. However, the current status of the counselling provided
by these and other similar cadres does not appear to adhere to
good counselling models.78,79 Their focus is on giving advice rather
than addressing mental health disorders. Nevertheless, there is
growing evidence that lay counsellors are able to provide good
c www.pmhp.za.org
d http://www.thuthuzela.co.za/
inequality and violence, the co-morbid nature of mental disorder,
the high burden of disease, and the large treatment gap underscore
the importance of an inter-sectoral response that goes beyond
health care services. Neglecting mental health services not only
affects people with mental disorders, but also people with mental
disorders secondary to physical illness, affecting their treatment
adherence and health-seeking behaviours. Therefore, an integrated
approach to mental health care seems to be the most promising
way forward. However, there remains limited evidence on the

158
S A H R 20 1 6
 Mental health

evaluation of models of integrated mental health care in South Africa

and internationally. Although the integration of mental health into
primary care is likely to present challenges, not doing so will result
in mental health continuing to be underfunded and relegated to the
margins. In particular, showing that integration can be both efficient
and cost-effective is a fundamental step.

The examples of research projects and service initiatives described

in this chapter show promise as effective interventions for mental
disorders. They reflect strategies of integration into PHC such as using
task-sharing together with a strong support structure for supervision
and referral. Once effectiveness is established, the challenge of how
to scale up of these interventions remains. Further research will be
required to evaluate both the outcomes of scaled-up mental health
care and the best practices to achieve this. These research studies

PM
utilise implementation science and health systems research methods
and frameworks to ensure effective programmes. The PRIME project
is starting to do this in the NHI pilot site in the North West Province.

16 6
Integration of mental health requires a vision, high-level commitment,
allocation of resources, as well as oversight and support to the

20 IL
provinces for the implementation of mental health services. The
vision is apparent in the South African Mental Health Policy and
Strategy Plan – implementation of this policy is the task ahead.
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

1 59
S A H R 20 1 6
References
1 Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H,
Williams DR. The South African Stress and Health (SASH)
study: 12-month and lifetime prevalence of common mental
disorders. S Afr Med J. 2009;99(5):339–44.
2 Stein DJ, Williams DR, Kessler RC. The South African Stress
and Health (SASH) study: A scientific base for mental health
policy. S Afr Med J. 2009;99(5):337.
3 Williams D, Herman A, Stein D, Heeringa SG, Jackson PB,
Moolmal H, et al. Twelve-month mental disorders in South
Africa: prevalence, service use and demographic correlates in
the population-based South African Stress and Health Study.
Psychol Med. 2008;38(2):211–20.
4 Daar AS, Jacobs M, Wall S, Groenewald J, Eaton J, Patel
V, et al. Declaration on mental health in Africa : moving to
implementation. Global Health Action. 2014;7:1–4.
5 Schneider M. Disability and the environment. In: Watermeyer
B, Swartz L, Lorenzo T, Schneider M, Priestley M, editors.
Disability and social change: A South African agenda.
Pretoria: HSRC Press; 2006. p.7–18. [Internet]. [cited 24
16 6
March 2016].
URL: http://www.hsrcpress.ac.za/product.php?mode=search
20 IL
&page=1&freedownload=1&productid=2151
6 DE Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen
Y T
D, Asai I, et al. Physical illness in patients with severe mental
disorders. I. Prevalence, impact of medications and disparities
A N
in health care. World Psychiatry. 2011 Feb;10(1):52–77.
[Internet]. [cited 24 March 2016].
M U
URL: http://www.pubmedcentral.nih.gov/articlerender.fcgi?a
rtid=3048500&tool=pmcentrez&rendertype=abstract
7 De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht
4 ED
S, Ndetei DM, et al. Physical illness in patients with severe
mental disorders. II. Barriers to care, monitoring and treatment
guidelines, plus recommendations at the system and individual
level. World Psychiatry. 2011 Jun;10(2):138–51. [Internet].
O
[cited 24 March 2016].
URL: http://www.pubmedcentral.nih.gov/articlerender.fcgi?a
G
rtid=3104888&tool=pmcentrez&rendertype=abstract
8 Thornicroft G. Physical health disparities and mental
R
illness: The scandal of premature mortality. Br J Psychiatry.
2011;199(6):441–2.
BA
9 Andersen L, Kagee A, O’Cleirigh C, Safren S, Joska J.
Understanding the experience and manifestation of depression
O
in people living with HIV/AIDS in South Africa. AIDS Care.
EM
2014;27(1):59–62. [Internet]. [cited 24 March 2016].
URL: http://www.tandfonline.com/doi/
abs/10.1080/0954012.2014.951306
10 Kagee A. Symptoms of depression and anxiety among a
sample of South African patients living with a chronic illness.
J Health Psychol. 2008;13(4):547–55. [Internet]. [cited 27
March 2013].
URL: http://www.ncbi.nlm.nih.gov/pubmed/18420763
11 Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM,
Bradshaw D. The burden of non-communicable diseases in
South Africa. Lancet. 2009;374(9693):934-47. [Internet].
[cited 23 July 2011].
URL: http://www.ncbi.nlm.nih.gov/pubmed/19709736
12 Boutayeb A. The double burden of communicable and
non-communicable diseases in developing countries. Trans R
Soc Trop Med Hyg. 2006;100(3):191–9. [Internet]. [cited 24
March 2016].
URL: http://trstmh.oxfordjournals.org/cgi/doi/10.1016/j.
trstmh.2005.07.021
1 60
S A H R 20 1 6
13 Tsai AC, Tomlinson M, Dewing S, le Roux IM, Harwood
JM, Chopra M, et al. Antenatal depression case finding by
community health workers in South Africa: feasibility of a
mobile phone application. Arch Womens Ment Health. 2014
Oct;17(5):423–31.
14 Rochat TJ, Bland RM, Tomlinson M, Stein A. Suicide ideation,
depression and HIV among pregnant women in rural South
Africa. Health. 2013;05(3.A):650–61.
15 Manikkam L, Burns JK. Antenatal depression and its risk
factors: An urban prevalence study in KwaZulu-Natal. S Afr
Med J. 2012;102(12):940–4.
16 Brittain K, Myer L, Koen N, Koopowitz S, Donald KA,
Barnett W, et al. Risk Factors for Antenatal Depression and
Associations with Infant Birth Outcomes: Results From a
South African Birth Cohort Study. Paediatr Perinat Epidemiol.
PM
2015;29(6):505–14. [Internet]. [cited 24 March 2016].
URL: http://doi.wiley.com/10.1111/ppe.12216
17 Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L,
Molteno C. Post-partum depression and the mother-infant
relationship in a South African peri-urban settlement. Br J
Psychiatry. 1999 Dec 1;175(6):554–8. [Internet]. [cited 3
December 2013].
URL: http://bjp.rcpsych.org/cgi/doi/10.1192/
bjp.175.6.554
18 Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C.
Improving quality of mother-infant relationships and infant
attachment in socioeconomically deprived community in South
Africa: randomised controlled trial. BMJ. 2009;338(b974):1–
8.
19 Tomlinson M, Rotheram-Borus MJ, Harwood J, le Roux IM,
O’Connor M, Worthman C. Community health workers
can improve child growth of antenatally-depressed, South
African mothers: a cluster randomized controlled trial. BMC
Psychiatry. 2015;15(1):225. [Internet]. [cited 24 March
2016].
URL: http://www.biomedcentral.com/1471-244X/15/225
20 Uthman OA, Magidson JF, Safren SA, Nachega JB.
Depression and adherence to antiretroviral therapy in low-,
middle- and high-income countries: a systematic review and
meta-analysis. Curr HIV/AIDS Rep. 2014;11(3):291–307.
21 Dimatteo MR, Lepper HS, Croghan TW. Depression Is a Risk
Factor for Noncompliance With Medical Treatment: meta-
analysis of the effects of anxiety and depression on patient
adherence. Arch Intern Med. 2000 Jul 24;160:2101–7.
22 Freeman M, Nkomo N, Kafaar Z, Kelly K. Mental disorder in
people living with HIV/AIDS in South Africa. S Afr J Psychol.
2008;38(3):489–500.
23 Kagee A, Martin L. Symptoms of depression and anxiety
among a sample of South African patients living with HIV.
AIDS Care. 2010;22(2):159–65. [Internet]. [cited 24 March
2016].
URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=R
etrieve&db=PubMed&dopt=Citation&list_uids=20390494
24 Peltzer K, Naidoo P, Matseke G, Louw J, McHunu G, Tutshana
B. Prevalence of psychological distress and associated factors
in tuberculosis patients in public primary care clinics in South
Africa. BMC Psychiatry. 2012;12:89.
25 Peltzer K, Louw J, Mchunu G, Naidoo P, Matseke G, Tutshana
B. Hazardous and harmful alcohol use and associated factors
in tuberculosis public primary care patients in South Africa. Int
J Environ Res Public Health. 2012;9(9):3245–57.
26 Karim SA, Churchyard G, Karim QA, Lawn S. HIV infection
and tuberculosis in South Africa: an urgent need to escalate
the public health response. Lancet. 2009;374(9693):921–33.

27 Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR,
et al. No health without mental health. Lancet. 2007 Sep
8;370(9590):859–77. [Internet]. [cited 16 July 2014].
URL: http://www.sciencedirect.com/science/article/pii/
S0140673607612380
28 Mayston R, Kinyanda E, Chishinga N, Prince M, Patel V.
Mental disorder and the outcome of HIV/AIDS in low-income
and middle-income countries: A systematic review. AIDS.
2012;26(SUPPL.2):S117–35.
29 Nakimuli-Mpungu E, Bass JK, Alexandre P, Mills EJ, Musisi
S, Ram M, et al. Depression, alcohol use and adherence to
antiretroviral therapy in sub-Saharan Africa: A systematic
review. AIDS Behav. 2012;16(8):2101–8.
30 Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K,
Aboyans V, et al. Global and regional mortality from 235
causes of death for 20 age groups in 1990 and 2010:
a systematic analysis for the Global Burden of Disease
Study 2010. Lancet. 2012 Dec 15;380(9859):2095–128.
[Internet]. [cited 16 September 2013].
URL: http://www.ncbi.nlm.nih.gov/pubmed/23245604
16 6
31 Beaglehole R, Epping-Jordan J, Patel V, Chopra M, Ebrahim
S, Kidd M, et al. Improving the prevention and management
of chronic disease in low-income and middle-income
20 IL
countries: a priority for primary health care. Lancet. 2008 Sep
13;372(9642):940–9. [Internet]. [cited 24 March 2016].
URL: http://www.sciencedirect.com/science/article/pii/
S014067360861404X
Y T
A N
32 Ngo VK, Rubinstein A, Ganju V, Kanellis P, Loza N, Rabadan-
Diehl C, et al. Grand Challenges: Integrating Mental Health
M U
Care into the Non-Communicable Disease Agenda. PLoS
Med. 2013;10(5):1–5.
33 Wadman MC, Muelleman RL, Coto JA, Kellermann AL. The
4 ED
pyramid of injury: Using ecodes to accurately describe the
burden of injury. Ann Emerg Med. 2003;42(4):468–78.
34 Norman R, Bradshaw D, Schneider M, Jewkes R, Mathews
O
S, Abrahams N, et al. Estimating the burden of disease
attributable to interpersonal violence in South African in
G
2000. S Afr Med J. 2007;97(8 Pt 2):653-6.[Internet]. [cited
24 March 2016].
URL: http://www.ajol.info/index.php/samj/article/
R
viewFile/13894/59675
BA
35 Atwoli L, Stein DJ, Williams DR, Mclaughlin KA, Petukhova
M, Kessler RC, et al. Trauma and posttraumatic stress disorder
in South Africa: analysis from the South African Stress and
O
Health Study. BMC Psychiatry. 2013;13(1):182. [Internet].
EM
[cited 24 March 2016].
URL: http://www.pubmedcentral.nih.gov/articlerender.fcgi?a
rtid=3716970&tool=pmcentrez&rendertype=abstract
36 Statistics South Africa. Poverty Trends in South Africa. 2014.
[Internet]. [cited 24 March 2016].
URL: http://www.statssa.gov.za
37 Allen J, Balfour R, Bell R, Marmot M. Social determinants
of mental health. Int Rev Psychiatry. 2014;26(4):392–407.
[Internet]. [cited 24 March 2016].
URL: http://informahealthcare.com/doi/abs/10.3109/0954
0261.2014.928270
38 Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska
JA, et al. Poverty and common mental disorders in low and
middle income countries: A systematic review. Soc Sci Med.
2010;71(3):517-28. [Internet]. [cited 9 March 2012].
URL: http://www.ncbi.nlm.nih.gov/pubmed/20621748
39 Patel V. Poverty, inequality, and mental health in developing
countries. In: Leon D, Walt G, editors. Poverty, Inequality and
Health. Oxford: Oxford University Press; 2001. p.247–62.
S A H R 20 1 6
Mental health
40 Saraceno B, Levav I, Kohn R. The public mental health
significance of research on socio-economic factors in
schizophrenia and major depression. World Psychiatry.
2005;4(1723–8617):181–5.
41 Tomlinson M, Lund C. Why does mental health not get the
attention it deserves? An application of the Shiffman and
Smith framework. PLoS Med. 2012;9(2):1–4.
42 National Planning Commission. National Development Plan
2030: Our Future – Make it Work. Pretoria: The Presidency,
Republic of South Africa; 2015. [Internet]. [cited 24 March
2016].
URL: https://nationalplanningcommission.files.wordpress.
com/2015/02/ndp-2030-our-future-make-it-work_0.pdf
43 South African National Department of Health. National
Mental Health Policy Framework and Strategic Plan
2013–2020. Pretoria: National Department of Health; 2013.
PM
p.1–60.
44 South African National Department of Health. White Paper
for the Transformation of the Health System in South Africa.
Pretoria: National Department of Health; 1997. [Internet].
[cited 24 March 2016].
URL: http://scholar.google.com/scholar?hl=en&btnG=Search
&q=intitle:White+Paper+for+the+transformaton+of+the+health
+system+in+south+africa#0
45 South African National Department of Health. National health
policy guidelines for improved mental health in South Africa.
Pretoria: National Department of Health;1997.
46 Lund C, Flisher AJ. Norms for mental health services in
South Africa. Soc Psychiatry Psychiatr Epidemiol. 2006
Jul;41(7):587–94. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/16572274
47 Lund C, Flisher AJ. A model for community mental health
services in South Africa. Trop Med Int Health. 2009
Sep;14(9):1040–7. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/19552657
48 Lund C, Boyce G, Flisher AJ, Kafaar Z, Dawes A. Scaling up
child and adolescent mental health services in South Africa:
Human resource requirements and costs. J Child Psychol
Psychiatry Allied Discip. 2009;50:1121–30.
49 Government of South Africa. Mental Health Care Act 17 of
2002. Government Gazette Vol. 449, 6 November 2002,
No. 24024. Pretoria: Government Printers; 2002. [Internet].
[cited 24 March 2016].
URL: http://www.capementalhealth.co.za/Images/Act.pdf
50 Draper CE, Lund C, Kleintjes S, Funk M, Omar M, Flisher
AJ, et al. Mental health policy in South Africa: Development
process and content. Health Policy Plan. 2009;24(5):342–56.
51 Lund C, Kleintjes S, Kakuma R, Flisher AJ. Public sector mental
health systems in South Africa: inter-provincial comparisons
and policy implications. Soc Psychiatry Psychiatr Epidemiol.
2010 Mar;45(3):393–404. [Internet]. [cited 24 March
2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/19506789
52 Petersen I, Fairall L, Bhana A, Kathree T, Selohilwe O, Brooke-
Sumner C, et al. Integrating mental health into chronic care in
South Africa: the development of a district mental healthcare
plan. Br J Psychiatry. 2016;101:s1–11. [Internet]. [cited 24
March 2016].
URL: http://bjp.rcpsych.org/cgi/doi/10.1192/bjp.
bp.114.153726
53 Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin
G, et al. Challenges and opportunities for implementing
integrated mental health care: A district level situation analysis
from five low- and middle-income countries. PLoS One.
2014;9(2):e88437.
161
54 Lancet Global Mental Health Group, Chisholm D, Flisher AJ,
Lund C, Patel V, Saxena S, Thornicroft G, Tomlinson M. Scale
up services for mental disorders: a call for action. Lancet.
2007 Oct 6;370(9594):1241–52. [Internet]. [cited 24 March
2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/17804059
55 World Health Organization. Mental Health Action Plan
2013–2020. Geneva: World Health Organization;
2013.p.1–44. [Internet]. [cited 224 March 2016].
URL: http://www.who.int/mental_health/publications/
action_plan/en/
56 Thornicroft G, Patel V. Including mental health among
the new sustainable development goals. BMJ. 2014 Aug
20;349:g5189. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/25145688
57 Votruba N, Eaton J, Prince M, Thornicroft G. The importance
of global mental health for the Sustainable Development
Goals. J Ment Health. 2014;23(6):283–6.
58 Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ. Mental
illness and lost income among adult South Africans. Soc
16 6
Psychiatry Psychiatr Epidemiol. 2013;48(5):845–51.
59 Dixon A, McDaid D, Knapp M, Curran C. Financing mental
20 IL
health services in low- and middle-income countries. Health
Policy Plan. 2006;21(3):171–82.
60 World Health Organization. Mental Health Atlas 2014.
Y T
Geneva: World Health Organization; 2014.
A N
61 Patel V. Mental health in low- and middle-income countries.
Br Med Bull. 2007 Jan;81–82:81–96. [Internet]. [cited 24
M U
March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/17470476
4 ED
62 Mahal A, Karan A, Engelgau M. The Economic Implications
of Non-Communicable Disease for India. Health, nutrition and
population (HNP) discussion paper. Washington, DC: Health,
Nutrition and Population Family (HNP) of the World Bank’s
O
Human Development Network; 2010.
63 World Health Organization. Mental Health Atlas. Geneva:
G
World Health Organization; 2011.
64 Goudge J, Gilson L, Russell S, Gumede T, Mills A. The
R
household costs of health care in rural South Africa with free
public primary care and hospital exemptions for the poor.
BA
N
Trop Med Int Health. 2009 Apr;14(4):458–67. [Internet].
[cited 24 March 2016].
O
URL: http://www.ncbi.nlm.nih.gov/pubmed/19254274
EM
65 South African National Department of Health. National Health
Insurance for South Africa. White Paper. December 2015.
[Internet]. [cited 24 March 2016].
URL: http://www.health-e.org.za/wp-content/
uploads/2015/12/National-Health-Insurance-for-South-Africa-
White-Paper.pdf
66 Bateman C. Mental health under-budgeting undermining SA’s
economy. S Afr Med J. 2015;105(1):8–9.
67 Petersen I, Lund C, Bhana A, Flisher AJ. A task shifting
approach to primary mental health care for adults in South
Africa: human resource requirements and costs for rural
settings. Health Policy Plan. 2012 Jan;27(1):42–51. [Internet].
[cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/21325270
68 Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju
K, Morris JE, et al. Human resources for mental health care:
current situation and strategies for action. Lancet. 2011 Nov
5;378(9803):1654–63. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/22008420
1 62
S A H R 20 1 6
69 Spedding MF, Stein DJ, Sorsdahl K. Task-shifting psychosocial
interventions in public mental health: A review of the evidence
in the South African context. In: Padarath A, King J, English
R, editors. South African Health Review 2014/15. Durban:
Health Systems Trust; 2015. p.73–87. [Internet]. [cited 24
March 2016].
URL: http://www.hst.org.za/publications/south-african-health-
review-2014/15
70 Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R,
Jordans M, et al. PRIME: a programme to reduce the treatment
gap for mental disorders in five low- and middle-income
countries. PLoS Med. 2012 Jan;9(12):e1001359. [Internet].
[cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/23300387
71 Sorsdahl K, Stein DJ, Corrigall J, Cuijpers P, Smits N, Naledi
T, et al. The efficacy of a blended motivational interviewing
and problem solving therapy intervention to reduce substance
PM
use among patients presenting for emergency services in
South Africa: A randomized controlled trial. Subst Abuse
Treat Prev Policy. 2015;10(1):46. [Internet]. [cited 24 March
2106].
URL: http://substanceabusepolicy.biomedcentral.com/
articles/10.1186/s13011-015-0042-1
72 Lund C, Schneider M, Davies T, Nyatsanza M, Honikman S,
Bhana A, et al. Task sharing of a psychological intervention
for maternal depression in Khayelitsha, South Africa: study
protocol for a randomized controlled trial. Trials. 2014
Jan;15(1):457. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/25416557
73 Van Boekel LC, Brouwers EPM, Van Weeghel J, Garretsen
HFL. Stigma among health professionals towards patients
with substance use disorders and its consequences for
healthcare delivery: Systematic review. Drug Alcohol Depend.
2013;131(1–3):23–35. [Internet]. [cited 24 March 2016].
URL: http://dx.doi.org/10.1016/j.drugalcdep.2013.02.018
74 Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for
common mental disorders in low resource settings: reasons
for caution and a way forward. Int Health. 2013 Mar
1;5(1):11–4. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/23580905
75 Honikman S, van Heyningen T, Field S, Baron E, Tomlinson
M. Stepped care for maternal mental health: a case study of
the perinatal mental health project in South Africa. PLoS Med.
2012;9(5):e1001222.
76 Day C, Gray A. Health and related indicators. In: Padarath
A, English R, editors. South African Health Review 2012/13.
Durban: Health Systems Trust; 2013. p.207–322.
77 National Prosecuting Authority. Thuthuzela: turning victims into
survivors. 2009.
URL: https://www.npa.gov.za/sites/default/files/resources/
public_awareness/TCC_brochure_august_2009.pdf
78 Dewing S, Mathews C, Schaay N, Cloete A, Louw J, Simbayi
L. “It’s important to take your medication everyday okay?”
An evaluation of counselling by lay counsellors for ARV
adherence support in the Western Cape, South Africa. AIDS
Behav. 2013;17(1):203–12.
79 Petersen I, Fairall L, Egbe CO, Bhana A. Optimizing
lay counsellor services for chronic care in South
Africa: A qualitative systematic review. Patient Educ
Couns.2014;95(2):201–10. [Internet]. [cited 24 March
2016].
URL: http://dx.doi.org/10.1016/j.pec.2014.02.001
 Mental health

80 Brooke-Sumner C, Petersen I, Asher L, Mall S, Egbe CO,

Lund C. Systematic review of feasibility and acceptability
of psychosocial interventions for schizophrenia in low and
middle income countries. BMC Psychiatry. 2015;15:19.
[Internet]. [cited 24 March 2015].
URL: http://www.biomedcentral.com/1471-244X/15/19
81 Padmanathan P, De Silva MJ. The acceptability and feasibility
of task-sharing for mental healthcare in low and middle
income countries: a systematic review. Soc Sci Med. 2013
Nov;97:82–6. [Internet]. [cited 24 March 2016].
URL: http://www.ncbi.nlm.nih.gov/pubmed/24161092

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

1 63
S A H R 20 1 6
 164
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Sex work and South Africa’s health system:
addressing the needs of the underserved
14

Authors:
Andrew Scheibe i,ii
Marlise Richter iii,iv,v

PM
Jo Vearey v

16 6
S 20 IL
ex work remains illegal and highly stigmatised in South Africa, resulting in South Africa will not
sex workers – the majority of whom are internal or cross-border migrants –
Y T
experiencing ongoing human rights violations and a high HIV burden. High reach the United Nations
A N
levels of unemployment, limited socio-economic opportunities and associated Joint Programme on
migration dynamics mean that sex work remains a key livelihood option for many
HIV and AIDS 90-90-90
M U

cisgender and transgender women and men in sub-Saharan Africa.

targets unless adequate
This chapter reviews the health system’s response to sex work in South Africa, with
4 ED

a focus on HIV-related programmes. The analysis is based on the World Health attention and political will
Organization’s health system ‘building blocks’ framework and is informed by a are invested in sensitive,
policy scan, literature review, consultation with sex work experts, and reflection.
appropriate and evidence-
O

We provide an analysis of the politics of much-needed structural interventions such as

based responses to sex
G

sex work law reform, the removal of ideological provisions in donor grant agreements,
and the need for strong political will to roll-out sex work-specific health programmes. worker health.
R

The authors argue that South Africa will not reach the United Nations Joint Programme
BA

on HIV and AIDS (UNAIDS) 90-90-90 targets unless adequate attention and political
will are invested in sensitive, appropriate and evidence-based responses to sex
O

worker health.
EM

Limited but important progress has been made in expanding appropriate programmes
for sex workers in South Africa. Much more is needed to reach and empower sex
workers to keep themselves safe, safeguard public health, and achieve health-related
sustainable development goals. Delays in addressing data gaps, implementing
global recommendations on sex work law reform and evidence-based interventions
continue to impact negatively on sex worker morbidity and mortality, and have wide-
ranging implications for public health and related expenditure.

i Desmond Tutu HIV Centre

ii Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, Universit y of
Cape Town
iii Sonke Gender Justice
iv School of Public Health and Family Medicine, Universit y of Cape Town
v African Centre for Migration and Societ y, Universit y of the Wit watersrand, Johannesburg

1 65
Introduction
The healthcare system is a central determinant of health, with quality
and access – comprising availability, acceptability and affordability
– to health services being recognised as key to achieving equity in
health and wellbeing.1 This is especially relevant for populations on
the peripheries: those who are often excluded from social welfare
provision, face disproportionately high levels of vulnerability to
illness, and endure an increased impact of poor health.2 The context
of sex work in South Africa places sex workers – referred to here as
adults who consent to the sale of sex3 – on the periphery: individuals
involved in the sale of sex in South Africa are criminalised; are
particularly vulnerable to illness, sexually transmitted infections
(STIs), violence and abuse; and are underserved by the current
health system. As a result, sex workers face increased exposure to
system that may not meet their health needs. Against this background,
the chapter reviews current sex worker health interventions in South
Africa, and analyses policy and legal frameworks relating to sex
workers, the sex work setting and public health. The analysis
focuses on the World Health Organization (WHO) health system
‘building blocks’ framework4 from a sex worker health perspective.
The chapter concludes with recommendations for health system
strengthening to address the health inequities experienced by sex
workers in South Africa. Some of the key terms used in this chapter
are presented in Box 1.
Methods

health risks and are often unable to mitigate dangers. These risks
are compounded by migration status, sexual orientation, gender
non-conformity, working in unsafe spaces where clients are solicited,
and through harmful substance use.
PM
A rapid analysis of sex work, health and rights, with a focus on
HIV, in the South African context was conducted. The WHO Health
Systems Framework was used to analyse the South African health
system from a sex work health perspective, structured on the health

16 6
system building blocks7 (see Figure 1). Data were collected through
This chapter provides a contextual understanding of sex work in

20 IL
a policy scan and literature review, supported by engagement
South Africa, and an overview of the health and rights inequities
with sex worker service providers and reflections on the authors’
experienced by sex workers. These inequities are linked to their
professional experience. Each author has over eight years’
Y T
exclusion from society, and their dependence on a public health
experience of working on issues relating to sex worker health in
A N
South Africa, with various areas of focus, including HIV prevention,
Box 1: Key definitions and terminology
sex worker human rights advocacy and law reform, and migration
M U

and health.
Terminology, identity politics and sexual behaviours
Gender refers to the social attributes and opportunities associated with The literature review on sex work and health in South Africa
4 ED

being male and female, which are socially constructed, learnt and presented in this chapter builds on recently published work and
therefore changeable.3 work in press undertaken by the authors, with searches conducted
Biological sex is a classification based on reproductive organs and via ScienceDirect, Pubmed and Google Scholar. Apart from data
functions that are present from birth.3
O

and literature used to provide a historical perspective of sex work

Cisgender refers to the alignment of gender identity and expression to law reform and policy processes, data sources published between
G

norms and expectations traditionally associated with biological sex.3 2005 and 2015 and focusing on sex work, health and rights in
Transgender refers to people whose gender identity and expression does the South African and sub-Saharan setting were incorporated.
R

not conform to the norms and expectations traditionally associated with The review of grey literature, policy and technical documents
their sex at birth.3 was informed through the authors’ ongoing work in this area,
BA

Who is a sex worker? involvement in policy spheres, and through engagement with key
An important assumption of sex work-specific health care programming actors and experts who were invited to share recent unpublished
O

is that healthcare users would self-identify as the target group – thus grey literature. A range of sex work experts were contacted via
EM

that women, men and transgender people who sell sex would perceive
themselves as being ‘sex workers’ – and would want to utilise these
services. “Conceptually – but also programmatically – some of the biggest
challenges for policy-makers and researchers in Africa in addressing
this vulnerability [to STIs] are the diverse forms of sex work and their
overlap with sexual networks in the general population. The difficulty
of distinguishing ‘sex work’ from transactional sex in all its various
manifestations demonstrates this vividly”.5
email or telephone and programme documentation was reviewed.
Expert key informants included sex workers, programme managers,
researchers and representatives from technical agencies, who were
requested to provide additional information related to the WHO
health system building blocks. Recommendations were developed
using a social determinants of health lens.1

While precise definitions of sex work remain elusive, the outdated socio-
legal understanding of ‘sex-for-reward’ could conceivably include a
cascade of sexual interactions including transactional sex, ‘sugar-daddies’,
survival sex and even sex within marriage.6 Although definitions remain
varied and imprecise, the importance of peer educators reaching out
into sex worker communities and linking health care users to specialised
services remains important.

Terminology on sex work and gender identities

Cisgender-female sex workers: Refers to sex workers who were born
biologically female and identify as female.

Transgender-female sex workers: Refers to sex workers who were born

biologically male but identify as female.

Male sex workers: Refers to sex workers who were born biologically male.

166 S A H R 20 1 6
 Sex work

Figure 1: World Health Organization Health Systems Framework

System building blocks Goals/outcomes

Leadership / governance Improved health

(level and equity)
Access

Health care financing Coverage

Responsiveness
Health workforce

Medical products, technologies

Financial risk protection
Quality
Information and research Safety

PM
Improved efficiency
Service delivery

16 6
Source: World Health Organization, 2016.7

20 IL
Key findings Y T
Context
A N
Background to sex work in South Africa
M U

In 2013 it was estimated that between 132 000 and 182 000 restrictive Immigration Act – which makes it difficult for lower-skilled
people sold sex in South Africa.8 Sex work is an important livelihood and job-seeking migrants to regularise their stay in the country –
4 ED

strategy and approximately two-thirds of female sex workers in the presents additional legal challenges for non-national sex workers
sub-Saharan region report being responsible for dependants.5 The who may struggle to obtain and maintain the documents required
majority of female sex workers operate on their own and seldom rely to be in South Africa legally.17,18 This compounds the discrimination
O

on intermediaries (such as ‘pimps’ or ‘controllers’). In South Africa, experienced from healthcare providers and the police.19
sex work typically offers higher earnings than other work available
G

Research has shown that the removal of criminal penalties for sex
for the same education level.9–11 Many part-time sex workers do
work – specifically the decriminalisation of sex work where no
not identify with the term, concept or identity associated with sex
R

criminal law is applied and sex work is regulated within a human

work5,12 and as a result may not be exposed to sex work-specific
rights framework and existing labour laws – has a far-reaching
BA

health promotion campaigns or know about the risks associated with

N

impact on sex worker and public health.20 More specifically, a

sex work. Sex work and places of solicitation are heterogeneous,
recent modelling study based on data from Canada, Kenya and
O

such as indoor (e.g. brothels or massage parlours), outdoor (on

India estimated that between 33% and 46% of HIV infections could
the street) or through media platforms (e.g. cell-phone, on-line or in
EM

be averted among female sex workers and clients within a decade

newspapers).13
There is a strong association between sex work and migration,
usually linked to people’s search for improved livelihood options. A
study conducted in Johannesburg, Cape Town and Rustenburg found
that the majority of female sex workers were either cross-border
(46.3%) or internal (39%) migrants.14
The impact of criminal law
In South Africa, all aspects of sex work are criminalised, which
reinforces and compounds the stigma attached to sex work. Sex
workers – and migrants – commonly experience a range of human
rights violations that affect their health, including stigma and
discrimination from law enforcement officers, criminal justice officials
and healthcare providers. High levels of violence perpetuated by
clients and police have been widely reported.5,15 Conviction with
a criminal record because of the criminalisation of sex work poses
additional obstacles if a sex worker chooses to exit sex work and
seek other forms of employment.16 South Africa’s increasingly
– in both generalised and concentrated HIV epidemic contexts – if
sex work were decriminalised.21 The Global Commission on HIV
and the Law recommends the decriminalisation of sex work; these
recommendations were based on over 18 months of research,
consultation, and a review of testimonies of people directly affected
by HIV-related legal environments from across the world, including
submissions from South Africa.20
Sex work and the law
All forms of sex work, including the purchasing of sexual services
and living off the proceeds of sex work, are illegal in South Africa.
According to the Sexual Offences Act (23 of 1957) it is a crime to
have ‘unlawful carnal intercourse’ or commit an act of ‘indecency’
with any person for reward. ‘Unlawful carnal intercourse’ is defined
as sex with anyone other than ones husband or wife. The reward is
not clearly explained but it is generally considered to be money. It
is also an offence to keep a brothel and conduct related activities.

S A H R 20 1 6 1 67
Often, municipal by-laws rather than the Sexual Offences Act are
used to arrest sex workers because of the difficulties inherent in
proving the elements of the offence, particularly in relation to the
client.
The South African Law Reform Commission was charged to research
and provide recommendations on law reform for sex work (South
African Law Reform Commission Project 107 ‘Adult Prostitution’).
This process has been ongoing for more than 15 years, and the
Commission has not yet released recommendations on amendments
to this outdated law.22
Sex work, health and HIV
Whilst this chapter will focus on HIV to highlight the ways in which
a range of social determinants influence the health and wellbeing
of sex workers, individuals who sell sex experience a wide range of
health inequities including those related to reproductive health and
rights, chronic illness, mental health and substance use.23
16 6
Unprotected paid sex is a significant factor in the HIV epidemics of
sub-Saharan Africa;24 HIV prevalence among sex workers and sex
20 IL
worker clients is about 10–20 times higher than among the general
population in the region.25 In 2013, the first multisite integrated
Y T
HIV biological behavioural surveillance (IBBS) study was conducted
among female sex workers in South Africa. The IBBS (n=2 180)
A N
estimated that HIV prevalence among female sex workers was
71.8% in Johannesburg (Gauteng Province); 39.7% in Cape Town
M U
(Western Cape Province), and 53.5% in Durban (KwaZulu-Natal
Province).26 In 2014, an IBBS found a sample HIV prevalence
4 ED
among 173 female sex workers in Harrismith (Free State Province)
and Pietermaritzburg (KwaZulu-Natal Province) to be 88.4%.27
Another study in 2014/15 found HIV prevalence among female
O
sex workers in Port Elizabeth (Eastern Cape Province) (n=410) to be
63.7%.28 These figures indicate that HIV prevalence among female
G
sex workers is 1.9 to 5.3 times higher than among females aged
R
15 years and older in the general population.29 Equally worrying
is the significant proportion of female sex workers who know that
BA
they are living with HIV but are not currently on antiretroviral
therapy (ART): 12% in Cape Town; 25% in Durban and 38% in
O
Johannesburg.28 A range of barriers – including mobility and their
EM
status as migrants – impede sex worker access to health care, HIV
testing, retention in treatment, care and support, and access to HIV
prevention technologies. Some of these are described in this section.
Critically, a lack of national data on (1) the number of sex workers
who are HIV-positive and have tested for HIV; (2) the number of sex
workers living with HIV who are eligible for ART; (3) the number of
sex workers on ART, and (4) the number of sex workers on ART who
are virologically suppressed, hinders the quantification of progress
towards reaching the Joint United Nations Programme on HIV and
AIDS (UNAIDS) 90-90-90 targets that are needed to bend the
trajectory of the HIV epidemic.30
Factors inf luencing HIV risk among sex workers
A number of characteristics of the sex work context increase the
risk of HIV acquisition and ill-health among sex workers and their
partners, most notably that of frequent sexual intercourse with
multiple partners where protected sex cannot always be negotiated.
Cisgender and transgender women and men who sell sex face
different configurations of HIV risk, related to social, biological
168 S A H R 20 1 6
and behavioural factors.15,31 The majority of sex workers are
migrants from elsewhere in South Africa (internal migrants) or from
neighbouring countries (cross-border migrants) and their status as
migrants presents additional HIV risk factors. Whilst a full discussion
of the association between migration and HIV is beyond the scope
of this chapter, please see Richter and Vearey (in press).17 In areas
where sex workers are poorly organised, negotiating condom use
with clients may be particularly fraught and sex workers may not be
able to insist on protected sex.32,33 Various studies have documented
harmful use of alcohol and drugs in sex work settings, which impacts
on sex workers’ ability to refuse dangerous clients or to negotiate
safer sex.34,35 Violence against sex workers remains high and has
been well documented as a risk factor for HIV.36,37 Regrettably,
few studies on sex work in South Africa focus on exploring the risk
mitigation strategies used by sex workers.5
PM
In the hierarchy of dangers associated with sex work, street-
based sex workers are often designated as the most vulnerable;
they tend to be independent operators not tied to obligations and
commissions associated with brothel-based sex work, with flexibility
of work and autonomy being prized,38 yet their visibility in public
spaces increases their exposure to police arrest, harassment
and abuse by the general public.39,40 Attempts at keeping their
profession a secret while having sex in cars or public places may
impose time and security pressures which impede safer sex.41,42
Whilst the stigmatising attitudes of healthcare workers have been
well documented, an increasing evidence base highlights the
police practice of using ‘condoms as evidence’.43 This involves the
police searching sex workers and, when finding condoms in their
possession, either confiscating or destroying them, or using them as
proof that the person is guilty of prostitution.44 This is in direct conflict
with public health policy, and this contradiction is highlighted in the
South African National Sex Worker HIV Plan.45
Sex work and the politics of HIV policy and implementation
Despite clear evidence being available since the onset of the HIV and
AIDS pandemic showing that sex workers are particularly vulnerable
to HIV, and that the sex work context impacts on public health, South
Africa’s health and policy responses to sex work have a chequered
history. South Africa’s first AIDS Plan in 1994 recommended that
the criminal law around sex work should be removed; several years
later, the only mention of sex work in the National HIV/AIDS/STD
Strategic Plan for South Africa 2000–2005 was to task several
government actors to investigate the decriminalisation of sex work.
The National Strategic Plan (NSP) 2007–2011 included a more
rigorous engagement with sex work; it rejected discrimination
against sex workers, acknowledged the increased vulnerability of
sex workers to HIV, recommended the rolling out of customised
prevention packages for sex workers, and proposed that sex work in
South Africa be decriminalised.46 Regrettably, little changed during
that period, with a mid-term review of the 2007 NSP noting scant
progress in the implementation of sex worker programmes.47
Significantly, sex workers were recognised as a key population
in the National Strategic Plan on HIV, STIs and TB 2012–2016
(the ‘2012 NSP’).48 The drafting of the 2012 NSP in 2011 saw
the insertion of several strong human rights provisions including
the decriminalisation of sex work. However, these important and
progressive additions were removed by Cabinet before the 2012
NSP was launched on World AIDS Day 2011, despite civil society

consensus on the inclusion of these provisions.49 The subsequent
South African National AIDS Council (SANAC) compromise with
the SANAC Sex Work Sector was the drafting of a separate NSP for
sex workers. Regrettably, this comprehensive National Strategic Plan
for HIV Prevention, Care and Treatment for Sex Workers (the ‘SW
NSP’)50 was never officially launched.
Despite the removal of some key human rights sections, the final
version of the 2012 NSP did include a number of key programmatic
areas for sex workers. In spite of this, the 2012 NSP Progress Report
noted limited successes in reaching the sex worker population,
despite citing studies that showed HIV prevalence among sex
workers to be 26–59.6%, thus highlighting the urgent need for
programmes to reach sex workers. The report described the Sex
Worker NSP (that was never officially launched), and a sex workers
size estimation survey, as “important achievements”.51
In 2015, the SANAC Secretariat brought together a Sex Worker
Technical Working Group to draft a South African National Sex
16 6
Worker HIV Plan 2016–2019 (‘the Sex Worker Plan 2016–2019’).
This plan was launched in March 2016 and emphasises a
20 IL
“comprehensive and nationally coordinated response”. It delineates
clear aims and targets, and recommends the decriminalisation of
sex work.45 Y T
A N
Review of South Africa’s health systems building blocks
from a sex work perspective
M U
This section presents a brief analysis of current responses to sex
worker health in relation to the health systems building blocks,
4 ED
noting successes and shortcomings.
Leadership and governance
O
Leadership, governance, legislation and policies – and the ways
in which they are implemented and monitored – are considered
G
to constitute the most critical and complex health system building
R
block.7 Many of the health inequities that sex workers experience,
including the high HIV burden, are compounded by the ongoing
BA
N
criminalisation of sex work in South Africa and the lack of political
will to reform criminal law in this regard. UNAIDS, the WHO and
O
the United Nations Development Programme (UNDP) recommend
EM
the decriminalisation of sex work.52 These recommendations are
informed by recommendations of the Global Commission on HIV
and the Law, which synthesised available evidence around the
advantages and disadvantages of a range of legal frameworks
and their influence on health and rights with a mounting evidence
base.20 The delay in legal reform and lack of high-level commitment
to address sex work issues in South Africa has contributed to ongoing
HIV infections among sex workers, their clients and society at large.
The lack of high-level stewardship to interrogate outdated morally
based frameworks that are often used to influence policy and laws
also contributes to the high levels of stigma and discrimination faced
by sex workers in the community, and ultimately in health facilities.53
Ideologically based (as opposed to evidence-based) considerations
in addressing sex work are also evident in international funding
decisions. Much of the funding for HIV prevention and programming
in South Africa comes from the international community, particularly
through the United States Presidents Emergency Plan for AIDS Relief
(PEPFAR) and the Global Fund to Fight HIV, Tuberculosis and Malaria
(the ‘Global Fund’).54 However, organisations that receive financial
S A H R 20 1 6
Sex work
support from PEPFAR are required to sign a so-called ‘Anti-prostitution
Pledge’. According to the United States’ ‘Leadership Against HIV/
AIDS, Tuberculosis, and Malaria Act of 2003’, all non-United States
(US) non-governmental organisations (NGOs) that receive United
States Government Grants (i.e. PEPFAR, United States Agency for
International Development (USAID), Centers for Disease Control and
Prevention (CDC)) are required to sign an agreement with PEPFAR
that commits them to the following (section 22 U.S.C. § 7631(f)):
No funds made available to carry out this chapter, or any
amendment made by this chapter, may be used to provide
assistance to any group or organization that does not have
a policy explicitly opposing prostitution and sex trafficking,
except that this subsection shall not apply to the Global Fund
to Fight AIDS, Tuberculosis and Malaria, the World Health
PM
Organization, the International AIDS Vaccine Initiative or to any
United Nations agency.
Even though these funding requirements have been found in various
court challenges to violate freedom of speech in the United States
and cannot be applied to NGOs in the US (‘domestic affiliates’)
or to its ‘foreign affiliates’ in other countries,55 they still apply to
‘foreign NGOs’.a,56 Commendably, PEPFAR has enabled the
scale-up of much-needed services and has thereby averted millions
of AIDS-related deaths and prevented HIV infections. Against the
backdrop of such far-reaching success and impact, it is regrettable
that organisations receiving PEPFAR funds that are aware of sex
worker human rights violations enabled under a criminalised
system, cannot promote law reform for sex work in case they are in
contravention of the Anti-prostitution Pledge.57
Stewardship around enabling all people to realise their rights to
health and freedom from discrimination is important. Mobilisation
and representation of sex workers on decision-making bodies and
public platforms are gaining traction and challenging negative
stereotypes of sex workers. Successes include the establishment
of the Sisonke Sex Worker Movement (a South African national
movement of sex workers) that has grown in size and in political
influence. SANAC established a Sex Work (Civil Society) Sector in
2009 comprising representatives involved in sex work, health and
rights.49
Due to the high levels of migration and mobility within South
Africa and the region, health policy and programmatic responses
should engage with migration and enable all people who migrate,
including sex workers, to have continued access to public healthcare
services.58 Within the Southern African Development Community
(SADC), efforts are under way to harmonise responses relating
to mobility and healthcare access, including the ratification of a
declaration on tuberculosis (TB) in the mines and the drafting of
a financing framework for a regional response to communicable
diseases and population mobility.58,59
a The Centre for Health and Gender Equity provides the following explanation:
“The 2013 Supreme Court ruling, holding the [PEPFAR Anti-Prostitution
Pledge] unconstitutional, applies only to U.S. NGOs and their foreign
affiliates. The [Pledge] is not unconstitutional when applied to foreign
NGOs, and therefore foreign NGOs are still required to have a policy
opposing sex work in order to receive PEPFAR funding. Foreign NGOs are
not protected by the U.S. Constitution’s First Amendment, and are thus not
provided the constitutional right of free speech.”
1 69
Financing
Globally, less than 1.0% of HIV prevention funding focuses on sex
work,60 while fewer than 50.0% of sex workers had access to HIV
prevention services in 2009.61,62 This investment-burden of disease
mismatch is reflected in South Africa’s investment in the HIV response.
In 2013/14, R130.7 million (R3.6 million by the Global Fund,
R23.7 million by PEPFAR and R103.4 million by the South African
Government) was spent on HIV prevention, HIV testing and linkage
to care programmes for sex workers. This is equivalent to about
1.5% of spending on ART, half the amount spent on communication
for behaviour change, and almost a tenth of the amount spent on
HIV testing services for the general population.54
Investments in 2013/14 were higher than in 2011, and reflected
investments from the South African Government, PEPFAR and the
Global Fund to support the scale-up of sex worker prevention and
testing services. Current funding mechanisms have supported civil
society organisations to provide sex work-appropriate services and
16 6
also enable effective public-private partnerships, largely through
the South African Government’s HIV/AIDS Conditional Grant,b
20 IL
PEPFAR through CDC and USAID, and the Global Fund’s ‘Red
Umbrella Programme’ that is co-ordinated through SANAC and the
Networking HIV/AIDS Community of South Africa (NACOSA).63,64
Y T
Regrettably, HIV expenditure on ART is not disaggregated by key
A N
population group. Current government financing does not allow for
M U
the provision of oral pre-exposure prophylaxis, ‘Universal Treatment’
and ‘Test and Treat’, which are key components to safeguarding
sex worker health. These are currently under consideration by
4 ED
the South African Government.65 Decreasing international donor
funding poses a particular threat to sex work programming as it
currently accounts for a quarter of direct financing for sex work
O
programmes.54
G
New mechanisms for financing health care in South Africa are
becoming more important as the country moves towards the
R
implementation of National Health Insurance which will finance
health services by pooling funds to increase access to quality and
BA
N
affordable personal health services in the country. In the context of the
criminalisation of sex work, sex workers will not be able to contribute
O
to National Health Insurance through salary-based taxation, while
EM
cross-border migrant sex workers may face particular barriers to
care. Compared to existing legislation, the current National Health
Insurance White Paper suggests a regression of the right to access
public health care for non-nationals, with full fees being proposed
for all undocumented migrants and asylum seekers.66 Given the
linkages between migration, sex work and HIV, it is essential that
access to health care for all – regardless of documentation status or
livelihood activity – is ensured within the framework of the National
Health Insurance system.
b Conditional Grants are financing mechanisms provided by the South African
Government to provincial government departments for specific programmes.
The Comprehensive HIV and AIDS Grant earmarks financial support for
Provincial Departments of Health to provide a range of HIV-related services
to develop an effective response to HIV and AIDS.
170
Health workforce
Healthcare providers in the community and in health facilities
play an important role in enabling health. An ethical health sector
response to sex work would aim to create a safe, effective and non-
judgemental space that would attract sex workers – including non-
national sex workers – to its services, with a workforce capacitated
to provide high-quality, acceptable health services.67,68
Peer-delivered prevention, testing and linkage to care services are
recommended best practices for sex work programming.52 Peers
provide a range of services within South African communities.
Between 2012 and 2015, there were 2 240 peer educators
employed as part of the National Department of Health’s High
Transmission Areas programme, 560 sex work peers through the
Global Fund-supported Red Umbrella programme, and 122 through
PM
PEPFAR-supported programmes.45
In 2012, Quality Assurance Standards for Peer Education and
Outreach Programmes for High Risk Vulnerable Populations in
South Africa were developed by ICF International, with input from
organisations implementing large-scale sex work programmes.69 The
National Department of Health’s High Transmission Area Guidelines
include minimum standards for peer outreach programmes and
recommendations for community mobilisation for key populations,
including sex workers.70 In 2015, South African Partners used
these as part of quality assurance and quality improvement
processes for key population peer programmes, including sex
worker programmes.71 While a recent systematic review found that
community empowerment-based approaches to addressing HIV
among sex workers were significantly associated with reductions in
HIV, and with increases in consistent condom use with all their clients,
it found pernicious challenges to scaling up these programmes,
including the legal context, ideological approaches to sex work,
and the stigma attached to sex work.72 The Disseminating Avahan
Lessons in South Africa Project, implemented by FHI360 between
2011 and 2015, provided technical support to SANAC and the
National Department of Health to enhance sex worker-related
policy and programmes in South Africa. This project was informed
by lessons learnt through India’s Avahan project that successfully
used sex worker community empowerment to reduce HIV-related
morbidity and improve the wellbeing of sex workers.73,74
The clinical setting remains the site of human rights abuses and the
unethical treatment of sex workers by healthcare providers. Research
with sex workers in South Africa and the region documents a range
of problems associated with healthcare provision in these countries:
poor treatment and discrimination by healthcare workers; having
to pay bribes to obtain services or treatment; being humiliated
by healthcare workers; and breaches of confidentiality.5,15 Other
studies in South Africa and elsewhere confirm that sex workers’
negative experiences with healthcare services act as a barrier
to accessing services and contribute to delays in treatment, not
accessing treatment, and loss to follow-up with associated poor
health outcomes. In addition, non-nationals are known to face
challenges in accessing health care, further marginalising cross-
border migrants engaged in the sex industry.75,76
Initial systems have been developed by civil society organisations
to capture human rights violations systematically within the health
sector. Systems include a telephonic hotline and paralegal training
S A H R 20 1 6

for peer outreach workers.77 However, data quantifying rights
violations in healthcare settings are not currently available.
To our knowledge, the University of Pretoria’s medical students’
service learning and community-based education programme is the
only undergraduate training programme for health professionals
that exposes students to community-based HIV-related programming.
Through this project, medical students engage with community-based
HIV prevention services for sex workers provided by civil society
organisations.78 The Desmond Tutu HIV Foundation developed sex
worker sensitisation training tools79 and organisations working with
sex workers implement in-service health worker sensitisation training
around sex work in line with WHO recommendations.52 Most
recently, the South African Government partnered in a programme
that integrated issues relating to sex work and other key populations.
Regrettably, inclusion of this training into medical and nursing
training colleges and into regional training centres, and subsequent
scale-up, have not happened.80 Laudably, the Southern African HIV
Clinicians’ Society has recently supported the decriminalisation
16 6
of sex work,81 while bodies such as the South African Medical
Association and the Nursing Council have yet to develop a position
20 IL
statement on the provision of services for sex workers.
A key concern relates to ensuring treatment continuity for HIV – and
Y T
other chronic conditions – for migrant and mobile sex workers. The
A N
World Health Assembly passed a Resolution in 2008 that provides
specifically for the need to improve health systems responses to
M U
migrant and mobile populations, which are critical for sex workers
in South Africa.58 Whilst healthcare workers currently receive no
4 ED
training on migration, which results in misunderstanding about
mobility and movement in the country and region, training modules
produced by the International Organization for Migration in
partnership with the African Centre for Migration and Society at the
O
University of the Witwatersrand, and helpful guidelines produced by
G
the United Nations High Commissioner for Refugees – in partnership
with various organisations including the Southern African HIV
R
Clinicians’ Society – are available.82
BA
Medical products, vaccines and technologies
O
Currently, a minimum package of HIV prevention services is
provided through peer-delivered mechanisms and a somewhat more
EM
comprehensive service from mobile clinics, specialised sex worker
health services and the public health sector. Although condoms
are widely available, the use of condoms as evidence of sex work
remains a barrier to their uptake and use by sex workers.44 Lubricant
is not widely distributed and access is limited; a government tender
for lubricant was only issued in 2014. Condoms remain the major
HIV prevention technology, but the limited range of sizes, colours
and scents has limited their appeal. Access to female condoms
is more limited than male condoms.34 Provincial Departments
of Health have started to place orders and receive stock of the
National Department of Health’s tender for one billion coloured and
scented male condoms and 20 million litres of lubricant as part of
the Department’s efforts to increase condom usage.c Dental dams,
a barrier prevention method to prevent STIs through oro-genital
and/or oro-anal contact, are not included as a standard part of
sex work HIV prevention commodities. While these prevention
technologies and their accessibility are of benefit to HIV prevention
c Personal communication: E. Marumo, National Department of Health, HIV,
STI and TB sub-directorate, 12 February 2016.
S A H R 20 1 6
Sex work
efforts in general, problems with supply and availability would have
a disproportionate effect on sex workers and their clients due to their
necessity and increased demand in the sex work setting.
The National Department of Health is developing Oral Pre-Exposure
Prophylaxis (PrEP) and Test and Treat guidelines.65 The targets of
the Sex Worker Plan 2016–2019 include the provision of PrEP to
3 000 sex workers and that 90% of sex workers who test positive
are on ART. HIV self-testing is currently being researched among
key populations.83 The National Department of Health’s National
Contraception and Fertility Planning Policy and Service Delivery
Guidelines and National Contraception Clinical Guidelines (2012)
explicitly include consideration of sex workers and of migration.84
Information
PM
The provision and use of high-quality information is another building
block of an effective health system. Information includes research,
surveillance and programmatic data.
A range of quantitative and qualitative sex worker research is
ongoing, spanning HIV biomedical prevention research (including
oral and topical PrEP and Test and Treat), health systems strengthening
(inclusion of sex worker services in existing health systems), and
epidemiology and other social determinants of health (including
violence and rights abuses).85–87 The process and ethics of research
on sex work is improving and sex workers are more involved in all
stages of research. Research–sex worker organisation partnerships
are being established, improving the quality and ethical nature of
research and enabling advocacy. Despite advances in research and
surveillance data, evidence-informed responses are lacking and
research gaps remain on male and transgender female sex workers
and the non-HIV health burden affecting sex workers.
There is a paucity of sex work programmatic and facility-based
data. The Division of Revenue Reporting Act indicators for the High
Transmission Areas programme were updated in 2014 to include the
number of sex workers seen at High Transmission Area programme
sites, which will increase understanding of the programme’s sex
worker reach.88
The criminalisation of sex work and associated stigma translate into
sex worker fears about discussing their occupation with healthcare
workers. Furthermore, none of the standard Department of Health
tools routinely enquires about sex work, and no indicators in the
District Health Information System or Tier.Net collect data from
patients who engage in sex work.89 Therefore, there are no data on
sex workers who access public health services, or who are on ART,
which limits the ability to monitor progress towards reaching the
90-90-90 targets for sex workers.
Some progress is being made to improve referrals and tracking for
ART service provision across borders, as well as between provinces
within South Africa. This takes the form of a patient-held record
and the provision of standardised referral letters. The TB/HIV
Care Association has been piloting the use of unique identification
numbers to enable tracking of sex workers who access services,
potentially from multiple locations, while protecting confidentiality.
This mechanism could provide a platform for the use of biometric
systems or other systems that link with the government health
information systems to improve client management and monitor the
impact of interventions.90 Issues of confidentiality remain crucial.
17 1
Routine data collection within the health information system does Sex worker programming
not include any measure of migration or mobility.58 As a result,
The increased focus on HIV prevention programming for sex
health system responses are not migration-aware nor responsive to
workers has enabled 152 993 interactions with sex workers to be
migration. Failure to collect information that can be disaggregated
documented between 2012 and 2015 (see Table 1). The majority
by migration status or sex work prevents monitoring of health system
of programmes employ peer-based mobilisation approaches
performance in real time, relies on expensive surveillance activities
that include basic behaviour change interventions, prevention
(i.e. IBBS), and will result in problems in managing migration,
commodities, and linkage to testing and other community-based
movement and ART adherence.
services. This approach is employed through the High Transmissions
Data gaps – including a lack of data on migration and mobility Area Programme which has the greatest reach, although the need
– impact resource allocation and the monitoring of impact. for peers working in areas targeting sex workers to be sex workers
Challenges in linking data between community and facility-based themselves was emphasised only in 2014.70
elements should be addressed, as these are important components
In 2015, the Red Umbrella Programme, implemented by the Sex
for tracking linkage to care and adherence, and for continuity of
Workers Education Advocacy Taskforce and 18 other sub-recipient
treatment for other conditions.
organisations through NACOSA, made contact with approximately

Service delivery  
UNAIDS recommends that the health system’s response to sex
work should be based on commitments to achieve universal
PM
40 000 sex workers per quarter across 70 sites across the country
and provided them with basic health services.92 However, a
reduction in Global Fund investments for sex work programmes

16 6
in South Africa has commenced, with the number of Global Fund-
access, a supportive environment, and the reduction of sex worker supported sex worker programmes diminishing to nine districts

20 IL
vulnerability.60 Sex work programming should be guided by the between 2016 and 2019.d
principles of meaningful involvement of sex workers, promotion of
Sex worker programmes supported by PEPFAR through USAID and
rights-affirming public health approaches, and implementation of
Y T the CDC include the University of the Witwatersrand’s Reproductive
appropriate interventions.60 The 2014 WHO Key Population HIV
Health and HIV Institute’s sites in the City of Johannesburg,
A N
Guidelines include a package of essential health sector interventions,
Ekurhuleni and Pretoria, and in collaboration with North Star
which are outlined in Box 2.52
M U

Alliance, eight sites along transport routes in Gauteng, Northern

Cape, KwaZulu-Natal, Mpumalanga, North West, Limpopo and
Box 2: WHO Comprehensive Package for Key Populations
Free State provinces.93 The CDC funds the TB/HIV Care Association
4 ED

Essential health sector interventions to provide mobile peer-based HIV prevention, testing and linkage-
❖❖ Condom and lubricant programming
to-care programmes in five major metropolitan areas;90 Re-Action!
Consulting, which provides HIV-related services to sex workers
O

❖❖ Harm reduction interventions for substance use

along transport routes and in mining areas of Mpumalanga and
❖❖ Behavioural interventions
North West provinces; and Health Development and Africa, which
G

❖❖ HIV testing and counselling provides peer-led prevention programmes targeting sex workers
❖❖ HIV treatment and care who operate in shebeens and bars in Mpumalanga Province.94
R

❖❖ Prevention and management of co-infections (viz. viral hepatitis, TB

BA

and mental health conditions)

❖❖ Sexual and reproductive health interventions

O

Essential strategies for an enabling environment

EM

❖❖ Supportive legislation, policy and financial commitment, including

decriminalisation of certain behaviours of key populations

❖❖ Addressing stigma and discrimination

❖❖ Making health services available, accessible and acceptable

❖❖ Community empowerment

❖❖ Addressing violence against people from key populations

Source: WHO, 2014.52

Sex worker healthcare services that have flexible hours, employ

non-judgemental staff who offer a confidential service, and include
outreach, have been shown to be successful in reducing the incidence
of HIV and STIs among sex workers.91 Important progress has been
made to increase access to a basic package of HIV prevention
services, HIV testing services and linkage to care for sex workers in
South Africa, as outlined in the following section.

d Personal communication: M Stacey, NACOSA Key Populations Manager:16

February 2016.

172 S A H R 20 1 6
 Sex work

Table 1: HIV, STIs and TB response for sex workers in South Africa (2012–2015)

Funder Number of supported sites / Number of sex workers Package of services

districts reached
National Department of Health 3 938 sites in 9 provinces 71 770e Peer education
Health care
The Global Fund to Fight AIDS, 70 sites in 9 provinces 39 312 Peer education
Tuberculosis and Malaria (the Global Health care
Fund)
Psychosocial service
Human rights
Social capital-building
The United States President’s 8 districts in 8 provinces 41 911 Peer education
Emergency Plan for AIDS Relief Health care
(PEPFAR)
Psychosocial service

Source: SANAC, 2015.95

PM
Sex worker-led movements such as Sisonke, and spaces formed for Conclusions
sex workers to come together (‘Safe Spaces’ in the Red Umbrella
Sex work like much other human behaviour is a complicated
Programme, ‘Community Advisory Groups’ established by the TB/
experience, and reductionist approaches, in which researchers

16 6
HIV Care Association, and ‘Creative Space’ set up by Sisonke)
and public health intervention implementers assume that sexual
provide mechanisms for community engagement and mobilisation.

20 IL
intercourse is always heterosexual, penile-vaginal, that all clients
Novel modalities of research, alongside the development of new
seek services of sex workers without the knowledge of their
information, education and communication materials, have been
Y T spouses, and that sex work is motivated by poverty, may not be
developed to improve research and to provide sex workers with
as meaningful as when the actual practices are understood.99
appropriate and attractive materials (see Box 3). Service delivery
A N
has been informed by local evidence, and will be bolstered by the Approximately 153 000 individuals in South Africa make a living in
implementation of the Sex Worker Plan 2016–2019. the sex industry.100 In a context of high unemployment and limited
M U

income-generating options, sex work enables many cisgender and

However, in line with processes of primary health care re-engineering
transgender women and men to earn a livelihood and to provide for
4 ED

and service integration, approaches should incorporate TB, chronic

their families. However, the prevailing sex work context involves a
illnesses, maternal and child health, and other primary health care
number of health risks that are compounded by the criminalisation of
services into sex worker services.96 The provision of support services
sex work and the challenges associated with a restrictive Immigration
and programmes to deal with substance use disorders is also of
O

Act. Until recently, the rights and health issues of sex workers have
importance.
been largely ignored and similarly have been reflected in the dearth
G

of information and research available on sex work in South Africa.

Box 3: Innovative communication
This omission in turn has shaped blunt responses to the sex work
R

context by the health system and healthcare providers, and has

The Amaqhawe magazine provides sex workers with information to
continued to render sex workers invisible.
BA

reduce risk and improve safety, packaged in a glossy magazine format.

Nine editions have been developed and 10 236 copies were distributed
The pace at which the health system’s building blocks are preparing
O

between July 2012 and September 2015. The magazine has been reported
to be a useful resource for sex workers.97 to improve the health outcomes for sex workers has been slow.
EM

Current legal frameworks on sex work and migration have far-

Izwi Lethu newsletter:f Our Voice, a monthly newsletter, written by sex
workers, was launched in 2015 as a collaboration between the African
Centre for Migration and Society and the Sisonke Sex Worker Movement.
The newsletter has focused on Johannesburg, with special issues featuring
Musina and Pretoria. Sex workers participate in a writing workshop to
produce stories. An advice column, “Dear MaStoep,” is used to respond to
sex worker questions. Many sex workers write stories of their trajectories
into the sex industry, often tied to their journey to Johannesburg, as well
as issues related to violence, homelessness, drug use, HIV, and access to
services. One writer composed “The Ten Commandments of Sex Work”,
including number 9: “Make sure you have enough condoms and go for
regular clinic visits” (Issue 7). A guest column provides other health and
related information. Izwi Lethu offers sex workers the opportunity to share
their stories with sex workers, policy-makers and service providers whose
decisions affect them.98
reaching negative health and economic consequences, not only for
sex workers, their clients and their families, but also for the population
as a whole. The devastating consequences of HIV on the sex worker
population is a clarion call for health practitioners, community
activists and researchers to demand the rapid implementation of the
SANAC Sex Worker Programme 2016–2019.
Recommendations
Leadership and governance
➢➢ The Department of Justice should propel the law reform process
and ensure that sex work is decriminalised. Government should
provide stewardship and support social norms and values that
recognise sex work as work, and ensure that sex workers
receive the same protection as other people who work.

e This is a National Department of Health estimate calculated on a ratio of sex

workers and other service users who accessed High Transmission Area sites
during this time period.
f https://issuu.com/move.methods.visual.explore

S A H R 20 1 6 173
Financing
➢➢ The South African Government should increase investments
in evidence-based, rights-affirming health programmes to
address existing inequities in access to health care for sex
workers.
➢➢ Novel methods of private sector financing for sex worker-
focused programmes should be explored.
➢➢ Financing should support the health and rights-related activities
of civil society organisations and sex worker-led movements.
Health workforce
➢➢ The Departments of Education and Health should ensure
that pre-service health professional training includes greater
broader health and social factors that are essential for health
and rights.
➢➢ The National Department of Health and other health service
providers should enhance surveillance systems in order for
data to be collected and used at the local level, and such
systems should facilitate size estimations, HIV prevalence
(and where possible incidence) and risk assessments, as well
as measures of entry and retention along the HIV treatment
cascade.
➢➢ Information and new research findings should be released
and made freely available as soon as possible. This is in line
with research ethics that stipulate respect for sex workers
who participate in research and the organisations involved.

emphasis on understanding the social determinants of health
and the dimensions of stigma and discrimination. Sensitive
and appropriate care for all marginalised groups – including
sex workers and migrants – must be emphasised and values-
PM
A responsive health system is reliant on high-quality, timeous
information.
➢➢ Health information systems should capture information about

16 6
clarification training should be conducted. sex work and migration more efficiently, while ensuring privacy
and confidentiality. The use of biometric systems, which can be

20 IL
➢➢ In-service training, particularly in large urban areas, along
transport routes and other locations where the demand for used for community-based interventions and could link data
sex work is high, should pay increased attention to building with government systems while maintaining confidentiality in
Y T
health worker capacity to provide sex worker- and migration-
appropriate and competent services.
the interim, should be explored in collaboration with the sex
worker community.
A N
➢➢ SANAC and the National Department of Health should ➢➢ The intelligent use of information and the decriminalisation
M U

implement mechanisms to monitor and quantify human rights of sex work and removal of legal risks posed by breaches
violations within the health system and the findings should be in confidentiality are needed to achieve the Sustainable
4 ED

used to inform appropriate remedies. Development Goals.

➢➢ The National Department of Health should strengthen Service delivery

mechanisms to enable sex workers to report poor-quality health
O

➢➢ The current models of service delivery should be scaled up to

services. Platforms to register complaints, like MomConnect101
ensure continued, universal access.
which provides a channel for patients accessing perinatal
G

services to register complaints, could be adapted for use ➢➢ Services should be provided by sensitive and competent
for other sexual and reproductive health service quality staff, with flexible and appropriate hours in locations that are
R

improvement. accessible to sex workers.

BA

➢➢ Regional responses around mobility and migration are

Medical products, vaccines and technologies
required to enable harmonisation of protocols for ART, to
O

➢➢ Universal access to a minimum package of health services support retention in care across geographical boundaries, to
(peer-delivered HIV prevention commodity distribution, peer maximise health outcomes and to reduce the risk of increased
EM

education and behaviour change, HIV testing services and costs due to treatment failure and new HIV infections.
linkage to other services, including biomedical interventions)
should be prioritised.

➢➢ The South African Government should fast-track the inclusion

of new HIV prevention methodologies, particularly PrEP, Test
and Treat, and access to HIV self-test kits, into an expanded
package of services that should be made available in areas
with a high HIV burden and areas with large sex worker
populations.

➢➢ Human papillomavirus vaccines and cervical screening

services and other sexual reproductive and health technologies
should be made available to sex workers.

Information
➢➢ Researchers should address current gaps in knowledge around
HIV (i.e. gaps among transgender and male sex workers; in
areas beyond major metropolitan areas; effectiveness of
interventions to retain sex workers in HIV treatment) and the

174 S A H R 20 1 6
 Sex work

Acknowledgements
Two anonymous reviewers, Sally-Jean Shackleton (Sex Worker
Education and Advocacy Taskforce), Kholi Buthelezi, Gavin Jacobs,
and Munya Masunga (Sisonke Sex Worker Movement), Eva Marumo
(National Department of Health), Maria Stacey and Marieta de
Vos (NACOSA), Kerry Mangold (South African National AIDS
Council), Helen Savva (United States Centers for Disease Control
and Prevention, South Africa), Leora Casey and Jami Johnson (Mott
MacDonald Development South Africa), Andrew Lambert (TB/
HIV Care Association), Teresa Guthrie (independent consultant),
Gesine Meyer-Rath (Health Economics and Epidemiology Research
Office (HE2RO), Department of Internal Medicine, Faculty of Health
Sciences, University of the Witwatersrand and Center for Global
Health and Development, Boston University), Thuba Ngubane and

PM
Anthony Diesel (South African Partners), Greta Schuler and Elsa
Oliveira (African Centre for Migration and Society, University of
the Witwatersrand), Mariette Slabbert and Wayne Helfrich (Wits
Reproductive Health and HIV Institute), Sharon White and Petro

16 6
Roussaeu (Re-Action! Consulting), Mike Grasso (University of

20 IL
California, San Francisco), Jenny Coetzee (Perinatal HIV Research
Unit), Nondumiso Makhunga-Ramfolo (FHI360), Jannie Hugo and
Angelika Schutte (University of Pretoria).
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 17 5
References
1 World Health Organization. Commission on Social
Determinants of Health. Closing the gap in a generation:
health equity through action on social determinants of health.
Final Report of the Commission on Social Determinants of
Health. Geneva: World Health Organization; 2008.
2 Marmot M. Public Health Social determinants of health
inequalities. Lancet. 2005;365:1099–104.
3 UNAIDS. UNAIDS Terminology Guidelines. Geneva: UNAIDS;
2015.
4 World Health Organization. Everybody’s business.
Strengthening health systems to improve health outcomes.
WHO’s Framework for action. Geneva: World Health
Organization; 2007.
5 Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, Lo YR.
Socio-demographic characteristics and behavioral risk factors
of female sex workers in sub-Saharan Africa: A systematic
review. AIDS Behav. 2012;16(4):920–33.
6 Richter M. Sex Work as a test case for African feminism.
16 6
In: BUWA! A Journal on African Women’s Experiences.
Johannesburg: Open Society Initiative for Southern Africa;
20 IL
2012. p.62–69
7 World Health Organization. The WHO Health System
Framework. Health services development. Geneva: World
Y T
Health Organization; 2016 [Internet]. [cited 12 February
2016].
A N
URL: http://www.wpro.who.int/health_services/
health_systems_framework/en/
M U
8 Konstant TL, Rangasami J, Stacey MJ, Stewart ML,
Nogoduka C. Estimating the Number of Sex Workers in
4 ED
South Africa: Rapid Population Size Estimation. AIDS Behav.
2015;19(S1):3–15.
9 Gould C, Fick N. Selling Sex in Cape Town: Sex Work and
Human Trafficking in a South African City. Pretoria: Institute
O
for Security Studies; 2008. p.214.
G
10 Gould C. Trafficking? Exploring the relevance of the notion
of human trafficking to describe the lived experience of sex
workers in Cape Town, South Africa. Crime, Law Soc Chang.
R
2011;56(5):529–46.
BA
11 Posel D. The Sex Market in the Inner City of Durban – The
Economic and Social Effects of Criminalising Sex work, and
O
the Search for Alternatives. Report No.: Occasional Paper
No. 28. Durban: University of Natal; 1993.
EM
12 Agustín L. Migrants in the mistress’s house: Other voices in the
“ Trafficking” debate. Soc Polit. 2005;12(1):96–117.
13 Harcourt C, Donovan B. The many faces of sex work. Sex
Transm Infect. England;2005 Jun;81(3):201–6.
14 Richter M, Chersich MF, Vearey J, Sartorius B, Temmerman
M, Luchters S. Migration Status, Work Conditions and
Health Utilization of Female Sex Workers in Three South
African Cities. J Immigr Minor Heal [Internet]. 2014 Feb
13;16(1):7–17.
15 Boyce P, Isaacs G. An Exploratory Study of the Social
Contexts, Practices and Risks of Men Who Sell Sex in
Southern and Eastern Africa. Pretoria: SWEAT; 2011.
16 South African Law Reform Commission. Sexual Offences,
Adult Prostitution. Discussion Paper 0001/2009 Project 107.
Pretoria: South African Law Reform Commission; 2009.
17 Richter M, Vearey J. Migration and sex work in South Africa:
key concerns for gender and health. In: Gideon J, editor.
Gender and Health Handbook. Cheltenham: Edward Elgar
Publishing; in press.
176 S A H R 20 1 6
18 Vearey J, Nunez L, Richter M, Moyo K. HIV prevention in the
workplace and beyond: the importance of engaging with
migration, urban livelihoods and the “informal economy” in
South Africa. Afr J AIDS Res. 2011;10:381–91.
19 Crago A-L, Arnott J. Rights Not Rescue: A Report on Female,
Trans, and Male Sex Workers’ Human Rights in Botswana,
Namibia, and South Africa. New York: Open Society Institute,
Sexual Health and Rights Project; 2008.
20 Global Commission on HIV and the Law. Global Commission
on HIV and the Law. Risks, rights and health. Final report.
New York: UNDP, HIV/AIDS Group; 2012.
21 Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi
P, Rusakova M, et al. Global epidemiology of HIV among
female sex workers: influence of structural determinants.
Lancet [Internet]. 2015 Jan;385(9962):55–71.
PM
22 Manoek S-L, Shackleton S, Richter M. Briefing on sex
work, the criminal law and law reform in South Africa.
Memorandum to the SANAC Legal and Human Rights
Technical Task Team. Cape Town: Women’s Legal Centre;
2015.
23 Rekart ML. Sex-work harm reduction. Lancet.
2005;366(9503):2123–34.
24 UNAIDS. Global Report. UNAIDS report on the global AIDS
epidemic. Geneva: UNAIDS; 2013.
25 World Health Organization. Preventing HIV among sex
workers in sub-Saharan Africa : A literature review. Geneva;
World Health Organization; 2011.
26 Lane T, Sibanyoni M, Manyuchi A, Osmand T, Marr A,
Grasso M, et al. High Utilization of Health Services and
Low ART Uptake among Female Sex Workers in Three South
African Cities: results from the South Africa Health Monitoring
Study. In: 8th IAS Conference on Pathogenesis, Treatment and
Prevention. Vancouver; 2015.
27 University of California San Francisco, Anova Health
Institute. Long distance truck drivers and sex worker
integrated biobehavioural survey (KPN3) Study. FACTSHEET.
Johannesburg: University of San Francisco Global Health
Sciences; 2015.
28 Journal of the International AIDS Society (JIAS). 8th IAS
Conference on HIV Pathogenesis, Treatment and Prevention
(IAS 2015). J Int AIDS Soc [Internet]. 2015;18(5 Suppl
4):20479. [cited 24 March 2016].
URL: http://www.jiasociety.org/index.php/jias/article/
view/20479/xml
29 Human Sciences Research Council. HIV Prevalence among
adults (15 years and above). Additional analysis of the 2012
National Household Survey conducted for the MSM data
triangulation process. Cape Town: Human Sciences Research
Council; 2014.
30 Joint United Nations Programme on HIV/AIDS (UNAIDS). 90-
90-90 – An ambitious treatment target to help end the AIDS
epidemic. Report. Geneva: Joint United Nations Programme
on HIV/AIDS; 2014. p. 40.
31 Hamblin R, Smit E. What are you? A report by Transgender
Sex Workers Cape Town SA. Cape Town: Gender Dynamix;
2011.
32 Pauw I, Brener L. “You are just whores—you can’t be raped’:
barriers to safer sex practices among women street sex
workers in Cape Town. Cult Health Sex [Internet]. 2003 [cited
2011 Jan 30];5(6):465–81. [cited 24 March 2016].
URL: http://www.informaworld.com/openurl?genre=article&d
oi=10.1080/136910501185198&magic=crossref||D404A
21C5BB053405B1A640AFFD44AE3

33 Varga CA. The condom conundrum: barriers to condom use
among commercial sex workers in Durban, South Africa. Afr J
Reprod Health. 1997;1(1):74–88.
34 Richter M, Chersich M, Temmerman M, Luchters S.
Characteristics, sexual behaviour and risk factors of female,
male and transgender sex workers in South Africa. S Afr Med
J. 2013;103(4):246–51.
35 Wechsberg WM, Wu L-T, Zule WA, Parry CD, Browne FA,
Luseno WK, et al. Substance abuse, treatment needs and
access among female sex workers and non-sex workers in
Pretoria, South Africa. Subst Abuse Treat Prev Policy. 2009
Jan;4:11.
36 Wechsberg WM, Luseno WK, Lam WK. Violence against
substance-abusing South African sex workers: intersection
with culture and HIV risk. AIDS Care. 2005 Jun;17 Suppl
1:S55–64.
37 Wechsberg WM, Luseno WK, Lam WKK, Parry CDH,
Morojele NK. Substance use, sexual risk, and violence: HIV
prevention intervention with sex workers in Pretoria. AIDS
Behav. 2006 Mar;10(2):131–7.
16 6
38 Abel GM, Fitzgerald LJ. “The street’s got its advantages”:
Movement between sectors of the sex industry in a
20 IL
decriminalised environment. Health Risk Soc. 2012;14(1):7–
23.
39 Campbell CA. Prostitution, AIDS, and preventive health
Y T
behavior. Soc Sci Med. 1991;32(12):1367–78.
A N
40 Agustin LM. Questioning Solidarity: Outreach with Migrants
Who Sell Sex. Sexualities. 2007;10(4):519–34.
M U
41 Hubbard P, Sanders T. Making space for sex work: female
street prostitution and the production of urban space. Int J
4 ED
Urban Reg Res. 2003;27(March):75–89.
42 Alexander P. Sex work and health: a question of safety in the
workplace. J Am Med Womens Assoc. 1998;53(2):77–82.
O
43 Wurth MH, Schleifer R, McLemore M, Todrys KW, Amon JJ.
Condoms as evidence of prostitution in the United States and
the criminalization of sex work. J Int AIDS Soc. 2013;16:1–3.
G
44 Shields A. Criminalizing Condoms: How Policing Practices
R
Put Sex Workers and HIV Services at Risk in Kenya, Namibia,
Russia, South Africa, the United States and Zimbabwe. New
BA
York: Open Society Foundations; 2012.
N
45 South African National AIDS Council. The South African
O
National Sex Worker HIV Plan. 2016–2019. Pretoria: South
African National AIDS Council; 2016.
EM
46 Richter M. Sex work, reform initiatives and HIV/AIDS in
inner-city Johannesburg. Afr J AIDS Res. 2008;7:323–33.
47 South African Government. National Strategic Plan 2007–
2011, Mid-term review. Pretoria: South African National AIDS
Council; 2010.
48 South African National AIDS Council. National Strategic Plan
on HIV, STIs and TB 2012–2016. Pretoria: South African
National AIDS Council; 2011.
49 Richter M, Chakuvinga P. Being pimped out: How South
Africa’s AIDS response fails sex workers. Agenda.
2012;26(2):65–79.
50 South African National AIDS Council. National Strategic Plan
for HIV Prevention, Care and Treatment for Sex Workers (final
draft). Pretoria: South African National AIDS Council; 2013.
51 South African National AIDS Council. Progress Report on The
National Strategic Plan for HIV, TB and STIs (2012–2016).
Pretoria: South African National AIDS Council; 2014.
52 World Health Organization. Consolidated Guidelines on
HIV Prevention, Diagnosis, Treatment and Care for Key
Populations. Geneva: World Health Organization; 2014.
S A H R 20 1 6
Sex work
53 Scheibe A, Drame FM, Shannon K. HIV prevention among
female sex workers in Africa. J Soc Asp HIV/AIDS.
2012;(November):167–72.
54 Guthrie T, Ryckman T, Soe-Lin S, Hecht R. Consolidated
spending on HIV and TB in South Africa (2011/12 –
2013/14). Draft report. Pretoria: Results for Development;
2015.
55 Krueger S. A Striking Defeat for U.S. Government’s Anti-
Prostitution Pledge. Open Society Voices [Internet]. 2015.
[cited 24 March 2016].
URL: https://www.opensocietyfoundations.org/voices/
striking-defeat-us-government-s-anti-prostitution-pledge
56 Centre for Health and Gender Equity. “Anti-Prostitution Loyalty
Oath.” Fact sheet. Washington, DC: Centre for Health and
Gender Equity; 2015.
57 Ditmore MH, Allman D. An analysis of the implementation
PM
of PEPFAR’s anti-prostitution pledge and its implications for
successful HIV prevention among organizations working with
sex workers. J Int AIDS Soc. 2013;16(December 2002).
58 Vearey J. Healthy migration: A public health and development
imperative for south(ern) Africa. S Afr Med J. 2014
Jul;104(10):663.
59 Walls HL, Vearey J, Modisenyane M, Chetty-Makkan CM,
Charalambous S, Smith RD, et al. Understanding healthcare
and population mobility in southern Africa: The case of South
Africa. S Afr Med J. 2015 Nov 24;106(1):14.
60 Joint United Nations Programme on HIV/AIDS (UNAIDS).
Guidance Note on HIV and Sex Work. Geneva: Joint United
Nations Programme on HIV/AIDS; 2009.
61 Joint United Nations Programme on HIV/AIDS (UNAIDS).
World AIDS Report 2011. How to get to zero: Faster. Smarter.
Better. Geneva: Joint United Nations Programme on HIV/
AIDS; 2011.
62 Shannon K, Montaner JSG. The politics and policies of HIV
prevention in sex work. Lancet Infect Dis. 2012;12(7):500–2.
63 South African Government. Provincial Government
Allocations. Government Gazette. 478 (27487). Pretoria:
South African Government; 2005.
64 Wilson D. HIV Programs for Sex Workers: Lessons and
Challenges for Developing and Delivering Programs. PLoS
Med. 2015;12(6):1–11.
65 South African National Department of Health. Oral pre-
exposure prophylaxis and test and treat. Draft national
guidelines. Working draft. Pretoria: National Department of
Health; 2016.
66 South African National Department of Health. National Health
Insurance for South Africa. Towards universal health coverage.
White Paper. Pretoria: National Department of Health; 2015.
67 Chersich MF, Luchters S, Ntaganira I, Gerbase A, Lo
Y-R, Scorgie F, et al. Priority interventions to reduce HIV
transmission in sex work settings in sub-Saharan Africa and
delivery of these services. J Int AIDS Soc. 2013;16(1):17980.
68 Stadler J, Delany S. The “healthy brothel”: the context of
clinical services for sex workers in Hillbrow, South Africa. Cult
Health Sex. 2006;8(5):451–64.
69 ICF International. Quality Assurance Standards for Peer
Education and Outreach Programmes for High Risk Vulnerable
Populations in South Africa (Draft). Georgia: ICF International;
2012.
70 South African National Department of Health. High
Transmission Area Guidelines. Pretoria: National Department
of Health; 2014.
17 7
71 South Africa Partners. SA Partners National QA/QI
programme for Key Populations. Report. Johannesburg: SA
Partners; 2015.
72 Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul
S, Mwangi P, Win KT, et al. A community empowerment
approach to the HIV response among sex workers:
Effectiveness, challenges, and considerations for
implementation and scale-up. Lancet. 2015;385(9963):172–
85.
73 Rua B. From Isolation to Solidarity: How community
mobilization underpins HIV prevention in the Avahan India
AIDS Initiative. Washington DC: Futures Group; 2013.
74 Management Services for Health. A Literature Review of HIV-
related Interventions for Long Distance Truck Drivers and Sex
Workers in the SADC Region November 2015. Gabarone:
SADC; 2015.
87 Aids Fonds. Hands Off! project. Amsterdam: Aids Fonds;
2015.
88 South African National Department of Health. High
Transmission Area (HTA) Guidelines. Pretoria: National
Department of Health; 2014.
89 Hennessey C, Hurter T. TIER.Net HIV Electronic Register
Training Guide. Pretoria: Department of Health; 2008.
90 Lambert A. Operationalising peer-linked mobile wellness
services: mapping and outreach database. In: Top2Bottom
MSM Symposium. Cape Town; 2013.
91 Vuylsteke B, Das A, Dallabetta G, Laga M. Preventing HIV
among sex workers. In: Mayer K, Pizer H, editors. HIV
prevention: a comprehensive approach. London: Academic
Press; 2009.
92 The Networking HIV/AIDS Community of South Africa

75 Vearey J, Richter M. A World Class African host for whom?
Implications of hosting the 2010 Soccer World Cup on the
lived experiences of migrant sex workers in Johannesburg,
South Africa. In: Design practices for urban safety and
PM
(NACOSA). Programme Description. Red Umbrella National
Sex Work Programme. Cape Town: NACOSA; 2015.
93 Wits Reproductive Health and HIV Institute. Fact Sheet: Sex
Worker and Male Client Programme. Johannesburg: Wits

16 6
security. Padova: Il Poligrafo; 2015. Reproductive Health & HIV Institute; 2015.
76 Richter M, Chersich MF, Vearey J, Sartorius B, Temmerman 94 Re-Action! Voices of Change Programme Overview.

20 IL
M, Luchters S. Migration Status, Work Conditions and Health Johannesburg: Re-Action! Consulting; 2016.
Utilization of Female Sex Workers in Three South African
Cities. J Immigr Minor Heal. 2014;16(1):7–17. 95 South African National AIDS Council. The South African
Y T
77 Kohn S. In South Africa, Sex Workers Arm Themselves with
the Law [Internet]. 2014 [cited 10 Feb 2016].
National Sex Worker HIV Plan. 2016–2019 (final draft).
Pretoria: South African National AIDS Council; 2015.
A N
URL: https://www.opensocietyfoundations.org/voices/south- 96 Pillay Y, Barron P. The implementation of PHC re-engineering
africa-sex-workers-make-law-work-them in South Africa. Public Health Association of South Africa
M U

[Internet]. 2011;1–6. [cited 24 March 2016].

78 Hugo J, Marcus T. Health Care Management as Biofilm: URL: https://www.phasa.org.za/wp-content/
Community Oriented Primary Care in the Inner City. Under uploads/2011/11/Pillay-The-implementation-of-PHC.pdf
4 ED

review. 2015.
97 Singizi Consulting. Mid Term Review of the Amaqhawe Project
79 Brown B, Duby Z, Bekker L-G. Sex Workers. An Introductory Prepared for Health & Development Africa. Johannesburg:
Manual for Health Care Workers in South Africa. 1st ed. Health & Development Africa; 2014.
O

Cape Town: Desmond Tutu HIV Foundation; 2012.

98 Schuler G, Masunga M. Izwi Lethu: Our Voice Newsletter.
80 Henderson AM. On the ground: Programmes serving the Johannesburg: African Centre for Migration and Society
G

needs of key populations. Report. Geneva: World Health (ACMS); 2015. [Internet]. [cited 11 March 2016].
Organization; 2014. p.1–58. URL: http://www.migration.org.za/page/newsletters-izwi-
R

81 Southern African HIV Clinicians Society. The Southern lethu/move

African HIV Clinicians Society states its support for the 99 Chipamaunga S, Muula AS, Mataya R. An assessment of
BA

decriminalisation of sex work. Press release, 9 March 2016. sex work in Swaziland: barriers to and opportunities for HIV
[Internet]. [cited 24 March 2016]. prevention among sex workers. SAHARA J [Internet]. 2010
O

URL: http://www.sahivsoc.org/policy-and-advocacy/ Oct;7(3):44–50.

statements
EM

100 Sex Workers Education and Advocacy Taskforce (SWEAT),

82 United Nations High Commissioner for Refugees (UNHCR). Impact Consulting. Sex Workers in South Africa: A rapid
Guidelines for the Delivery of Antiretroviral Therapy to population size estimation. Cape Town: South African
Migrants and Crisis-Affected Persons in Sub-Saharan Africa. National AIDS Council; 2013.
Geneva: United Nations High Commissioner for Refugees;
2014. 101 Health.enabled. MomConnect [Internet]. 2016 [cited 17
March 2016].
83 Lipman S. HIV self-testing in men who have sex with men. URL: http://www.healthenabled.org/our-work/momconnect
San Francisco: University of San Francisco Global Health
Sciences; 2015.
84 South African National Department of Health. National
Contraception and Fertility Planning Policy and Service
Delivery Guidelines. Pretoria: National Department of Health;
2012. p.106.
85 Wits Reproductive Health and HIV Institute (WRHI). TAPS
WRHI Project Brief 17 June 2014. Johannesburg: Wits
Reproductive Health and HIV Institute; 2014.
86 DIFFER Project. Report of situational analysis of reproductive
health services for general population women and female
sex workers in India, Kenya, Mozambique and South Africa.
Ghent: Ghent University; 2013.

178 S A H R 20 1 6
Trauma, a preventable burden of disease
in South Africa: review of the evidence,
15
with a focus on KwaZulu-Natal

Authors:
Timothy C. Hardcastle i George Oosthuizen ii
Damian Clarke ii Elizabeth Lutge iii

PM
16 6
T 20 IL
rauma is a major burden of disease in lower- and middle-income countries, Trauma constitutes
and to address the causes and treatment requires specialist services and
Y T
multidisciplinary care. Despite this, governments have given trauma low priority approximately 25% of the
A N
as they have focused largely on primary health care. emergency workload at
most public hospitals in
M U

This chapter demonstrates the extensive burden of trauma in KwaZulu-Natal (KZN)

and illustrates that the entire country experiences a similar disease burden. Recent KwaZulu-Natal, where
data from numerous studies are used to provide insight into the options for establishing
4 ED

systems of quality trauma care and accreditation programmes for hospitals and there is limited capacity for
systems. Current and optimal staffing of trauma-care facilities, compliance with rehabilitation and lack of
minimum equipment standards, and the potential for patient harm are addressed.
intensive care facilities.
O

The authors show that trauma constitutes approximately 25% of the emergency
G

workload at most public hospitals in KZN, where there is limited capacity for
rehabilitation and lack of intensive care facilities. There is no defined trauma system
R

and the existing resources at regional and tertiary public facilities are strained.
BA

The role of sound databases in providing numerical and outcome data is highlighted
and a call is made for the establishment of a National Trauma Data Bank. The
O

authors highlight the need for prevention programmes and draw attention to the
EM

cost implications of trauma care, noting the cost-benefit ratio of good trauma care
compared with the litigation risk to government when such care cannot be provided.

i Trauma Unit, Inkosi Albert Luthuli Central Hospital; and Department of Surgery, Universit y of KwaZulu- Natal
ii Pietermaritzburg Trauma Service; and Department of Surgery, Universit y of KwaZulu- Natal
iii Epidemiology Division, KwaZulu- Natal Department of Health; and Department of Public Health, Universit y of KwaZulu- Natal

179
Introduction
Trauma is well known to be a major disease burden in lower- and
middle-income countries (LMICs), with South Africa falling into the
middle-income group. Over 90% of trauma deaths occur in LMICs,
yet facilities that can provide optimal care and rehabilitation are
lacking in many of these countries. Recent publications from the
World Health Organization place the global injury mortality rate
at five million per annum, with one-fifth of these deaths occurring
in India, and almost one-fifth in Africa.1,2 In the near future, the
injury mortality rate will exceed that of HIV and AIDS, tuberculosis,
malaria and obstetric causes combined.1 Over 50 000 trauma-
related deaths were recorded in 2009 across South Africa, with the
majority related to transport and violence.3
mainly to local research published in the past five years from
KwaZulu-Natal (KZN) and other parts of South Africa, and from
theses published online by the University of KwaZulu-Natal (UKZN).
Data were also sourced from public service planning and policy
documents. Extrapolation of KZN data to arrive at national estimates
was based on the fact that the province contains over one-fifth of the
national population, rendering extrapolation from a 20% sample
statistically relevant.
The study addressed current and optimal staffing of trauma-care
facilities, compliance with minimum equipment standards, and the
potential for patient harm in the current trauma system. The chapter
provides insight into the accreditation programmes for hospitals,
and options for establishing cost-efficient high-quality trauma care

For every mortality that occurs it is estimated that there are between
10 and 50 injured survivors, half of whom will have a permanent
disability.4 Lack of access to rehabilitation services in most LMICs
leads to severe loss of disability adjusted life-years (DALYs).5
PM
systems. The role of sound databases in providing numerical and
outcome data is highlighted and a call is made for the establishment
of a National Trauma Data Bank. The chapter also provides insight

16 6
into the need for prevention programmes and the cost implications
Injuries in LMICs are largely violence or transport-related, and occur
of trauma care, noting the cost-benefit ratio of good trauma care

20 IL
mostly among young healthy men of low socio-economic status
compared with the litigation risk to government when such care
influenced by alcohol and drug misuse, which increases the burden
cannot be provided.
on developing communities. Data from Cape Town, where a large
Y T
single-centre electronic record was recently implemented, reflect the
same demographic pattern of violence- and transport-related injury
All these aspects are considered in the context of the relevant
Sustainable Development Goals (SDGs), specifically: SDG 3 (Good
A N
in young male adults, with alcohol playing a central role in the injury health and wellbeing); SDG 11 (Sustainable cities and communities);
M U

profile.6–8 and SDG 16 (Peace, justice and strong institutions).

The burden of trauma has been given low priority by government, We also identify some good practices and hindrances to policy
4 ED

and institutional apathy, lack of translational research and implementation, while noting possible implications for policy reform
government’s primary health care focus have resulted in neglect in terms of cost and human resource requirements.
of this disease process and a trauma care crisis. Trauma requires
O

access to specialist services and multidisciplinary care; however, it

is a largely preventable community-based pathology.9–11 A recent
Use of terms
G

inaugural professorial speech highlighted the following with regard For the purposes of this chapter, ‘trauma’ is defined as injuries,
to trauma: both intentional and non-intentional, while ‘major trauma’ is defined
R

as injuries that require hospital admission beyond the emergency

No-one talks about it or studies it; it’s not part of the Millennium
centre of the receiving hospital, i.e. where definitive in-patient care
BA

Development Goals; there are no global funds fighting it; and

is required, operative or otherwise, either in a ward or an intensive
the World Health Organization has devoted few resources to it.
care unit (ICU). In most cases, these are patients with an injury
O

This needs to change.9

severity score (ISS) greater than nine, and often greater than 16.14
EM

Potential preventive measures can be categorised as follows:

➢➢ primary prevention, which includes measures such as traffic-
calming and safety devices such as speed-bumps and helmet
use, legal compliance, alcohol avoidance, etc.;
➢➢ secondary prevention, which includes optimised pre-hospital
and in-hospital care; and
➢➢ tertiary prevention, which includes rehabilitation programmes
and support groups.
Actions focused on the ‘upstream’ conditions that promote health
and protect the community through injury reduction can alleviate
the ‘downstream’ injuries that fuel the trauma care crisis. However,
lack of compliance on the part of the community is not uncommon,
causing increased implications for more severe injury.12,13
An ‘emergency centre’ is the term used by the National Department
of Health for the emergency area at any hospital, often incorrectly
termed ‘casualty’ or the ‘emergency department’, while a ‘trauma
centre’ is a hospital (usually at regional or tertiary level) that has
a demonstrated commitment to providing quality definitive trauma
care in line with the criteria of the Trauma Society of South Africa,
and may be inspected and accredited at an appropriate ‘level’.15
An emergency centre is found within every acute care hospital, but
not every emergency centre is in a designated trauma centre, which
would be the case for most district-level hospitals.

This chapter aims to demonstrate the extensive burden of trauma in

South Africa, using recent data mainly from large public hospitals
currently bearing the extensive burden of trauma care. It refers

180 S A H R 20 1 6

Review of the evidence
The burden of injuries
Trauma forms a significant component of the emergency centre
workload at public hospitals and involves indeterminate budget
consumption due to unpredictability of the general burden and
injury severity. Additionally, the need for scarce high-dependency
and intensive care resources16 leads to roll-over blockages for
urgent elective surgery.17,18 In order to assess and contextualise
this healthcare burden and its impact on the health system, a series
of studies,17–19 was undertaken in 2010 to determine the trauma
burden in KZN covering three major categories of injury, namely
motor-vehicle-related, violence-related and domestic/work-related.
These studies examined both the pre-hospital and in-hospital disease
burden, using two non-holiday season months extrapolated to a one-
year incidence, and determined that almost 102 000 pre-hospital
trauma (emergency medical services (EMS)) call-outs were recorded,
equating to almost 12/1 000 of the population per year, while
16 6
over 124 000 persons were treated in public hospitals for these
20 IL
three injury categories in 2010. Over 70% of these EMS callouts
or hospital attendances were for either motor-vehicle related or
violence-related injuries.
Y T
The challenge noted was that almost 80% of patients were
A N
considered serious or critical (meeting the criteria for major trauma),
yet due to the primary-care focused referral pathway, only 40%
M U
were admitted directly to the correct level of care. These rates far
exceed the comparative international incidence.17,18 Furthermore,
4 ED
recent work showed that almost 15% of the total trauma burden
are critically injured patients requiring direct admission to a major
trauma facility20 and this data correlates with the 18% determined
O
in the pre-hospital phase of the 2010 studies. This distribution of
patients to the incorrect level delays definitive care, mostly provided
G
at regional and tertiary facilities, and necessitates costly inter-
hospital transfers.
R
A similar pattern was seen in the Eastern Cape, where almost 70%
BA
of all trauma admissions to the teaching hospitals were due to either
transport- or violence-related mechanisms and almost 38% of these
O
incidents were preventable.21,22 Similar patterns were also reported
EM
in Mpumalanga.23 The excessive EMS workload means that many
patients do not arrive during the immediate post-injury period.24
Findings in the Western Cape (mainly urban areas) are in keeping
with the numbers and mechanisms of injury found in more rural
provinces, and the need for improved, locally relevant injury
surveillance programmes applicable to LMICs has been identified.25
Other studies examining the epidemiology of injuries have largely
focused on single-centres or specific pathologies. For example,
Howlett and colleagues found that passengers on the back of pick-up
trucks (‘bakkies’) were at severe risk of injury through ejection (90%
of such injuries involved prolonged hospital stays of around two
weeks, and almost one-third of survivors required ICU admission).26
Mnguni et al. examined abdominal injury over a seven-year period
at King Edward VIII Hospital in Durban and noted that 488 cases
were admitted to a single surgical firm (of six firms in total), with
penetrating trauma outnumbering blunt trauma by a staggering
9:1, and an overall mortality rate of 11%.27 Extrapolation of these
figures suggests that around 18 000 abdominal trauma cases will be
S A H R 20 1 6
Trauma
seen in the major KZN hospitals annually. This implies that around
90 000 cases will be seen annually across the country.
Wall and associates28 examined trauma incidence among the
pregnant population in Pietermaritzburg and surrounding areas,
and found that 4% of all female trauma cases admitted to the
Pietermaritzburg Trauma Service were injured during pregnancy,
with over 50% due to assault; this resulted in foetal loss in over
33% of cases, rising to 86% in those requiring emergency surgery.
They further noted that 3 000 female patients sought trauma care
in the 30-month study period, implying 1 200 cases per year at
their centre. This was extrapolated to around 8 400 female trauma
patients per year across the major KZN hospitals, and therefore
almost 42 000 countrywide.
Moodley and associates29 examined trauma burden and mortality
PM
in the Pietermaritzburg region and noted that over 5 000 trauma
cases per year were treated at the three hospitals under review,
with an almost 4:1 male/female ratio. Extrapolation of these figures
to the province suggests that almost 35 000 trauma admissions
occur per year in KZN. During that period, 1 105 trauma deaths
underwent forensic post-mortems, of which over half took place at
the accident scene.29
Pillay, Ross and Van der Linde30 reviewed King Edward VIII
Hospital’s emergency centre trauma attendances and noted that in
a one-month period, 1 465 trauma cases were treated, equating
to over 17 500 per annum for their facility alone. Importantly, over
66% of cases had a violent underlying cause and almost 10%
required ICU admission.
This disease burden involves not only the emergency centre or the
surgical wards; it also influences the workload of orthopaedics,
with 63% of the 850 operative cases at one facility in 2000 being
due to injury.31 Similar figures were noted by Parkinson et al., with
over 100 patients treated for road-related injury per month at the
Pietermaritzburg service, one-third of which required admission
for surgery.32 Incidence of pedestrian injury is far higher than one
would expect, with almost 50% of vehicular trauma sustained by
pedestrians,32,33 and with figures in the paediatric population
ranging from 21% to 58% at a referral centre and as high as 75%
in those with major chest trauma.34–36 Recent published data from
the Red Cross War Memorial Children’s Hospital, a referral centre
in Cape Town, demonstrates very similar rates of injury mechanism,
with boys between five and nine years of age accounting for 75%
of pedestrian trauma cases. Many of them had traumatic brain
injury.37,38
Most of these studies excluded burn patients; however, the burn-
injury burden in KZN was reviewed in four recent papers from
the three main burn centres in the province (two regional and one
quaternary). The reviews demonstrated that children and epilepsy
sufferers were at particular risk, with flame burns and hot-water
scalds predominating. Annual incidence across the province was
estimated to be somewhere between 7 000 and 30 000 cases,
depending on whether minor burns treated at clinics and outpatient
facilities were included.39–42 Major burns (>30% body surface area
in adults and >20% in children) constituted around 320 cases per
year referred to the major burn units, with regional and district
hospitals caring for the majority of moderate and minor burns. Data
from other major burn centres in Cape Town show that across the
181
Western Cape (a better-resourced province) there was satisfactory
initial burn care, but again a delay in definitive care through the
primary care pathway, leading to multiple transfers.43
Much of the published work from other trauma care facilities around
South Africa reports on the specific management of single injuries
or small numbers of complex injury patterns, while some report
on management consequences after ICU admission. While these
facilities are excellent in clinical management, there is insufficient
overall information provided to determine the actual provincial
trauma burden in the host provinces to enable comparative
extrapolation of the disease burden of trauma. What these studies
do highlight is the enormous surgical burden that trauma adds to the
already large burden of non-communicable surgical disease.44–59
It is also readily acknowledged that emergency centres worldwide
are faced with a major space challenge, and overcrowding is not
uncommon in South Africa. Trauma care often requires more time
and resources than ordinary medical care, so that given the huge
16 6
burden identified in these studies, it is even more essential to develop
robust trauma systems in South Africa.60,61
20 IL
The KZN studies led to the development of the first province-wide
data-capture tool linked to the District Health Information System
Y T
(DHIS),62 which captures basic epidemiological data from every
public district, regional and tertiary, as well as the single quaternary
A N
central hospital. Over two years’ data have been collected, collated
M U
and summarised, which has enabled a province-wide overview of
the actual trauma burden, incorporating some of the variables not
collected in previous studies. The aggregated data show that there
4 ED
were 197 219 emergency department visits for trauma in the period
under review, which constituted 27% of all emergency department
visits in the province, with 18 716 cases (9.5%) requiring ward
O
or ICU admission. This demonstrates that the actual burden was
significantly greater than earlier estimates.63,64 While similar
G
figures were reported from primary care facilities in the Western
Cape where injuries accounted for 20% of the emergency centre
R
workload,65 at the present time there is no parallel system linked to
BA
the DHIS in the other provinces with which to compare these results.
N
O
The cost of trauma care
EM
Healthcare costing is a difficult process, given that government-
employed healthcare practitioners are salaried staff, and that
trauma patients may require multiple aspects of care (emergency
department, ward care, intensive care, rehabilitation services, allied
health services and various medical specialists, etc.). Despite these
challenges, a number of recent studies have attempted to provide
trauma costing in South Africa.
Lutge and Muirhead31 undertook costing using a bottom-up/top-
down approach to determine the costs of managing orthopaedic
injuries in the year 2000, and found that using either method,
the costs were in excess of R5 million. Allorto and colleagues66
undertook a costing study on burns patients at Edendale Burn
Service over an 18-month period and estimated an overall cost in
excess of R29 million for the 450 patients treated during that period.
Parkinson et al. examined the cost of road-traffic injury in
Pietermaritzburg67 and found that the cost per patient was around
US$6 988.50 (almost R105 000 at current rates). However,
Bowman et al.68 highlighted that costing and a cost-culture were
1 82 S A H R 20 1 6
largely absent in the public sector, making accurate costing difficult.
They examined trauma patients in Johannesburg in 2004 and found
that for 48 patients reviewed, the cost was in excess of R220 000,
excluding personnel and bed costs. More recent work from a large
trauma referral centre serving most of rural KZN showed that the
cost of interpersonal violence only (38% of the trauma burden),
amounted to over R8 million per three-month period, therefore more
than R32 million per year.69
Costing estimates using data from trauma-burden studies17,18,70
show that at 2010 Rand-value, the overall cost of trauma care in
KZN would amount to almost R5.4 billion, excluding the cost of
proposed facility upgrades to ensure compliance with the National
Core Standards.70,71
PM
Human resources
There are low staffing levels in emergency departments, which
are often served by the most junior doctors; insufficient basic
resuscitation facilities; and limited imaging facilities at clinics and
district hospitals, especially after normal hours, which is when most
trauma incidents occur. This leads to delays in initial care and
definitive care, resulting in more complications and the subsequent
need for ICU care. There is also a lack of nurses specifically trained
to manage trauma and emergency cases.16–18 Moreover, there is
poor access to surgical facilities and, despite expectation of the
existence of surgical capability, very few minor operations are
possible in district hospitals.72
The human resources required to establish an efficient trauma system
have been estimated using standardised formulae applied to public-
service facilities. Estimations include the following, per referral
hospital expected to manage major trauma:64,65
➢➢ Three to six medical officers per emergency centre (depending
on size) dedicated to trauma and acute care, with two
emergency medicine specialists to lead the emergency centre
in regional or large district hospitals (per unit). District hospitals
would be staffed with family physicians.
➢➢ Nurses trained in emergency nursing to staff the emergency
centres in ratios of one professional nurse (PN) per resuscitation
bed and one PN per five other (non-resuscitation) patients,
with enrolled nurses (ENs) to assist in a ratio of three per 10
patients.
➢➢ Radiographers to cover computed tomography (CT) and other
imaging services 24/7.
➢➢ Laboratory service staff to cover all laboratories 24/7.
➢➢ Surgeons with a commitment to consultant-led trauma care,
ideally headed by a certified trauma surgeon, if available, at
regional hospital level, preferably in a hospital certified as a
‘Trauma Centre’.
➢➢ Allied health service staff to provide ward services.
➢➢ Operation room staff (scrub nurse, circulating nurse and
anaesthetic assistant) to provide a dedicated trauma operation
suite 24/7, not competing with Caesarean sections and non-
trauma acute surgery, or elective surgery; plus anaesthetic
specialist cover for the operation suite.
➢➢ Clerk and porter services to ensure adequate internal
administrative support.

➢➢ Cleaners and infection-control staff to ensure a safe working
environment.
➢➢ Management support, enabling patient-focused resource
allocation.
➢➢ Wards staffed with nurses in a 1:10 PN/patient ratio and a
1:5 EN/patient ratio, with the High Dependency Unit (HDU)
staffed in a 1:2 nurse/patient ratio and ICU staffed in a 1:1
PN/patient ratio, with additional staff to allow for continuity of
care during teas and lunches.
➢➢ ICU staff should be trained to use dialysis equipment.
➢➢ Regarding pre-hospital trauma care, there should be at least
one intermediate paramedic per ambulance and at least one
advanced paramedic per five ambulances; this should exclude
staff at the call centres and management officers who should
be trained in efficient management of resources.
Infrastructure requirements
16 6
Despite self-reported assurances regarding the existence of
20 IL
adequate equipment at various healthcare facilities, one study18 in
KZN showed this was not the case, with 54% of district facilities
having inadequate resuscitation-area facilities, none having in-
Y T
house CT-scanners, only 62.5% having emergency mobile X-ray
A N
units, and 58% not having access to an emergency operating room
(a requirement of the District care-package). Only 25% of district
M U
hospitals had an emergency observation ward, despite the need
to accommodate many patients awaiting transfer to a higher level
4 ED
of care. Sixty-two per cent of medical staff had no formal trauma
training, and 50% of the hospitals had inadequate helicopter-
landing facilities.
O
Equipment and facilities will need to be upgraded according to the
established national norms, such as the Trauma Society of South
G
Africa (TSSA) criteria for trauma centres, the Council for Scientific
and Industrial Research (CSIR) built-environment guidelines,
R
the administrative recommendations of the Council for Health
Service Accreditation of Southern Africa (COHSASA) trauma
BA
document,15,73,74 and the National Core Standards.70 Active liaison
O
with clinicians in the field of trauma care is essential to ensure that
optimal equipment choices are made. For example:
EM
➢➢ Sufficient ambulances will be required to ensure the minimum
correct ambulance-to-patient ratio of 1:10 000 population,
and they must be stocked with appropriate equipment for mass
casualty and normal patient treatment.
➢➢ Operating resources should include an electronic link between
all hospitals to enable data capture on the regional trauma
registry, data storage for the image services, and facilities to
transfer images more effectively and allow for telemedicine
consultations between regional and district facilities.
The need for a national trauma database
A national minimum trauma database is required urgently in the
country; this could include identifiers at facility level to ensure the
ability to update outcome data. Data should be collated nationally
to establish trends, disease burden, injury severity patterns and
outcomes. This would enable rational funding for trauma care, the
identification of areas with specific need, and accurate prediction of
the need for rehabilitation services. Additionally, the results would
S A H R 20 1 6
Trauma
indicate the success of prevention strategies if reduced injury numbers
were achieved over time. There are currently locally designed and
highly functional local and regional databases that could easily be
expanded to provide such a national trauma database, including a
‘shareware’ phone-based app offered by the Trauma Association of
Canada.33,75–79
Accreditation programmes
To achieve both competence and a demonstrable commitment to
quality trauma care, independent assessment of trauma facilities is
common practice across the world, as reflected in World Health
Organization and American College of Surgeons documents.80,81
The Trauma Society of South Africa15 has developed a locally
relevant assessment model and accreditation programme, currently
PM
with uptake mainly in the private health sector, and with over 15
hospitals currently accredited. However, there may be merit in
examining the system for its suitability in the public sector.
Quality assurance in trauma care
A useful overview of management theory relative to quality assurance
in trauma care highlighted that using a strategic planning approach
enables quality metrics to be applied to the acute care system.82
Additionally, a number of other studies have demonstrated that
quality assurance systems can be implemented effectively and readily
assessed.83–88 Many of the problems identified in such assessments
are related to missed injury89,90 or delayed diagnosis, which can
be addressed through the various quality assessment tools and
systems. Similar findings from a pre-hospital study in Johannesburg
highlight the need for optimised patient management.91 The World
Health Organization offers a Trauma Quality Assurance tool that
can guide the assessment of quality of care and the success of new
interventions undertaken.
The role of primary health care in trauma
Primary health care services have a pivotal role to play in
implementing effective trauma primary prevention strategies.
Examples include education on safe pedestrian practice, use of
seatbelts, and reduced alcohol abuse. These strategies can be
introduced when people with minor injuries present to a primary
care facility, or when the primary care staff undertake local
outreach. Education should also be directed at basic first-aid
instruction and appropriate use of emergency care services.92–95
Simple interventions have led to dramatic injury reduction in certain
areas,96 and many novel concepts have been mooted.97,98
The existing referral pathway in the public sector is protracted,
resulting in the delay of appropriate care to the trauma victim. Pre-
hospital services transport approximately 70% of all trauma cases
to district hospitals and clinic facilities. It is then the responsibility of
the treating nurses and doctors to manage the patient, irrespective
of whether the facility is adequately staffed or suitably equipped.
The facility is then responsible for arranging transfer of the patient
to a higher level of care if required; an ambulance must be booked
and the patient must wait to be transferred. This process protracts the
time taken to reach definitive care and increases the risk of sepsis,
resulting in a more urgent need for ICU admission, prolonged stay
in hospital and higher mortality.
1 83
In the case of severe injury (major trauma/ISS>16), patients taken
to regional-level hospitals have to compete for emergency care with
medical and obstetric emergencies, often in inadequately designed
and equipped emergency centres. There is also competition for
access to operation rooms and imaging facilities, which may be
unavailable after hours. There is also insufficient ICU capacity at
most regional facilities, and lack of dialysis for acute kidney injury,
which often complicates major trauma and other emergencies.
Risks of litigation
When the care of trauma and other emergency cases is not
adequate, there is a significant possibility of litigation against the
various Departments of Health.99,100
The obligation to provide emergency medical care was illustrated in
countries, in particular developing countries, with regard to early
warning, risk reduction and management of national and global
health risks, achievable though disaster planning that would include
EMS and trauma care.
SDG 11 addresses the potential root cause of violence-related
trauma through recommending that cities be made safe and
sustainable by ensuring access to safe and affordable housing.
This also involves upgrading slum settlements, investing in public
transport, creating green public spaces, and improving urban
planning and management in a way that is both participatory and
inclusive, thus reducing reliance on own-transport and potentially
reducing pedestrian collisions on highways.
SDG 11 can be read hand-in-hand with SDG 16, which aims
to reduce all forms of violence significantly, and to encourage

PM
a recent Constitutional Court ruling in the case of Oppelt vs. Head: governments and communities to work together to find lasting
Health Western Cape.101 The court held that any life-threatening solutions to conflict and insecurity. By strengthening the rule of law
medical emergency requiring further specialist intervention as through effective policing and traffic enforcement, the two major

16 6
part of the resuscitation/stabilisation process is now regarded components of the trauma burden can be prevented and mitigated.
as part of emergency medical treatment, and any specialist/ Promoting respect for human rights is central to this process.

20 IL
consultant contacted by an emergency department doctor for further
assistance/consultation and who refuses to provide such support, Good practices and hindrances to policy
will be held liable for refusing emergency medical treatment.
Y T implementation
The court also held that strict adherence to a protocol that does
Good practices in the current KZN trauma care environment are
A N
not accommodate emergencies is not an excuse for the delays
mainly based on optimal clinical care in the face of logistical and
caused by such refusal. The court also found that the purpose
human resource challenges. The Pietermaritzburg Metropolitan
M U

of Section 27(3) of the Constitution is to ensure that treatment is

Trauma Service and the Inkosi Albert Luthuli Central Hospital
given in an emergency, and that it is not frustrated by reason of
(IALCH) Trauma Unit are examples of where the best use is made
4 ED

bureaucratic requirements or other formalities, and that a person

of the current system to achieve the best potential outcomes, in line
who suffers a sudden catastrophe calling for immediate medical
with management strategies developed by international consensus
attention should not be refused ambulance or other emergency
and collaboration.19,33,77,105,106
services that are available, and should not be turned away from a
O

hospital that is able to provide the necessary treatment. The court Some examples of the results of good practice at these units include:
G

found that emergency medical treatment is not confined to that ➢➢ assessment of the knowledge and skills of junior staff regarding
which is undertaken in an emergency department, but includes that chest-drain placement, an important technical skill;107
R

which is continued into definitive medical care if this is required

➢➢ diagnosis and management of blunt cardiac injury and acute
for life-saving reasons, and may therefore also involve referral of
BA

kidney injury;108,109
multi-trauma patients to a Level 1 Trauma Unit.101 This judgment has
implications for the National Department of Health to plan efficient, ➢➢ avoidance of tracheal damage due to high cuff pressures or
O

cost-effective and defensible trauma systems to maximise survival misplaced tubes;110

EM

and minimise morbidity, and avoid costly legal battles. This would
➢➢ optimal control of body temperature in trauma patients (now
indirectly release more money to fund actual health care across all
part of the National Core Standards);111
the disease burdens.102
➢➢ optimal management of vascular injury in the polytrauma
Sustainable Development Goals population;112 and

➢➢ reduction in complications and errors in care.83–87,90,113

The United Nations has recently established a set of Sustainable
Development Goals (SDGs),103 some of which have a direct bearing
on trauma prevention and mitigation, through either healthcare or
generic interventions aimed at improving access to health care and
reducing risk-taking behaviour. SDGs 3, 11 and 16 in particular
relate to such aspects, which if optimally addressed will result in
achievement of the stated targets. Specifically, SDG 3, which
relates to health care, aims to halve the number of global deaths
and injuries from road-traffic accidents by 2020, and to achieve
universal health coverage (including financial risk protection),
access to quality essential healthcare services, and access to safe,
effective, quality and affordable essential medicines and vaccines
for all (potentially addressed in the National Health Insurance White
Paper).104 Additionally, the aim is to strengthen the capacity of all
Outcome prediction, using lactate clearance, for mortality risk and
timing of safe orthopaedic intervention, has also been studied,114–116
as has the management of penetrating trauma, which makes up
35% of the trauma burden due to violence.117–120
At national level, implementation of the National Core Standards,70
in particular those relating to the emergency centre and the ICU,
serve to improve quality and to reduce financial implications for
the injured. The major units in KZN have achieved good results in
the peer-review process in this regard, with IALCH achieving almost
90% compliance.12
One of the aims of the National Health Insurance (NHI) White
Paper104 is to provide a mechanism for cross-subsidisation across

184 S A H R 20 1 6
 Trauma

the entire health system, while meeting acceptable standards of care
and achieving positive health outcomes. This aim is similar to that of
trauma care and as such is unfortunately a cost driver for curative
care in a poorly resourced and poorly structured health system. This
is seen in light of the major cost drivers such as blood products,
surgical consumables and laboratory services. Given the scale of
the injury burden, this is not unexpected, but it is worsened by the
private sector, which treats limited trauma profiles and refers many
of the indigent cases to the already overburdened public sector.
However, the injury burden cited in the White Paper seems to
underestimate significantly the real effect on the healthcare system,
and the financing mechanisms have not yet been clearly spelt
out.121,122
It is encouraging that emergency medical services have been
Implications of findings
The findings illustrate the burden of injuries and violence on the health
system, both in KZN and nationally,127,128 and the current lack of
human and infrastructural resources to mitigate this burden. Proper
re-engineering of the primary care pathway and strengthening of
the regional and tertiary/quaternary levels of care, together with
establishment of committed and well-resourced trauma care services
will reduce risk of litigation. Prevention and rehabilitation services
at primary-care level should include community health improvement
strategies, which will enhance the return of injured survivors to
gainful employment.
A multi-sector approach is required, including strategies to reduce or
prevent motor-vehicle and interpersonal or industrial injuries through

highlighted in the White Paper and that comprehensive pre- and
in-hospital aspects are mentioned, with a specific note that district
hospitals may be partially removed from emergency care in favour
of regional and higher levels of care due to the need for specialist
PM
inter-ministerial units including law-enforcement (Justice/Police),
road safety (Transport) and social change (Social Development/
Home Affairs). The recently implemented Road Incident Management
System (RIMS) is a good example of interaction between the

16 6
involvement.104 Optimal preparation of the system for trauma Departments of Health, Transport, Police Services and broader
care, in anticipation of the single-payer national plan, must include professional societies.129

20 IL
consultation with practising trauma surgeons.

Potential for policy reform Y T Conclusion

KwaZulu-Natal (and the rest of South Africa) faces a huge injury
A N
It has been shown in both developed and developing-world
burden, and requires a multi-sector approach, beyond health, to
scenarios that reducing the steps to definitive trauma care improves
M U

achieve the SDGs and ensure a functional trauma system that is both
outcomes.72,123–126 The current referral pathway in South Africa
cost-efficient and quality-assured, for the proposed NHI to succeed.
delays the time to arrival at the appropriate facility. There is also
The KZN DHIS model should be adopted as a national priority.
4 ED

an insufficient number of ambulances, often with poorly trained staff

at basic ambulance attendant level, which limits efficient triage and Government must engage with professional societies and thought-
intervention in the pre-hospital phase of care.17 This results in a lack leaders in injury prevention, disaster mitigation and curative trauma
of ability to bypass lower-level facilities, even when the patient would
O

care in order to establish a coherent functional trauma system,

clearly benefit from direct bypass to a regional or central hospital. from pre-hospital to hospital level; the system should deliver the
G

Policy reform in trauma care must therefore be considered in the light right patient to the right facility in the right timeframe, and reduce
of the disease burden outlined, and take into account the challenges morbidity and mortality through provision of quality care. A national
R

of the current human resources and facilities. A system of trauma Trauma Data Bank should be established to detail the disease
care must be implemented that ensures early access to definitive burden and the current outcomes, while at the same time, taking into
BA

care, allowing EMS bypass of less-equipped facilities and ensuring account the varying injury and trauma profiles across the county.
that the patient gets to the appropriate facility within the correct Additionally, there should be access to rehabilitation services across
O

timeframe, thus reducing morbidity and preventing unnecessary the spectrum of care to ensure that injured patients are restored as
EM

mortality.102 The current primary care pathway is not optimal for economically viable members of society, through a well-orchestrated
trauma care. The major challenge is that time is required to gauge continuous care pathway.
the long-term mortality reduction of trauma systems, with most
reports suggesting a 10-year time-lag before statistically significant
change can be recorded.124–126

In an ideal system there will be adequately staffed and equipped

emergency centres, dedicated trauma wards under a trauma service
team, with adequate operation room facilities (featuring separate
trauma and non-trauma access) at regional and central hospitals,
which will have been accredited as Trauma Centres. ICU back-
up, with acute dialysis facilities, must be established at regional
centres, with bed allocation based on disease burden. Definitive
care facilities must be designed such that acute non-trauma, elective
procedures and trauma can be addressed concurrently without one
out-competing the other – this may require increased human and
structural resources or the designation of certain facilities as ‘trauma
hospitals’ and diversion of all major injuries to these designated
hospitals.18,63,64,72

S A H R 20 1 6 1 85
References
1 Lozano R, Naghavi M, Foreman K, et al. Global and regional
mortality from 235 causes of death for 20 age groups in
1990 and 2010: a systematic analysis for the Global Burden
of Disease Study 2010. Lancet. 2013;380:2095–128.
2 Mathers C, Boersma T, Ma Fat D. The Global Burden of
Disease, 2004 update. Geneva: World Health Organization;
2008.
3 Matzopoulos R, Prinsloo M, Pillay-van Wyk V, et al. Injury-
related mortality in South Africa: a retrospective descriptive
study of postmortem investigations. Bull World Health Organ.
2015;93(5):303–13.
4 Gosselin RA, Spiegel DA, Coughlin R, Zirkle LG. Injuries: the
neglected burden in developing countries. Bull World Health
Organ. 2009;87:246–246a.
5 Dalal K, Lin Z, Gifford M, Svanström L. Economics of Global
Burden of Road Traffic Injuries and Their Relationship
with Health System Variables. Int J Prev Med. 2013
Dec;4(12):1442–50.
16 6
6 Hinsberger M, Sommer J, Kaminer D, et al. Perpetuating the
cycle of violence in South African low-income communities:
20 IL
attraction to violence in young men exposed to continuous
threat. Eur J Psychotraumatol. 2016;7:29099.
7 Lewis C, Wood D. Interpersonal violence as a major
Y T
contributor towards the skewed burden of trauma in KwaZulu-
Natal, South Africa. S Afr Med J. 2015;105(10):827–30.
A N
8 Nicol A, Knowlton LM, Schuurman N, et al. Trauma
M U
Surveillance in Cape Town, South Africa: An Analysis of
9236 Consecutive Trauma Centre Admissions. JAMA Surg.
2014;149(6):549–56.
4 ED
9 Wallis LA. Shifting Focus: Addressing the neglected pandemic.
Professorial inaugural lecture, University of Cape Town. Cape
Town; 2 April 2014.
O
10 Wallis LA. Trauma care in South Africa – a call to arms. S Afr
Med J. 2011;101(3):171.
G
11 Gouveia J, Seedat MA, Ekman R, et al. Tracing the utility of
injury surveillance data in Pretoria (South Africa) and Borås
R
(Sweden). Int J Inj Contr Saf Promot. 2011;18(1):75–83.
12 Van Hoving DJ, Sinclair M, Wallis LA. Patterns of seatbelt use
BA
in different socioeconomic communities in the Cape Town
Metropole, South Africa. S Afr Med J. 2013;103(9):628–31.
O
13 Van Hoving DJ, Hendrikse C, Gerber RJ, et al. Injury severity
EM
in relation to seatbelt use in Cape Town, South Africa: a pilot
study. S Afr Med J. 2014;104(7):488–92.
14 Association for the Advancement of Automotive Medicine
(AAAM). Abbreviated Injury Scale, 1998 Update of the 1990
Revision. Barrington, Illinois; AAAM; 2001.
15 Hardcastle TC, Steyn E, Boffard KD, et al. Guideline for the
assessment of trauma centres for South Africa. S Afr Med J.
2011;101:189–94.
16 Gordon K, Allorto N, Wise R. Analysis of referrals and triage
patterns in a South African metropolitan adult intensive care
service. S Afr Med J. 2015;105(6):491–5.
17 Hardcastle TC, Finlayson M, Van Heerden M, Johnson B,
Samuel C, Muckart DJJ. The prehospital burden of disease
due to trauma in KwaZulu-Natal: The need for Afrocentric
Trauma Systems. World J Surg. 2013;37(7):1513–25.
18 Hardcastle TC, Samuels C, Muckart DJ. An assessment of the
Hospital Disease Burden and the facilities for the in-hospital
care of trauma in KwaZulu-Natal, South Africa. World J Surg.
2013;37(7):1550–61.
186 S A H R 20 1 6
19 Hardcastle TC, Reeds MG, Muckart DJJ. Utilisation of a
Level 1 Trauma Centre in KwaZulu-Natal: Appropriateness
of referral determines trauma patient access. World J Surg.
2013;37(7):1544–9.
20 Owen R, Dimopoulos GE. An analysis of advanced life
support in the greater Durban area. Trauma Emerg Med (SA).
1994;May/June:1053–7.
21 John J, Matshoba W. Trauma care – the Eastern Cape story.
S Afr Med J. 2015;105(6):500.
22 Dhaffala A, Longo-Mbenza B, Kingu JH, et al. Demographic
profile and epidemiology of injury in Mthatha, South Africa.
Afr Health Sci. 2013;13(4):1144–8.
23 Nzaumvila D, Govender I, Kramer EB. Glass injuries seen in
the emergency department of a South African district hospital.
PM
Afr J Prim Health Care Fam Med. 2015;7(1):E1–8.
24 Thurston B, Chowdhury S, Edu S, et al. Time since injury is
the major factor in preventing tranexamic acid use in the
trauma setting: An observational cohort study from a major
trauma centre in a middle-income country. S Afr J Surg.
2015;53(1):13–8.
25 Schuurman N, Cinnamon J, Walker BB, et al. Intentional injury
and violence in Cape Town, South Africa: an epidemiological
analysis of trauma admissions data. Glob Health Action.
2015;8:27016.
26 Howlett JB, Aldous C, Clarke DL. Injuries sustained by
passengers travelling in the cargo area of light delivery
vehicles. S Afr J Surg. 2014;52(2):49–52.
27 Mnguni MN, Muckart DJ, Madiba TE. Abdominal trauma in
Durban, South Africa: factors influencing outcome. Int Surg.
2012 Apr–Jun;97(2):161–8.
28 Wall SL, Figueiredo F, Laing GL, Clarke DL. The spectrum and
outcome of pregnant trauma patients in a metropolitan trauma
service in South Africa. Injury. 2014;45(8):1220–3.
29 Moodley NB, Clarke DL, Aldous C. Current trauma patterns
in Pietermaritzburg. S Afr J Surg. 2015;53(3&4):37–9.
[Internet]. [cited 22 December 2015].
URL: http://www.sajs.org.za/index.php/sajs/article/
view/1994/821
30 Pillay KK, Ross A, Van der Linde S. Trauma unit workload at
King Edward VIII Hospital, Durban, KwaZulu-Natal. S Afr
Med J. 2012;102(5):307–8.
31 Lutge EE, Muirhead D. The epidemiology and cost of trauma
to the orthopaedic department at a secondary-level hospital.
S Afr J Surg. 2005;43(3):74–7.
32 Parkinson F, Kent S, Aldous C, Oosthuizen G, Clarke DL.
Patterns of injury seen in road crash victims in a South African
trauma centre. S Afr J Surg. 2013;51(4):131–4.
33 Cheddie S, Muckart DJJ, Hardcastle TC, Den Hollander D,
Cassimjee H, Moodley S. An audit of a new level 1 Trauma
Unit in urban KwaZulu-Natal. S Afr Med J. 2011;101:176–8.
34 Manchev V, Bruce JL, Oosthuizen GV, Laing GL, Clarke DL.
The incidence, spectrum and outcome of paediatric trauma
managed by the Pietermaritzburg Metropolitan Trauma
Service. Ann R Coll Surg Engl. 2015;97(4):274–8.
35 Naidoo N, Muckart DJ. The wrong and wounding road:
Paediatric polytrauma admitted to a level 1 trauma
intensive care unit over a 5-year period. S Afr Med J.
2015;105(10):823–6.
36 Skinner DL, den Hollander D, Laing GL, Rodseth RN, Muckart
DJ. Severe blunt thoracic trauma: differences between
adults and children in a level I trauma centre. S Afr Med J.
2015;105(1):47–51.

37 Isaac KN, Van Niekerk A, Van As AB. Child road traffic crash
injuries at the Red Cross War Memorial Children’s Hospital in
Cape Town, South Africa in 1992, 2002 and 2012. Int J Inj
Contr Saf Promot. 2015;22(4):352–8.
38 Schrieff LE, Thomas KG, Dollman AK, et al. Demographic
profile of severe traumatic brain injury admissions to Red
Cross War Memorial Children’s Hospital, 2006–2011. S Afr
Med J. 2013;103(9):616–20.
39 Den Hollander D, Albert M, Strand A, Hardcastle TC.
Epidemiology and referral patterns of burns admitted to the
Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban.
Burns. 2014;12(6):1201–8.
40 Allorto NL, Oosthuizen GV, Clarke DL, Muckart DJ. The
spectrum and outcome of burns at a regional hospital in South
Africa. Burns. 2009;35(7):1004–8.
41 Scheven D, Barker P, Govindasamy J. Burns in rural KwaZulu-
Natal: epidemiology and the need for community health
education. Burns. 2012;38(8):1224–30.
42 Faurie MP, Allorto NL, Aldous C, et al. A closer look at burn
injuries and epilepsy in a developing world burn service.
16 6
S Afr J Surg. 2015;53(4):48–50.
20 IL
43 Rode H, Rogers AD, Numanoglu A, et al. A review of primary
and secondary burn services in the Western Cape, South
Africa. S Afr Med J. 2015;105(10):853–7.
Y T
44 Krige JE, Kotze UK, Nicol AJ, et al. Isolated pancreatic
injuries: An analysis of 49 consecutive patients treated at a
A N
Level 1 Trauma Centre. J Visc Surg. 2015;152(6):349–55.
45 Conradie WJ1, Gebremariam FA. Can computed
M U
tomography esophagography reliably diagnose traumatic
penetrating upper digestive tract injuries? Clin Imaging.
4 ED
2015;39(6):1039–45.
46 Pillai J, Yazicioglu C, Moeng S, et al. Prevalence and
patterns of infection in critically ill trauma patients admitted
to the trauma ICU, South Africa. J Infect Dev Ctries.
O
2015;9(7):736–42.
47 Naidoo NG1, Navsaria P, Beningfield SJ, et al. Stent graft
G
repair of subclavian and axillary vascular injuries: The Groote
Schuur experience. S Afr J Surg. 2015;53(1):5–9.
R
48 Krige JE, Navsaria PH, Nicol AJ. Damage control laparotomy
BA
and delayed pancreatoduodenectomy for complex combined
N
pancreatoduodenal and venous injuries. Eur J Trauma Emerg
Surg. 2015 Apr 8. [Epub ahead of print].
O
49 Wells BJ, Roberts DJ, Grondin S, et al. To drain or not to
EM
drain? Predictors of tube thoracostomy insertion and outcomes
associated with drainage of traumatic hemothoraces. Injury.
2015;46(9):1743–8.
50 Krige JE, Kotze UK, Setshedi M, et al. Prognostic factors,
morbidity and mortality in pancreatic trauma: a critical
appraisal of 432 consecutive patients treated at a Level 1
Trauma Centre. Injury. 2015;46(5):830–6.
51 Nicol AJ, Navsaria PH, Beningfield S, et al. Screening
for occult penetrating cardiac injuries. Ann Surg.
2015;261(3):573–8.
52 Nicol AJ, Navsaria P, Hommes M, et al. Sternotomy or
Drainage for a Hemopericardium After Penetrating Trauma:
A Safe Procedure? Ann Surg. 2016;263(2):e32.
53 Hommes M, Navsaria PH, Schipper IB, et al. Management
of blunt liver trauma in 134 severely injured patients. Injury.
2015;46(5):837–42.
54 Navsaria PH, Nicol AJ, Edu S, et al. Selective nonoperative
management in 1106 patients with abdominal gunshot
wounds: conclusions on safety, efficacy, and the role of
selective CT imaging in a prospective single-center study. Ann
Surg. 2015;261(4):760–4.
S A H R 20 1 6
Trauma
55 Forgus S, Delva W, Hauptfleisch C, et al. Community v.
non-community assault among adults in Khayelitsha, Western
Cape, South Africa: a case count and comparison of injury
severity. S Afr Med J. 2014;104(4):299–301.
56 van Rooyen PL, Karusseit VO, Mokoena T. Inferior vena
cava injuries: a case series and review of the South African
experience. Injury. 2015;46(1):71–5.
57 Banderker MA, Navsaria PH, Edu S, et al. Civilian popliteal
artery injuries. S Afr J Surg. 2012;50(4):119–23.
58 Moolman C, Navsaria PH, Lazarus J, et al. Nonoperative
management of penetrating kidney injuries: a prospective
audit. J Urol. 2012;188(1):169–73.
59 Hosking C, Wilander P, Goosen J, et al. Low central venous
oxygen saturation in haemodynamically stabilized trauma
patients is associated with poor outcome. Acta Anaesthesiol
Scand. 2011;55(6):713–21.
PM
60 Obermeyer Z, Abujaber S, Makkar M, et al. Emergency care
in 59 low- and middle-income countries: a systematic review.
Bull World Health Organ. 2015; 93:577–86.
61 Affleck A, Parks P, Drummond A, et al. Emergency department
overcrowding and access block. Can J Emerg Med.
2015;15(6):359–70.
62 Lutge E, Moodley N, Tefera A, Sartorius B, Hardcastle TC,
Clarke DL. A hospital based surveillance system to assess the
burden of trauma in KwaZulu-Natal Province South Africa.
Injury. 2016;47:135–40.
63 Hardcastle TC. Continuity of Care: Trauma, surgery, ICU and
rehabilitation suggestions for improved and enhanced service
delivery for emergency care. In: Wallis LA, editor. Report to
the Ministerial Task Team on Emergency Care, 2012–2013.
Pretoria: National Department of Health; 2013.
64 Hardcastle TC, Clarke DL, Brysiewicz P. The Burden of Trauma
in KZN, projections for the next five years and suggestions for
improved and enhanced service delivery to meet the projected
needs. Report for the KwaZulu-Natal Department of Health;
2013.
65 Govender I, Matzopoulos R, Makanga P, et al. Piloting a
trauma surveillance tool for primary healthcare emergency
centres. S Afr Med J. 2012;102(5):303–6.
66 Allorto N, Clarke DL, Thomson SR. A cost model case
comparison of current versus modern management of burns at
a regional hospital in South Africa. Burns. 2011;37(6):1033–
7.
67 Parkinson F, Kent SJ, Aldous C, Oosthuizen G, Clarke
D. The hospital cost of road traffic accidents at a South
African regional trauma centre: a micro-costing study. Injury.
2014;45(1):342–5.
68 Bowman B, Stevens G, Seedat M, et al. Costing injuries in
South Africa: preliminary results and challenges from a pilot
study. Afr J Health Sci. 2010;16:57–63.
69 Bola S, Dash I, Naidoo M, et al. Interpersonal violence:
quantifying the burden of injury in a South African trauma
centre. Emerg Med J. 2016;33(3):208–12.
70 Hardcastle TC. A Trauma System for KwaZulu-Natal – Local
development for local need. PhD Thesis, University of
KwaZulu-Natal; 2013.
71 South African National Department of Health. National Core
Standards for Health Establishments in South Africa. Pretoria:
National Department of Health; 2011.
72 Clarke DL, Aldous C, Thomson SR. Assessing the gap between
the burden of trauma in Sisonke District and the surgical
capacity of the district hospitals: What are the implications for
planning? Eur J Trauma Emerg Surg. 2014;40(3):303–8.
1 87
73 Council for Health Service Accreditation of Southern Africa
(COHSASA). Emergency Centre Standards, Post Pilot,
November 2007. Cape Town: Council for Health Service
Accreditation of Southern Africa; 2007.
74 Fleming E, IUSS N&S Task Team. Infrastructure Unit Support
Systems (IUSS) Health Facility Guides. Emergency Centres,
Discussion draft 1.2, November 2012. Pretoria: CSIR Built
Environment Unit; 2012.
75 TraumaBank and MediBank. [Internet]. [cited 29 December
2015].
URL: http://www.medibank.co.za/
76 Razek T, Deckebaum D, Bracco D. iTrauma: a novel electronic
data collection system designed to collect essential trauma
information in resource-poor settings. [Internet]. [cited 29
December 2015].
URL: https://www.androidpit.com/app/com.phonegap.
itrauma
77 Laing GL, Bruce JL, Aldous C, Clarke DL. The design,
construction and implementation of a computerised trauma
registry in a developing South African metropolitan trauma
16 6
service. Injury. 2014;45:3–8.
78 Zargaran E, Schuurman N, Nicol AJ, et al. The electronic
20 IL
Trauma Health Record: design and usability of a novel
tablet-based tool for trauma care and injury surveillance in
low resource settings. J Am Coll Surg. 2014;218(1):41–50.
Y T
79 Zargaran E, Adolph L, Schuurman N, et al. A global agenda
for electronic injury surveillance: Consensus statement from the
A N
Trauma Association of Canada, the Trauma Society of South
Africa, and the PanAmerican Trauma Society. J Trauma Acute
M U
Care Surg. 2016;80(1):168–70.
80 Rotondo M, Cribari C, Smith RS for the Committee on Trauma.
4 ED
Resources for the optimal care of the injured patient. Chicago:
American College of Surgeons; 2014.
81 Mock C, Lormand JD, Goosen J, Joshipura M, Peden M.
O
Guidelines for essential trauma care. Geneva: World Health
Organization; 2004.
G
82 Clarke DL. Trauma quality improvement: The Pietermaritzburg
Metropolitan Trauma Service experience with the development
R
of a comprehensive structure to facilitate quality improvement
in rural trauma and acute care in KwaZulu-Natal, South
Africa. S Afr Med J. 2015;105(2):92–5.
BA
83 Clarke DL, Aldous C, Thomson SR. The implications of the
O
patterns of error associated with acute trauma care in rural
hospitals in South Africa for quality improvement programs
EM
and trauma education. Injury. 2014;45:285–8.
84 Laing GL, Skinner DL, Bruce JL, Aldous C, Oosthuizen GV,
Clarke DL. Understanding the burden and outcome of trauma
care drives a new trauma systems model. World J Surg.
2014;38(7):1699–706.
85 Laing GL, Bruce JL, Clarke DL. Tick-box admission forms
improve the quality of documentation of surgical emergencies,
but have limited impact on clinical behaviour. S Afr Med J.
2014 Apr 30;104(6):435–8.
86 Kong VY, Oosthuizen GV, Sartorius B, Keene C, Clarke
DL. An audit of the complications of intercostal chest drain
insertion in a high volume trauma service in South Africa. Ann
R Coll Surg Engl. 2014 Nov;96(8):609–13.
87 Clarke DL, Furlong H, Laing GL, Aldous C, Thomson SR. Using
a structured morbidity and mortality meeting to understand
the contribution of human error to adverse surgical events in
a South African regional hospital. S Afr J Surg. 2013 Oct
22;51(4):122–6.
188 S A H R 20 1 6
88 Alexander T, Fuller G, Hargovan P, Clarke DL, Muckart DJ,
Thomson SR. An audit of the quality of care of traumatic brain
injury at a busy regional hospital in South Africa. S Afr J Surg.
2009 Nov;47(4):120–2,124–6.
89 Hardcastle TC. Missed Injury: Decreasing Morbidity and
Mortality. A literature review. S Afr J Surg. 2011;49:199–
201.
90 Clarke DL, Gouveia J, Thomson SR, Muckart DJ. Applying
modern error theory to the problem of missed injuries in
trauma. World J Surg. 2008 Jun;32(6):1176–82.
91 Stassen W, Welzel T. The prevalence of hypotension and
hypoxaemia in blunt traumatic brain injury in the prehospital
setting of Johannesburg, South Africa: A retrospective chart
review. S Afr Med J. 2014;104(6):424–7.
92 Geduld H, Wallis LA. Taxi driver training in Madagascar: the
first step in developing a functioning prehospital emergency
PM
care system. Emerg Med J. 2011;28:794–6.
93 Tiska M A, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN. A
model of prehospital trauma training for lay persons devised
in Africa. Emerg Med J. 2004;21:237–9.
94 Sun JH, Wallis LA. Learning and retention of emergency first
aid skills in a violent, developing South African township.
Emerg Med J. 2013;30(2):161–2.
95 Sun JH, Shing R, Twomey M, Wallis LA. A strategy to
implement and support pre-hospital emergency medical
systems in developing, resource-constrained areas of South
Africa. Injury. 2014;45(1):31–8.
96 Nadesan-Reddy N, Knight S. The effect of traffic calming on
pedestrian injuries and motor vehicle collisions in two areas
of the eThekwini Municipality: a before-and-after study. S Afr
Med J. 2013;103(9):621–5.
97 Chokotho LC, Matzopoulos R, Myers JE. Drivers’ risk profile
indicates the need for a graduated driving licence in South
Africa. S Afr Med J. 2012;102(9):749–51.
98 van Hoving DJ, Lategan HJ, Wallis LA, et al. The
epidemiology of major incidents in the Western Cape
Province, South Africa. S Afr Med J. 2015;105(10):831–4.
99 Hardcastle TC. Ethical and Medico-legal aspects of Trauma.
S Afr J Bioethics Law. 2010; 3:25–7.
100 McCaffrey S. Challenging the cost of clinical negligence.
Casebook, MPS. 2015:23(2):6–7.
101 Constitutional Court of South Africa. Oppelt vs Head:
Department of Health Provincial Administration: Western
Cape. CCT 185/14, Judgement dated 14 October 2015.
102 Hardcastle TC. The 11 P’s of an Afrocentric Trauma System.
S Afr Med J. 2011;101:160–2.
103 United Nations. Sustainable Development Goals. [Internet].
[cited 23 December 2015].
URL: https://sustainabledevelopment.un.org/
104 South African National Department of Health. National Health
Insurance for South Africa. White Paper version 40. Pretoria:
National Department of Health; 10 December 2015.
105 Roberts DJ, Bobrovitz N, Zygun DA, et al. Indications for Use
of Damage Control Surgery in Civilian Trauma Patients: A
Content Analysis and Expert Appropriateness Rating Study.
Ann Surg. 2015 Oct 1. [Epub ahead of print]
106 Roberts DJ1, Bobrovitz N, Zygun DA, et al. Indications for use
of thoracic, abdominal, pelvic, and vascular damage control
interventions in trauma patients: A content analysis and expert
appropriateness rating study. J Trauma Acute Care Surg.
2015;79(4):568–79.
 Trauma

107 Kong VY, Oosthuizen GV, Sartorius B, Keene CM, Clarke
DL. Correlation between ATLS training and junior doctors’
anatomical knowledge of intercostal chest drain insertion.
J Surg Educ. 2015;72(4):600–5.
108 Skinner DL, Laing GL, Ryan L, Rodseth RN, Hardcastle TC,
Muckart DJJ. Blunt cardiac injury in critically ill trauma patients
– a single centre experience. Injury. 2015;46(1):66–70.
109 Skinner DL, Hardcastle TC, Rodseth RN, Muckart DJ.
The incidence and outcomes of acute kidney injury
amongst patients admitted to a level 1 trauma unit. Injury.
2014;45(1):259–64.
110 Hardcastle TC, Faurie M, Muckart DJJ. Endotracheal tube cuff
pressures and tube position in critically injured patients on
arrival at a referral centre: avoidable harm? Afr J Emerg Med.
2016 (on-line first).
111 Hardcastle TC, Stander M, Kalafatis N, Hodgson E, Gopalan
123 Cameron PA, Gabbe BJ, K. Smith K, Mitra B Triaging the right
patient to the right place in the shortest time. Br J Anaesth.
2014;113(2):226–33.
124 Nathens AB, Jurkovich GJ, Cummings P, et al. The effect of
organized systems of trauma care on motor vehicle crash
mortality. J Am Med Assoc. 2000;283:1990–4.
125 Mann NC, Cahn RM, Mullins RJ, et al. Survival among injured
geriatric patients during construction of a statewide trauma
system. J Trauma. 2001; 50:1111–6.
126 Moore L, Hanley JA, Turgeon AF, et al. Evaluation of the
long-term trend in mortality from injury in a mature inclusive
trauma system. World J Surg. 2010;34:2069–75.
127 Matzopoulos RG, Prinsloo MR, Bopape JL, et al. Estimating
the South African trauma caseload as a basis for injury
surveillance. Pretoria: South African Medical Research
Council; 1999.

PM
D. External patient temperature control in emergency
centres, trauma centres, intensive care units and operating 128 Bowley DMG, Khavadi A, Boffard KD, et al. The malignant
theatres: A multi-society literature review. S Afr Med J. epidemic – changing patterns of trauma. S Afr Med J.
2013;103:609–11. 2002;92:798–802.

16 6
112 Muckart DJJ, Hardcastle TC, Pillay B, Skinner DL. Vascular 129 Road Incident Management Systems. Pietermaritzburg: South
injuries following blunt polytrauma. Eur J Trauma Emerg Surg. African National Department of Transport; 2012.

20 IL
2014;40(3):315–22.
113 Steinwall D, Befrits F, Naidoo SR, Hardcastle TC, Eriksson
A, Muckart DJ. Deaths at a level 1 Trauma Centre: A
Y T
clinical finding and post-mortem correlation study. Injury.
2012;43:91–5.
A N
114 Heinonen E, Hardcastle TC, Barle H, Muckart DJJ. Lactate
M U

clearance predicts outcome after major trauma: Audit of a

trauma ICU population. Afr J Emerg Med. 2014;4:61–5.
4 ED

115 Grey B, Rodseth RN, Muckart DJ. Fracture stabilisation

in a polytraumatised African population – a comparison
with international management practice. Injury. 2012;
43(2):219–22.
O

116 Grey B, Rodseth RN, Muckart DJ. Early fracture stabilisation

in the presence of subclinical hypoperfusion. Injury.
G

2013;44(2):217–20.
117 Clarke DL, Quazi A, Rebby K, Thomson SR. Emergency
R

operation for penetrating thoracic trauma in a metropolitan

surgical service in South Africa. J Thorac Cardiovasc Surg.
BA

2011;142:563–8.
118 Madsen AS, Laing GL, Bruce JL, Oosthuizen GV, Clarke
O

DL. An audit of penetrating neck injuries in a South

EM

African trauma service. Injury. 2015; doi: 10.1016/j.

injury.2015.07.032. [Epub ahead of print]
119 Eniker B, Gonya S, Hardcastle TC. Spinal Stab Injury with
Retained Knife Blades: 51 consecutive patients managed at a
regional referral unit. Injury. 2015;46(9):1726–33.
120 KwaZulu-Natal Department of Health. KZN Health MEC
congratulates Inkosi Albert Luthuli Central Hospital on its latest
accolade!!! Media Release, 23/06/2015 [Internet]. [cited 29
December 2015].
URL: http://www.kznhealth.gov.za/mediarelease/2015/
MEC-congratulates-Inkosi-Albert-Luthuli-Central-Hospital-latest-
accolade.htm
121 RAF experiencing shortfalls, delays due to increased accident
claims, SABC News 19 December 2014. [Internet]. [cited 27
December 2015].
URL: http://www.sabc.co.za/news/a/
a3915f80469f4301a328fb36c8191a9f/RAF-experiencing-
shortfalls,-delays-due-to-increased-accident-claims
122 Erlich R. Persistent failure of the COIDA system to compensate
occupational disease in South Africa. S Afr Med J.
2012;102:95–7.

S A H R 20 1 6 1 89
190
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Strengthening the measurement of quality
of care
16

Authors:
Ronelle Burger i
Shivani Ranchod ii

PM
Laura Rossouw i
Anja Smith i

16 6
T 20 IL
here is growing recognition that access to healthcare facilities is unlikely to More public debate is
improve health outcomes if the quality of the care provided at these facilities
Y T
is inadequate. The emerging consensus on the importance of quality of health needed on meaningful,
A N
care is reflected in proposed policy reforms in South Africa, as well as in increased affordable and robust
measurement of quality at primary health care facilities.
approaches to quality
M U

Through focus on clinical quality and client satisfaction, we provide a critique of measurement.
current approaches used to measure quality. We argue that the measurement of
4 ED

quality will be strengthened by complementing current approaches with alternatives

such as standardised clients and vignettes. Other alternative approaches that are
also considered include health worker knowledge tests, direct observation and asking
O

clients about the clinical dimensions of client-provider interaction. The presented

alternative measures can help to overcome biases inherent in current approaches
G

and assist in establishing a better understanding of the state of clinical quality in

R

primary health care facilities.

More public debate is needed on meaningful, affordable and robust approaches

BA

to quality measurement. We recommend that such debates should consider and

O

discuss the affordability, feasibility, reliability, credibility and relevance of current

and alternative approaches.
EM

i Department of Economics, Economic and Management Sciences Facult y, Stellenbosch Universit y

ii Department of Actuarial Science, Commerce Facult y, Universit y of Cape Town

191
Introduction
There is growing recognition that access to health facilities is unlikely
to improve health outcomes if the quality of care at these facilities is
inadequate.1 Increasingly, it has become clear in South Africa that
reliable access to affordable public health care providers is no longer
a serious constraint,2 yet health outcomes remain disappointing,
with a high burden of disease3 and too many preventable deaths.4,5
South Africa’s under-performance is often attributed to the country’s
high HIV burden6 and the inequitable health system,6,7 but new
studies are pointing towards poor quality of care and missed
opportunities at healthcare facility level as contributing factors.8,9
In South Africa, the move towards increased emphasis on quality
has been reflected in recent reforms, including the National Health
Insurance (NHI) plan. The White Paper on universal health coverage
acknowledges concerns about the quality of care provided in the
public sector and makes clear the intention to invest in quality
improvement.10 Similarly, the National Development Plan identifies
16 6
“quality health care for all” as a key priority for the country.11
20 IL
Directly related to the overarching policy context for quality
improvement is the imperative to strengthen quality measurement
in South Africa.a This is clear from a number of important policy
Y T
initiatives and processes including the establishment of the Office
of Health Standards Compliance (OHSC).14 The OHSC was
A N
tasked with the development of a set of National Core Standards
M U
(NCS) against which to measure and monitor the quality of care
provided, with the aim of supporting the improvement of quality of
care in health facilities.15 By 2011, the NCS were finalised and
4 ED
implementation of the standards by the OHSC had commenced.15
More recently, the Ideal Clinic Initiative was launched; it aims to
O
provide detailed, tangible benchmarksb for how the National
Department of Health wants clinics to function and what it means
G
to be a well-functioning clinic.16 According to the National Health
Council directive, the aim is for all clinics to achieve Ideal Clinic
R
status by April 2018.17
BA
The renewed focus on quality also links to increasing emphasis
on how monitoring and evaluation systems can reliably identify
O
under-performing facilities or clinics that need more support.15
EM
These policy shifts are overdue and have created a window of
opportunity to debate how the elusive concept of ‘quality’ should be
understood within health care and to experiment with how we can
best approximate and measure it. The definition and measurement
of quality is at the heart of policy debates on how we can make the
health system function better to ensure that clients are respected and
that avoidable mistakes and the associated negative outcomes such
as injuries and deaths are reduced or eliminated altogether.
This chapter aims to contribute to the on-going discussion on how
to improve the quality of care in South Africa. We critically analyse
current quality measurement tools in the South African public
sector, suggest alternative quality measurement tools, and make
recommendations for improved quality measurement.
a Although the focus here is on quality measurement, the goal of measuring
quality is to enable quality improvement, as is the case in most of the
international literature.12,13
b The dashboard includes 212 elements, categorised into 10 components and
32 subcomponents.
1 92
What does ‘quality of health care’ mean?
A significant challenge in researching the measurement of quality
of health care is the lack of conceptual clarity. Indeed, as Buttell
and colleagues note if “a group of healthcare professionals is asked
what quality means, there may be as many definitions as people in
the room”.18
In this chapter we employ the widely used definition of the Institute
of Medicine (IOM), which defined quality as
the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge.19
For the purposes of this chapter we selected two specific dimensions
of quality, namely clinical quality and client satisfaction to examine
PM
in more depth. Clinical quality is expected to increase the likelihood
of desired health outcomes.20,21 Client satisfaction can be a useful
construct and measure due to its linkages to client responsiveness
and client-centric care, but there is little reason to anticipate a strong
correlation with clinical quality or health outcomes. However, client
satisfaction is important in its own right because satisfaction serves
as a mediating variable for health-seeking behaviour and adherence
to treatment,22 which is expected to link to health outcomes at a
population or sub-population level.
Current approaches to measuring client
satisfaction and clinical quality in the public
health sector
There have been few attempts at measuring clinical quality in the
public sector, presumably because of the complexities of ensuring
access to an unbiased and comprehensive account of the client-
provider contact without distorting the interaction. Both the core
standards, used by the OHSC to assess the performance of health
care facilities, and the quality indicators of the Ideal Clinic Initiative,
focus mainly on structural measures of quality of care, namely the
nature and availability of physical, administrative and managerial
infrastructure at health care facilities.23 These measures do not
explicitly measure clinical quality of delivered services. While, for
example, the Ideal Clinical Initiative includes client safety (clinical
governance and clinical care) as one of its 10 domains,16 this is
measured by focusing on the existence and availability of these
protocols to staff, rather than measuring the actual implementation
of these protocols.24
Data on some health outcomes are routinely collected at facility level
through the District Health Information System (DHIS).25 However,
these health outcomes are often too complex to interpret meaningfully
without information on the underlying health needs and burden of
disease of the facility’s clients.13 Additionally, outcomes tend to
reflect both client factors such as early health-seeking behaviour
or adherence to treatment, and provider factors such as correct
diagnosis, explaining the risks of the disease and guiding the client
to make the correct treatment choice. Without additional survey
work, analysts and researchers cannot isolate the clinical quality-
of-care component. Research that investigates the clinical quality
of care in for example maternal health26 therefore supplements the
analysis of individual-level health records25 with additional survey
work, but such work is relatively rare.
S A H R 20 1 6

The available measures of client satisfaction are usually generated
via client-satisfaction surveys. The government’s Programme of
Action serves as a recent and prominent example of the use of client-
satisfaction surveys in the public health sector.27 The popularity
of client-satisfaction surveys may be attributable to the allure of
collapsing a complicated, opaque and multi-faceted health system
experience into a simple indicator, and its intuitive alignment with a
client-centred and client-responsive approach.28,29 In health services,
the popularity of client-satisfaction or client-experience surveys may
be further promoted by the absence of affordable, reliable and
simple alternative indicators of facility-level clinical quality or health
outputs and outcomes.30 However, there are several problems with
the use of client-satisfaction surveys as a measure of quality of care:
➢➢ Opacity and complexity of the concept of satisfaction: Client
satisfaction ratings are influenced by the personal preferences
of the client, the client’s expectations, and the health care
16 6
received.31 Disregard for the complexities of the concept
has been described as the “single greatest flaw”32 in client
20 IL
satisfaction research.
➢➢ Fallibility of self-reported information: The respondent’s
Y T
responsiveness to perceived social norms and time pressure
can compromise the reliability of self-reported information,33,34
A N
yet few studies critically consider these concerns.
M U
➢➢ Positivity bias: The statistical distribution of client-satisfaction
survey scores tends to be negatively skewed and overly
4 ED
positive, which could be attributed to the perceived social
desirability of positive and optimistic responses.29,35–37
➢➢ Lack of a population perspective: Non-response to surveys is
O
often systemic,c but poorly documented.40,41 It is important
to note that client surveys do not provide a population
G
perspective, but represent an optimistic picture of the general
public outlook because such surveys exclude individuals who
R
are not utilising the provider’s services.
BA
➢➢ Poor diagnostic tool: Low client satisfaction may signal that
N
a specific facility is experiencing problems, but it cannot
O
diagnose the underlying causes of reported disappointing
client experiences.42,43
EM
➢➢ Weak link to health outcomes: Client satisfaction can make
a difference in terms of health-seeking behaviour. However,
while client satisfaction is a necessary condition for improved
health outcomes, it is not a sufficient condition. Consequently,
it is not surprising that there is a lack of evidence showing
significant impact of client satisfaction on health outcomes.28
c For instance, when respondents are not remunerated for a survey – which is
often the case for client surveys – an individual with more leisure time such
as a retired pensioner is more likely to reply than for instance a domestic
worker who is working long hours.38 Furthermore, when a survey is hosted
online or distributed via email, this can distort the response by excluding
those without smart phones or reliable and affordable email access (i.e.
non-coverage) and by increasing response likelihood from individuals who
have more screen time in an average day.39
S A H R 20 1 6
Quality of care
The limitations of client-satisfaction surveys
To illustrate the limitations of client-satisfaction surveys, we examined
them in more detail using analysis from the nationally representative
South African General Household Surveys of 2009 and 2010.d,44,45
We present an argument in this section that it is plausible that these
surveys may overestimate the client satisfaction of health services
amongst the poor.
Our analysis showed that there is little sensitivity in the client-
satisfaction scores, with close to 80% of urban public clinic clients
indicating that they were either very satisfied or somewhat satisfied
with the service they had received. These high satisfaction levels
were reported despite 40% of this group of urban public clinic
users admitting that there were problems when asked more specific
questions about rude staff, drug stock-outs or long waiting times.
PM
It is useful to make a distinction here between satisfaction reports
and satisfaction ratings.31 Satisfaction reports consider specific
and often more tangible elements of providers and health care
(e.g. waiting times), while satisfaction ratings capture a personal
evaluation of care that is not verifiable or observable by a third
party.31 A satisfaction rating is more subjective, with a larger
component that could be reflective of the respondent rather than
the health care service.31 Consequently, this measure would also be
more amenable to social conditioning and social desirability. This
could explain the high overall satisfaction ratings we found in the
General Household Surveys amidst unfavourable satisfaction reports
highlighting several serious complaints about providers and the care
received.
Satisfaction is a complicated concept including clinical dimensions,
personal preferences and individual expectations.31 This is further
complicated by individuals’ adjusting their expectations to match
their past experiences and their circumstances. For example, clients
who are accustomed to long waiting times may rate their evaluation
of service differently to those who have an expectation of shorter
waiting times.48
Differences in expectations will therefore be reflected in clients’
interpretation and response to the subjective questions in surveys,
and an identical health visit may be rated differently depending on
the expectations of individual respondents. Expectations may also
vary between social groups and socio-economic levels.46
To illustrate this point, we analysed the health visit-satisfaction ques-
tions in the General Household Surveys of 2009 and 2010.44,45
Our analysis showed that among urban public clinic users, those
in the lowest-income quintiles were less likely to report long waiting
times and rude nursing staff or to express their dissatisfaction with
the services they had received. Figure 1 shows the satisfaction
scores after public clinic visits by per-capita expenditure group. The
results suggest that the poorest 40% of public clinic visitors felt more
satisfied with the care received than visitors in quintiles 3 and 4.
This is contrary to intuition – it is plausible that the kink in the line
graph may be generated by two counteracting relationships The
first possible relationship is between wealth and service quality: it
is possible that more affluent clients actually received better health
services or care when accessing public clinics. The second possible
relationship is between wealth and expectations: it is possible that
d These are not the most recent survey data, however the data are used
here for illustrative purposes and it is the differences in scores that are of
relevance rather than the absolute levels.
1 93
more affluent clients had higher service expectations than poorer
clients, who may have been more accepting of the status quo.
Figure 1: Satisfaction scores after public clinic visits, by per capita
expenditure group
0.89
0.87
0.85
Satisfaction scores
0.83
0.81
0.79
0.77
0.75
Most poor 2 3 4 Most affluent
16 6
Per capita expenditure categories
20 IL
Source: Authors’ calculations using Statistics South Africa, 2010,44 2011.45
Y T
Alternative approaches to the measurement of
A N
client satisfaction and clinical quality
M U
As a response to the critique of current approaches to the
measurement of clinical quality and client satisfaction, we discuss
4 ED
alternative approaches, drawing on both established but rarely
used approaches, as well as innovative approaches in the emergent
academic literature.
O
Measuring client satisfaction
G
Anchoring vignettes
R
Anchoring vignettese describe a hypothetical person’s experience of
the health system. Survey respondents are asked to rate the health
BA
system’s responsiveness (or health system experience) relative to the
particular hypothetical person for a specific health system domain.
O
Client-experience surveys can be enhanced by collecting subjective
EM
assessments of the services received, and by using more objective
indicators such as vignettes to compensate for biases described
earlier. Including vignettes in client-experience surveys can be a
useful tool to evaluate socio-economic status (SES) differences in
client satisfaction and experience across sub-groups.
Given that all persons in a survey sample are given the same
hypothetical scenario to evaluate, this means the quality and
condition of the hypothetical health system in the vignette is constant
across individuals and sub-groups. Reporting bias can then be
estimated by analysing the way that sub-groups rate the health
system experiences of the hypothetical individuals in anchoring
vignettes. Using various statistical techniques, anchoring vignettes
are used to create a comparable scale, making sub-group analysis
and comparison more viable.48 Respondents’ ratings reflect their
view on how the person in the hypothetical vignette was treated.
Using this tool, we can establish whether a specific sub-group is
e An example of a vignette from the WHO SAGE study: “[Stan] broke his leg.
It took an hour to be driven to the nearest hospital. He was in pain but had
to wait an hour for the surgeon and was only operated on the next day. Q.
How would you rate the amount of time [Stan] waited before being attended
to? [1] Very good [2] Good [3] Moderate [4] Bad [5] Very bad.”47
1 94 S A H R 20 1 6
systematically more or less likely to overestimate or underestimate
the quality of the health system’s responsiveness.49
Vignettes have been used to control for reporting bias in self-reported
measures in various areas of research, including self-assessed
health,50–54 economic status,55 and clinical practices.56
Despite the growing popularity of vignettes as a tool, there still
remains scope for academic and formal evaluation of the tool’s
ability to correct for reporting bias. Use of vignettes involves several
stringent assumptions, which are rarely tested.57 Furthermore,
vignette collection can be an onerous and data-heavy process. As
a result, vignettes are often only included in surveys for a portion or
sub-set of respondents53 in order to prevent survey fatigue.
The strengths of vignettes in correcting for reporting bias:
PM
We explored the 2008 World Health Organization’s Study on
Global Ageing and Adult Health (SAGE) data47,48 for South Africa
to provide evidence on how vignettes can be used to correct for
reporting bias. The SAGE data contains a set of questions asking
respondents who interacted with the health system about the manner
and environment in which they were treated during the interaction
with the system (health system responsiveness or experience).59 This
innovative section of the survey allows for a separation of the client’s
reported experience of the health system from his or her expectations
of the system.46 This separation is accomplished in two ways: firstly,
by focusing on relatively objective dimensions of client experience,
such as waiting time and cleanliness and, secondly, through the use
of anchoring vignettes.49
One drawback of the WHO SAGE data set is that it is a nationally
representative household survey only including South Africans aged
50 years and older. The data were collected as part of a multi-
country study, with the goal of studying aging populations in low- to
middle-income countries. It is currently the only publicly available
and reliable South African data set containing client-experience
vignettes and we therefore used it here although the data are slightly
dated.
Figure 2 shows the difference between self-reported client experi-
ence prior to and after controlling for reporting bias. The figure
shows the percentage of clients in wealth quintile 160 (the poorest
quintile) reporting moderate, poor or very poor (i.e. not good)
service during their interaction with the health system, compared
with clients in quintile 5f (the richest quintile). The graph shows that
persons in wealth quintile 1 reported experiencing better service
in terms of waiting times, privacy and cleanliness of the health
system than persons in wealth quintile 5 (the richest quintile) before
controlling for reporting bias (the grey bars). Once we controlled
for differences in reporting bias using anchoring vignettes (the blue
bars), the disparities in reported experience became positive and
more pronounced: in all domains the poor (quintile 1) reported
experiencing worse service than the rich (quintile 5). This confirms
previous findings in the literature61,6 showing that when client-
experience surveys take client responses at face value (i.e. without
adjustments via anchoring vignettes) they lead to an overly positive
assessment of the health-provider experience, especially among
the poor and vulnerable. While we have chosen to illustrate the
potential distortions in response using SES, such distortions are not
limited to this sub-group.
f Quintile 5 forms the reference group. All responses of quintile 1 have to be
interpreted relative to quintile 5.
 Quality of care

Figure 2: Percentage of respondents in wealth quintile 1 reporting moderate to very poor outpatient health care services experiences

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

-2.0%

PM
-4.0%

-6.0%
Waiting time Treated Clear Involved in Privacy Freedom inchoice of Cleanliness
respectfully explanation decision process healthcare provider

16 6
Unadjusted Adjusted

20 IL
Source: Authors’ calculations using World Health Organization data.g,58

Measurement of clinical quality

Y T
A N
Standardised or simulated client approach
M U

A standardised (simulated) client or patient (SP) measurement prejudice. This is done through the detection of variation in clinical
approach involves the use of an actor or a community member who quality across clients.
presents to a nurse or doctor with a set of typical symptoms that
4 ED

Ethics can be a major concern in SP studies. The main ethical concerns

should predictably map to a set of probes, a diagnosis and treatment
include both the risks of discovery and/or possible health risks to the
or next steps1,64,65 The health situation portrayal by the actor/
SP (e.g. invasive medical procedures, unclean instruments such as
community member/field worker is referred to as a ‘standardised
O

thermometers), and also ethical problems concerning concealment

client’. This ‘client’ undertakes to present to different health providers
and dishonesty towards health care workers.67 The risks to the SP
with exactly the same opening statement, set of symptoms and
G

can, however, be minimised by not only training and preparation,

life story to enable detection in variation of the quality of health
but also by deliberately picking health test cases that do not
providers. The SPs generally complete a survey upon exit from the
R

involve intrusive procedures.67 Studies that use these measurement

provider situation to capture data on the clinical experience and
approaches will require a waiver of informed consent at the point
BA

questions asked by the provider.

of interaction between the standardised client and the health care
Comparing the clinical treatment received by SPs with clinical best provider. However, this can be compensated for by obtaining the
O

practices and policy protocols enables researchers to test clinical consent of providers a while before the standardised client arrives
EM

quality at facility level across a sample of SPs. While this approach
is expensive, various studies have shown that it provides reliable
results that do not necessarily correlate with alternative facility
measures such as user satisfaction or clinical knowledge.67–69 A
recent study using a sample of TB SPs in India validated quality
of the data collected by showing high reliability of recall among
the SPs upon exiting health care facilities. The study found only
a small difference between data collected through exit interviews
with the SPs (relying on memory), and data collected through voice
recordings of the interactions between SPs and providers.65
The SP method allows for the measurement of a unique and
important dimension of health care. While the method is used mainly
to ascertain clinical and/or process quality, it can also be used to
measure staff attitudes, client responsiveness and discrimination or
at their facility. Obtaining the cooperation and buy-in of providers
before the study commences is one way of compensating for lack
of informed consent at the point of interaction with the SP.68 This
type of concealed research is referred to as ‘covert’ research and
is ethically allowable if it is integral to the nature of the research
question and if the research question is deemed important enough
from a societal perspective.69
The time burden on scarce nursing staff is always a concern, but a
SP does not necessarily present a greater time burden than surveys
that require interviews with nursing staff. Furthermore, it is generally
only ethically advisable to conduct this type of research at primary
health care (PHC) level. Gathering data through SPs at secondary
or tertiary levels of care will potentially consume critical and life
saving resources.

g These percentages were calculated while also controlling for differences in It has been proposed that SPs should be used in the training of South
gender, education, age, marital status and race of clients. Other factors that African health students70,71 as is done internationally. Currently this
were controlled for include whether respondents lived in an urban area,
whether they accessed private or public facilities, their self-reported quality method is not widely used in South Africa to evaluate the quality of
of life and health, how long it took them to travel to the facility, the gender of PHC. We were able to find only one South African study that utilised
the doctor who assisted them, and their health outcome after accessing the
facility.63

S A H R 20 1 6 195
this methodology to assess quality of care. In that study, the method
was used to evaluate the impact of three different training initiatives
to improve the management and treatment of sexually transmitted
infections in South Africa at PHC (clinic) level.72 The study was done
across 40 clinics (four intervention arms, three health sub-districts)
and included a total of 242 analysed SP interactions. It found an
increase of 11% in the average number of sexually transmitted
infection tasks (as defined by the study) completed by health care
workers at the facilities in the intervention arms, which had received
training.72
Clinical knowledge tests
Clinical or medical vignettes can be used to measure the
knowledge of frontline health care workers.1,66 Clinical vignettes
use a hypothetical medical scenario involving a hypothetical client
presenting with certain symptoms. To simulate an actual client
interaction, the interviewer poses as the hypothetical client and the
clinician is invited to proceed as she normally would, asking questions
16 6
on illness history or conducting required examinations.1,65,66 The
interviewer provides standard predetermined responses for all
20 IL
questions and examinations. A recorder (or second interviewer)
notes the observation and provides supplementary information
as required if the interviewer or test client is unable to provide
Y T
additional information in response to questions by the health care
A N
worker. The provided responses are evaluated relative to clinical
best practice (protocol).1 Studies using clinical vignettes have been
M U
done in countries like India and Tanzania.66,67,73
This process measure avoids the potential bias of client-satisfaction
4 ED
or experience surveys by focusing on a more objective process
measure. Depending on the assessment of the health care worker’s
knowledge and adherence to protocols as measured through
O
the clinical vignette, the measure potentially also provides clear
guidance on remedial action. It is, however, important to note
G
that data collected through clinical vignettes represent a best case
or upper bound scenario as the medical vignettes only measure
R
knowledge or ‘competence’ and not actual effort.1
BA
N
It is useful to compare data collected from the application of
health worker knowledge vignettes with data collected through
O
a SP process. The difference between knowledge (as measured
EM
by clinical vignettes) and implementation of this knowledge (as
measured through SPs) is referred to as the ‘know-do gap’.1 In a
recent study using a sample of TB SPs in India, a large know-do gap
was found in the sample of 69 providers.65 While 73% took the
correct clinical action when presented with a potential TB client (i.e.
ordering a chest radiograph or sputum test) during the vignette, only
10% did so during the real SP interactions.65
Direct observation
An alternative to clinical vignettes is direct observation of health
staff. With direct observation an interviewer will spend long
periods of time directly observing and noting a health care worker’s
interaction with clients.1,66 Detailed notes will have to be made
about actual time spent with clients, all questions asked by clients,
physical examinations and the prescribed course of action.
Data collected through direct observation of health care workers
are likely to reflect the Hawthorne effect,1 with health care workers
1 96 S A H R 20 1 6
adjusting their behaviour because they know that they are being
observed. A further drawback with direct observation is that there
may be a selection effect in terms of the type of clients examined.
There is a possibility that only clients with a limited set of health
conditions will present for care.66 This means that the observer
may not be able to build a full picture of the health care worker’s
competency across a number of health areas or cases. However,
knowledge or clinical vignettes combined with direct observation,
provides a way to ensure a more balanced case-load mix when
assessing the competence of providers.66
Including questions on clinical dimensions of client-provider
interaction
Client-experience surveys can also be enhanced by including
specific questions on symptoms experienced when care was
PM
sought, actual services received as well as the specific nature of the
interaction with the health care worker (nurse or doctor). Questions
can, for example, be asked about whether an HIV test was offered,
whether the client’s weight and blood pressure were measured
and communicated, and whether any questions were asked about
medical history. A drawback of this type of data collection is that it is
likely to suffer from recall bias.74 It is thus important that respondents
be interviewed as soon as they leave health care facilities and not
at a later stage. Depending on the way the question is phrased, it
may also evoke social desirability bias in the respondent’s answer.
Consequently, careful thought has to be given to the phrasing of the
question.
Questions like these have already been incorporated into some
surveys exploring care-seeking behaviour in South Africa (such
as antenatal care attendance and care for a cough or possible
TB symptoms). A study on the timing of the initiation of antenatal
care attendance in inner-city Johannesburg found low levels of
compliance with some service components that are considered
antenatal care best practice in the public sector.75 Only 67.2% of
those who attended antenatal care (n=198) reported having been
informed of pregnancy danger signs, while only 59.6% reported
having all routine health checks included in the survey done at the
first screening visit. In a sample of Western Cape adults (n=403)
who reported coughing for two or more weeks and who reported
seeking help for their cough at public PHC facilities, TB testing
protocol adherence was found to be weak by frontline staff.9 Only
68.7% of adults reported being offered a sputum test, despite the
protocol within all PHC facilities requiring sputum testing for a cough
with a duration of two or more weeks.
Discussion and conclusion
This chapter set out to critique current approaches to measuring
clinical quality and client satisfaction in the public sector, against
the backdrop of planned public-sector reform and efforts to improve
quality measurement in PHC. It also outlined a number of alternatives
that can complement existing methods. All of the methods outlined
in this chapter can become part of an overall toolkit to measure
quality of care and to triangulate between different measurement
methodologies. The chapter highlights three sets of criteria to
consider when making decisions about how to measure quality:
 Quality of care

➢➢ Relevance: When considering quality indicators, it is vital to

also examine linkages to health outcomes to ensure that the
cost and effort of gathering and validating the data yields the
expected returns in terms of improvements in health outcomes.

➢➢ Reliability and credibility: Monitoring, validation and

triangulation of quality indicators is crucial to ensure credibility.
Greater transparency and more independent analysis of
such indicators will also help to validate and improve these
quality indicators. Where government employees help to
document and capture health outcomes and quality data,
such responsibilities should be clearly defined and should
be prominent in their performance assessments. This assures
oversight and monitoring of the reliability of such data
capturing.

PM
➢➢ Affordability and feasibility: In a resource-constrained
setting, the cost and time invested in gathering data will be
an important consideration. The costs and value of quality
indicators will have to be balanced. While SP studies are

16 6
relatively expensive, the approach is unique because it allows

20 IL
researchers a very detailed and reliable account of the patient-
provider interaction. Including vignettes into client-satisfaction
surveys increases the length and therefore cost of such surveys.
Y T
However, implementation can be made more feasible by
A N
including these measures for only a sub-set of the sample.

Measurement of quality, and ultimately the improvement of quality,

M U

is pivotal for ensuring that the planned health-system reforms are

effective in promoting health, ensuring client safety and saving lives.
4 ED

It is therefore crucial that we promote continued critical reflection

and debate on how to best measure quality in the public sector.
O
G
R
BA

N
O
EM

S A H R 20 1 6 1 97
References
1 Das J, Hammer J. Quality of primary care in low-income
countries: Facts and economics. Annu Rev Econ. 2014;
6(1):525–53.
2 Burger R, Bredenkamp C, Grobler C, van der Berg S. Have
public health spending and access in South Africa become
more equitable since the end of apartheid? Dev South Afr.
2012; 29(5):681–703.
3 Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Karim
SSA, Coovadia HM. Health in South Africa: changes and
challenges since 2009. Lancet. 2012; 380(9858): 2029–43.
4 Pattinson R, Rhoda N. Saving Babies 2012–2013: Ninth
report on perinatal care in South Africa. Pretoria: Department
of Health; 2014.
5 Moodley J. Saving Mothers 2011–2013: Sixth report on
confidential enquiries into maternal deaths in South Africa,
Short report. Pretoria: Department of Health; 2014.
6 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D.
The health and health system of South Africa: historical
16 6
roots of current public health challenges. Lancet. 2009;
374(9692):817–34.
20 IL
7 McIntyre D, Thiede M, Nkosi M, Mutyambizi V, Castillo-
Riquelme M, Gilson L, et al. SHIELD work package 1 report:
A critical analysis of the current South African Health System;
Y T
2007. [Internet cited 7 April 2016].
URL: http://s3.amazonaws.com/zanran_storage/web.uct.
A N
ac.za/ContentPages/49502722.pdf
M U
8 Claassens M, Du Toit E, Dunbar R, Lombard C, Enarson D,
Beyers N, et al. Tuberculosis clients in primary care do not
start treatment. What role do health system delays play? Int J
4 ED
Tuberc Lung D. 2013; 17(5):603–7.
9 Smith A, Burger R, Claassens M, Ayles H, Godfrey-Faussett P,
Beyers N. Health care workers’ gender bias in testing could
contribute to missed tuberculosis among women in South
O
Africa. Int J Tuberc Lung D. 2016; 20(3):350–6.
G
10 National Department of Health, Republic of South Africa.
National Health Insurance for South Africa: Towards Universal
Health Coverage. Pretoria; 2015.
R
11 National Planning Commission. National Development Plan
BA
2030 – Our future – Make it work. Pretoria; 2012. [Internet].
[cited 7 April 2016].
O
URL http://www.poa.gov.za/news/Documents/NPC%20
National%20Development%20Plan%20Vision%202030%20
EM
-lo-res.pdf
12 Berwick DM, James B, Coye MJ. Connections between
quality measurement and improvement. Med Care. 2003;
41(1):(1 Suppl):130-8.
13 Chassin MR, Loeb JM, Schmaltz SP, Wachter RM.
Accountability measures—using measurement to promote
quality improvement. New Engl J Med. 2010; 363(7):683–8.
14 Republic of South Africa. National Health Amendment Act.
Pretoria; 2013.
15 Molekoi W, Msibi EB, Marshall C. Recent developments in
ensuring quality of care in health establishments in South
Africa. In: Padarath A, English R, editors. South African
Health Review 2012/13. Durban: Health Systems Trust,
2013; p. 25–32.
16 Fryatt R, Hunter J, Matsoso P. Innovations in primary health
care: Considerations for National Health Insurance. In:
Padarath A, English R, editors. South African Health Review
2012/13. Durban: Health Systems Trust, 2013; p. 33–44.
17 Steinhobel R, Massyn N, Peer N. The Ideal Clinic Programme
2015/16. Durban: Health Systems Trust, 2015.
1 98 S A H R 20 1 6
18 Buttell P, Hendler R, Daley J. Quality in healthcare: concepts
and practice. In: Cohn K, and Hough D, editors. The Business
of Healthcare: Volume 3, 2008; p. 61–95. [Internet cited 7
April 2016)
URL: http://www.healthcarecollaboration.com/docs/
quality_buttell.pdf
19 Institute of Medicine. Medicare A Strategy for Quality
Assurance, Volume I. Washington, DC: The National
Academies Press; 1990.
20 Chung S-C, Sundström J, Gale CP, James S, Deanfield J,
Wallentin L, et al. Comparison of hospital variation in acute
myocardial infarction care and outcome between Sweden
and United Kingdom: population based cohort study using
nationwide clinical registries. BMJ. 2015; 351:h3913.
21 Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis
PM
RG, et al. Association between hospital process performance
and outcomes among clients with acute coronary syndromes.
JAMA. 2006; 295(16):1912–20.
22 Dang BN, Westbrook RA, Black WC, Rodriguez-Barradas
MC, Giordano TP. Examining the link between client
satisfaction and adherence to HIV care: a structural equation
model. PloS One. 2013; 8(1):e54729.
23 Donabedian A. Evaluating the quality of medical care.
Milbank Q. 2005; 83(4):691–729.
24 Department of Health. Ideal Clinic Manual Version 16.
Pretoria: Department of Health; 2016.
25 Day C, Gray A. Health and related indicators. In: Padarath
A, King J, English R, editors. South African Health Review
2014/15. Durban: Health System Trust; 2015.
26 National Committee for Confidential Enquiry into Maternal
Deaths. Sixth report on the Confidential Enquiries into
Maternal Deaths in South Africa 2011–2013. Pretoria:
Department of Health.
27 Republic of South Africa. National Progress Report,
Programme of Action. Pretoria: Republic of South Africa;
2015. [Internet cited 11 March 2016].
URL: http://www.poa.gov.za/health/Pages/Progress-Reports.
aspx
28 Al-Abri R, Al-Balushi A. Client satisfaction survey as a
tool towards quality improvement. Oman Med J. 2014;
29(1):3–7.
29 Williams B, Coyle J, Healy D. The meaning of client
satisfaction: an explanation of high reported levels. Soc Sci
Med. 1998; 47(9):1351–9.
30 Smith PC, Mossialos E, Papanicolas I. Performance
measurement for health system improvement: experiences,
challenges and prospects. Geneva: World Health
Organization; 2008. [Internet cited 7 April 2017].
URL: http://www.who.int/management/district/performance/
PerformanceMeasurementHealthSystemImprovement2.pdf
31 Ware JE, Snyder MK, Wright WR, Davies AR. Defining and
measuring client satisfaction with medical care. Eval Program
Plann. 1983;6(3):247–63.
32 Sitzia J. How valid and reliable are client satisfaction data?
An analysis of 195 studies. Int J Qual Health Care. 1999;
11(4):319–28.
33 Huang JL, Bowling NA, Liu M, Li Y. Detecting insufficient effort
responding with an infrequency scale: Evaluating validity and
participant reactions. Journal of Business and Psychology.
2015;30(2):299–311.
34 DeMaio TJ. Social desirability and survey measurement: A
review. In: Turner C, Martin E, editors. Surveying Subjective
Phenomena, Volume 2. p. 257–82

35 Veenhoven R. Databook of Happiness. Dordrecht: Reidel;
1984.
36 Peterson RA, Wilson WR. Measuring customer satisfaction:
fact and artifact. Journal of the academy of marketing
science. 1992; 20(1):61–71.
37 Dillman DA, Phelps G, Tortora R, Swift K, Kohrell J, Berck J, et
al. Response rate and measurement differences in mixed-mode
surveys using mail, telephone, interactive voice response (IVR)
and the Internet. Social Sci Res. 2009; 38(1):1–18.
38 Groves RM, Couper MP. Nonresponse in household interview
surveys: New York: John Wiley; 2012.
39 Couper MP, Kapteyn A, Schonlau M, Winter J. Noncoverage
and nonresponse in an Internet survey. Social Sci Res.
2007;36(1):131–48.
40 Sitzia J, Wood N. Response rate in client satisfaction
research: an analysis of 210 published studies. Int J Qual
Health Care. 1998;10(4):311–7.
41 Korinek A, Mistiaen JA, Ravallion M. Survey nonresponse and
the distribution of income. J Econ Inequal. 2006; 4(1):33–55.
16 6
42 Boyer L, Francois P, Doutre E, Weil G, Labarere J. Perception
and use of the results of client satisfaction surveys by care
20 IL
providers in a French teaching hospital. Int J Qual Health
Care. 2006; 18(5):359.
Y T
43 Draper M, Cohen P, Buchan H. Seeking consumer views: what
use are results of hospital client satisfaction surveys? Int J Qual
A N
Health Care. 2001; 13(6):463–8.
44 Statistics South Africa. General Household Surveys 2009
M U
[datasets]. Pretoria: Statistics South Africa; 2010.
45 Statistics South Africa. General Household Surveys 2010
4 ED
[datasets]. Pretoria: Statistics South Africa; 2011.
46 Murray CJ, Kawabata K, Valentine N. People’s experience
versus people’s expectations. Health Aff. 2001; 20(3):21–4.
O
47 World Health Organization. South Africa – Study on Global
Ageing and Adult Health–2007/8, Wave 1. Geneva: World
G
Health Organization; 2008.
48 Salomon JA, Tandon A, Murray CJ. Comparability of self
R
rated health: cross sectional multi-country survey using
anchoring vignettes. BMJ. 2004; 328(7434):258.
BA
49 Tandon A, Murray CJ, Salomon JA, King G. Statistical models
for enhancing cross-population comparability. In: Murray CJ,
O
Evans DB, editors. Health systems performance assessment:
debates, methods and empiricism. Geneva: World Health
EM
Organization, 2003; p. 727–46.
50 Bago d’Uva T, Van Doorslaer E, Lindeboom M, O’Donnell O.
Does reporting heterogeneity bias the measurement of health
disparities? Health Econ. 2008;17(3):351–75.
51 Guindon GE, Boyle MH. Using anchoring vignettes to assess
the comparability of self-rated feelings of sadness, lowness
or depression in France and Vietnam. Int J Methods Psychiatr
Res. 2012; 21(1):29–40.
52 Bago d’Uva T, O’Donnell O, van Doorslaer E. Differential
health reporting by education level and its impact on the
measurement of health inequalities among older Europeans.
Int J Epidemiol. 2008; 37(6):1375–83.
53 Zhang H, d’Uva TB, van Doorslaer E. The gender health
gap in China: A decomposition analysis. Econ Human Biol.
2015;18:13–26.
54 Dowd JB, Todd M. Does self-reported health bias the
measurement of health inequalities in US adults? Evidence
using anchoring vignettes from the Health and Retirement
Study. J Gerontol B Psychol Sci Soc Sci. 2011; 66(4):478–89.
S A H R 20 1 6
Quality of care
55 Beegle K, Himelein K, Ravallion M. Frame-of-reference bias in
subjective welfare. J Econ Behav Org. 2012; 81(2):556–70.
56 Koedoot C, De Haes J, Heisterkamp S, Bakker P, De Graeff
A, De Haan R. Palliative chemotherapy or watchful waiting?
A vignettes study among oncologists. J Clin Oncol. 2002;
20(17):3658–64.
57 Rice N, Robone S, Smith P. Analysis of the validity of
the vignette approach to correct for heterogeneity in
reporting health system responsiveness. Eur J Health Econ.
2011;12(2):141–62.
58 Kowal P, Chatterji S, Naidoo N, Biritwum R, Fan W,
Ridaura RL, et al. Data resource profile: the World Health
Organization Study on global AGEing and adult health
(SAGE). Int J Epidemiol. 2012; 41(6):1639–49.
59 Valentine NB, de Silva A, Kawabata K, Darby C, Murray
CJL, Evans DB, et al. Health system responsiveness: concepts,
PM
domains, and operationalization. In: Murray CJL, Evans
DB, editors. Health systems performance assessment:
debates, methods and empiricism. Geneva: World Health
Organization, 2003; p. 573–96.
60 He W, Muenchrath MN, Kowal PR. Shades of gray: a
cross-country study of health and well-being of the older
populations in SAGE countries, 2007–2010: US Department
of Commerce, Economics and Statistics Administration, US
Census Bureau; 2012.
61 Malhotra C, Do YK. Socio-economic disparities in health
system responsiveness in India. Health Policy Plan. 2013;
28(2):197–205.
62 Rice N, Robone S, Smith PC. International comparison of
public sector performance: the use of anchoring vignettes to
adjust self-reported data. Evaluation. 2010;16(1):81–101.
63 Bago d’Uva T, Rossouw L. Stata Code. 2015.
64 Aung T, Montagu D, Schlein K, Khine TM, McFarland W.
Validation of a new method for testing provider clinical quality
in rural settings in low-and middle-income countries: the
observed simulated client. PLoS One. 2012;7(1):e30196.
65 Das J, Kwan A, Daniels B, Satyanarayana S, Subbaraman R,
Bergkvist S, et al. Use of standardised clients to assess quality
of tuberculosis care: a pilot, cross-sectional study. Lancet Infect
Dis. 2015; 15(11):1305–13.
66 Das J, Hammer JS. Which doctor? Combining vignettes and
item response to measure doctor quality. World Bank Policy
Research Working Paper. Research Working Paper (3301).
Washington, DC: World Bank; 2004.
67 Das J, Holla A, Das V, Mohanan M, Tabak D, Chan B. In
urban and rural India, a standardized client study showed low
levels of provider training and huge quality gaps. Health Aff.
2012; 31(12):2774–84.
68 Das J, Holla A, Kremer M, Mohanan M, Muralidharan K.
Medical Advice, Quality, and Availability in Rural India.
Mimeo, Harvard University; 2011.
69 Van Niekerk AA. Moral perspectives on covert research. S Afr
J Bioeth Law. 2015; 7(2):55–8.
70 Draper CE, Moller N, Aubin L, Edelstein G, Weiss R.
Developing a standardised client programme in a primary
healthcare curriculum: A needs analysis. Afr J Health Prof
Educ. 2012; 4(2):97–101.
71 Uys Y, Treadwell I. Using a simulated client to transfer client-
centred skills from simulated practice to real clients in practice.
Curationis. 2014; 37(1):1–6.
199
72 Weaver MR, Pillay E, Jed SL, de Kadt J, Galagan S, Gilvydis
J, et al. Three methods of delivering clinic-based training
on syndromic management of sexually transmitted diseases
in South Africa: a pilot study. Sex Transmit Infect. 2016;
92(2):135-41.
73 Leonard KL, Masatu MC. The use of direct clinician
observation and vignettes for health services quality
evaluation in developing countries. Soc Sci Med. 2005;
61(9):1944–51.
74 Onishi J, Gupta S, Peters D. Comparative analysis of exit
interviews and direct clinical observations in pediatric
ambulatory care services in Afghanistan. Int J Qual Health
Care. 2011;23(1):76–82.
75 Solarin I, Black V. “They told me to come back”: women’s
antenatal care booking experience in inner-city Johannesburg.
Matern Child Health J. 2013; 17(2):359–67.

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

20 0 S A H R 20 1 6
 EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM

20 1
Financing and Medical Products
 Financing and Medical Products

202
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
HIV and AIDS financing in South Africa:
sustainability and fiscal space
17

Authors:
Mark S. Blecher i Gesine Meyer-Rath ii,iii
Calvin Chiu ii Yogan Pillay iv

PM
Fareed Abdullah v Aparna Kollipara i
Jonatan Davén i Michael Borowitz vi

16 6
Nertila Tavanxi vii

S 20 IL
outh Africa has the largest number of persons living with HIV and on Overall, the analysis suggests
antiretroviral treatment (ART) in the world. In December 2015, 3.26 million
Y T
South Africans were on ART, with this figure scaling up by approximately that introducing the
A N
400 000 persons per annum. To sustain increasing ART roll-out an additional HIV 90-90-90 targets will
R1–1.5 billion above inflation has been allocated annually over recent years, while
be hard to achieve, but
M U

R8.9 billion of the Comprehensive HIV and AIDS Conditional Grant is budgeted for
the ART programme in 2015/16. that they are likely to be
4 ED

The roll-out may need to expand more rapidly, as South Africa has amended the affordable and cost-effective,
treatment threshold to a CD4 cell count of 500 cells/mm3 and aims to reach the Joint provided that this is done in a
United Nations Programme on HIV/AIDS 90-90-90 targets, effectively a form of
phased way and that annual
O

test-and-treat, and to expand various prevention interventions.

increments to Government
G

HIV and AIDS treatment accounts for a significant and growing share of limited health
budgets over the medium term through the current period of fiscal constraint. These AIDS budgets are sustained.
R

pressures will be aggravated by other competing demands such as the 2015 wage
agreement. Simultaneously in terms of bilateral agreements, funding is declining
BA

from donors such as the United States President’s Emergency Plan for AIDS Relief.
O

This chapter analyses these questions using the results of the recent HIV and tuberculosis investment case, which includes the most
EM

recent national costing, cost-effectiveness and allocative efficiency modelling of the epidemic, while on the funding side it includes
fiscal and budgetary information from recent national budgets, including Budget 2016.

Overall, the analysis suggests that introducing the HIV 90-90-90 targets will be hard to achieve, but that they are likely to be
affordable and cost-effective, provided that this is done in a phased way and that annual increments to Government AIDS budgets are
sustained. The HIV Investment Case has shown that the most cost-effective set of interventions can still massively affect outcomes such
as mortality and HIV incidence. If Government spends more now on the most cost-effective interventions, the impact over 20 years will
be greater, resulting in improvements in outcomes along with reductions in total spending in the long run.

i National Treasury, South Africa

ii Health Economics and Epidemiology Research Office (HE 2 RO), Facult y of Health Sciences,
Universit y of the Wit watersrand, Johannesburg
iii Center for Global Health and Development, Boston Universit y, USA
iv South African National Department of Health
v South African National AIDS Council (SANAC)
vi Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Geneva
vii Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva

203
Introduction
Globally, South Africa has the largest number of persons living with
HIV and AIDS and on antiretroviral treatment (ART). Even though
South Africa is an upper middle-income country, it has continued
to receive significant funding support from the Global Fund to Fight
AIDS, Tuberculosis and Malaria (GFATM) and the United States
President’s Emergency Plan for AIDS Relief (PEPFAR), given its
high disease burden. With 6.4–6.8 million South Africans being
HIV-infected and 3.26 million persons on ARTa in December 2015,
scale-up of the treatment programme by 400 000–600 000 persons
per annum has necessitated that an additional R1–1.5 billion above
inflation be allocated annually over recent years. R8.9 billion of the
Comprehensive HIV and AIDS Conditional Grant is budgeted for
the ART programme in 2015/16, which comprises 61% of the total
unless cost-saving measures such as task-shifting are implemented.5
This chapter looks closely at this potential challenge by analysing
the fiscal space and sustainability of expanding the national HIV
and AIDS programme.
The objectives of this chapter are to describe the following:
➢➢ Cost implications over time of scenarios studied in the recent
national HIV investment case, including the 90-90-90 scenario
and enhanced prevention interventions
➢➢ Affordability in terms of fiscal space, government health
spending and total spending
• Trends in public health spending and budgets, and to
what extent health spending growth projections allow for

PM
health sector HIV and AIDS budget. However, the programme may increasing HIV and AIDS spending, also in the light of
need to expand even more rapidly, given South Africa’s increased future NHI financing reforms
treatment threshold, namely a CD4 cell count of 500 cells/mm3,
• Trends in total government expenditure and revenue and
and its aim to reach the UNAIDS 90-90-90 targets.b,1

16 6
the health sector’s share of these:
The issue of fiscal sustainability refers to the ability of countries – These trends in the context of fiscal space and overall

20 IL
to afford and continue to implement programmes using domestic macro-economic indicators such as the national gross
funding in the short, medium and long term, without jeopardising domestic product (GDP) growth and government debt;
Y T
their national fiscal position. In the field of public health,
sustainability (which has both fiscal and programmatic dimensions)
– Macro-economic indicators benchmarked against other
A N
upper middle-income countries.
has been defined as the capacity to maintain programme services
at a level that will provide ongoing prevention and treatment for ➢➢ Sustainability of HIV and AIDS funding in light of:
M U

a health problem after termination of major financial, managerial • declining donor funding and ultimately full reliance on
and technical assistance from an external donor.2 An entire service domestic sources; and
4 ED

may be continued under its original or an alternative organisational

• financial as well as programmatic aspects of sustainability.
structure, parts of the service may be continued, or there may
be a transfer of some or all services to local service providers.2 HIV and TB Investment Cases
O

Sustainability does not imply either that a service continues within

In 2013, the South African National Department of Health (NDoH)
its original organisational structure or that no changes are made in
and the South African National AIDS Council (SANAC) initiated
G

the service. Sustainability is closely linked to the concept of fiscal

national HIV and tuberculosis (TB) Investment Cases, the findings
space, which refers to the additional spending that countries might
of which were released in 2015. Underpinning this work is the
R

be able to afford without jeopardising their fiscal position and

investment approach first suggested by the UN General Assembly
unduly burdening future generations with debt.3,4
BA

High Level Meeting on HIV and AIDS in 20116,7 which has been
While South Africa has increasing national spending needs, embedded in South Africa’s National Strategic Plan for HIV, TB and
O

funding is simultaneously declining from major donors such as sexually transmitted infections (STIs) (2012–2016).8 The GFATM
defines an HIV investment case as a document that:
EM

PEPFAR and GFATM. Furthermore, the South African Government

has announced that it will adhere to a fiscal spending ceiling, as
previously budgeted, given fiscal constraints arising from, inter alia:
low economic growth, the weakening Rand, a high fiscal deficit,
and lower credit ratings that have increased the cost of national
borrowing.
The annual additional costs of ART expansion consume a significant
portion of the available funds in the existing national health budget,
which faces considerable limitations in a period of overall fiscal
constraint. In the 2012/13 South African Health Review, Venter5
examined various potential challenges pertaining to the expansion
of the South African ART programme. While noting that South Africa
is a unique case in that it has both a high HIV burden and the ability
to fund its ART programme mainly from the national fiscus, concerns
were raised about the long-term affordability of the programme
a National Department of Health Annual Report, 2014/15; 3.26 million
people remaining on ART in quarter 3 performance report, December 2015.
b 90% of all people living with HIV will be diagnosed, 90% of all people
diagnosed as HIV-positive will be on ART, and 90% of all people on ART will
be virally suppressed.
makes the case for optimized HIV investments. At its core is a
description of returns on investment in a country’s optimized
HIV response over the long term (typically 10+ years). It
summarises the state of the HIV and AIDS epidemic and the
response, describes the prioritized interventions, populations,
and geographic areas to be implemented to achieve the
greatest impact over the long term and the resources required.
It also outlines the main access, delivery, quality and efficiency
issues to be addressed to improve HIV and AIDS services and
describes what will be done to address these issues. It includes
an analysis of, and plan for, realistic and more sustainable
financing of the HIV and AIDS response, including increases in
domestic financing where relevant.9
The South African HIV Investment Case borrows elements of the
investment framework, such as the consideration of biomedical and
behavioural interventions alongside strategic enablers of the HIV
response and development synergies, implementation of which often
falls into the remit of government departments other than Health. In

20 4 S A H R 20 1 6

the case of HIV, the South African Investment Case added a category
of technical efficiencyc (TE) factors, which work to improve the
efficiency of single interventions (whereas enablers and synergies
often aim at improving the efficiency or uptake across a number
of interventions). Furthermore, the South African HIV Investment
Case placed the optimisation of allocative efficiencyd at the heart
of the exercise by pioneering a novel optimisation methodology that
allows for consideration of the combined impact of a large number
of interventions, TE factors, and enablers on the programme’s
effectiveness and cost.
Separate but interrelated investment cases were developed for TB
and HIV. This chapter focuses on the results and recommendations
of the HIV Investment Case only; the results of the TB Investment
Case as well as further details regarding the methods and evidence
review and synthesis process of the investment case overall can be
found elsewhere.8,10
16 6
Methodology
The aim of the South African HIV Investment Case was to establish
20 IL
the most cost-effective mix of interventions against HIV for South
Africa over the next 20 years (from 2014/15 to 2034/35), with
Y T
the aim of improving the allocative efficiency of HIV funding. Cost-
effectiveness was measured as cost per life year saved by the entire
A N
programme of interventions, incremental to a baseline of current
M U
coverage with all interventions constant over 20 years. In order to
assess the comparative merits of a range of interventions, several
different scenarios for HIV were constructed (Table 1), based on
4 ED
the currently available budget envelope for the current mid-term
expenditure framework (MTEF) timeframe (i.e. covering the three
financial years from 2016/17 to 2018/19) and a custom-built
O
optimisation routine.11 Costs were modelled in real 2014/15
Rands over a 20-year period. A further 90-90-90 scenario was
G
also constructed, but in the final iteration this was so similar to
the constrained optimisation scenario that it is not reported on
R
separately here.
BA
Table 1: List of scenarios analysed under the HIV investment case
O
Scenario Description
EM
Baseline The baseline for the incremental analysis. This
scenario keeps the coverage of all interventions and
technical efficiency factors constant at current (2014)
coverage levels throughout the 20-year projection
period.
Unconstrained Using a custom-built optimisation routine that
optimisation considers the cost-effectiveness of each intervention
and iteratively adds the most cost-effective
intervention to a rolling baseline, this scenario scales
up interventions without regard to a funding envelope.
Constrained This scenario repeats the optimisation routine
optimisation but stops once the total cost of the package of
interventions exceeds the combined available budget
for the HIV programme (i.e. from the South African
Government, PEPFAR, and the GFATM) in any of the
years from 2015/16 to 2017/18.
c Technical efficiency in the context of this analysis refers to the maximisation
of output (for example, HIV tests done) given a set level of inputs (for
example, healthcare staff).
d Allocative efficiency in the context of this analysis refers to the maximisation
of a socially desirable output (for example, life years saved) given a set level
of funding.
S A H R 20 1 6
H IV and A IDS financing
The process of identifying interventions to be included into the
investment case started with stakeholder consultation workshops
attended by over 250 participants representing government,
academia, civil society, non-governmental organisations and
the healthcare profession. Based on the outputs from stakeholder
consultation workshops, the evidence collected went through several
rounds of scrutiny, using a standardised grading system – first by
members of the Investment Case Task Team who reviewed the evidence
for each intervention under one of 10 programme areas, then by
members of the economics and modelling sub-working group. In
short, interventions had to have strong evidence demonstrating their
effectiveness, and be compatible with existing model architecture
in order to be included. Table 2 lists the interventions, technical
efficiency factors and critical enablers that passed successive rounds
of scrutiny and were included in the HIV Investment Case for testing
PM
within the optimisation model.
The model computed the incremental cost-effectiveness ratio (ICER)
for each intervention and scenario, using cost per life year saved. A
total of 50 combinations of interventions and coverage levels were
modelled and ranked using the ICER. Subsequently, the most cost-
effective option was added onto the baseline scenario. This process
was repeated iteratively until the budgetary constraint was reached
(in the constrained optimisation scenario). The full list of options was
defined as the unconstrained optimisation scenario.
An established epidemiological model projected the HIV epidemic in
South Africa under each of the four scenarios. The Thembisa model,
a dynamic model of the South African HIV epidemic maintained by
the Centre for Infectious Disease Epidemiology and Research at the
University of Cape Town,12 produced the number of HIV infections
averted and the number of life years saved over 20 years under
each scenario. Thembisa was chosen over other models used in
applying the investment framework internationally, such as Spectrum
or Optima, as it provides a better fit to the past and current HIV
epidemic in South Africa.
Affordability and sustainability
The cost implications arising from the Investment Case were
assessed with reference to domestic fiscal and budgetary trends
over the medium term. Current funding levels as estimated by the
South African National Treasury are summarised. In addition, the
fiscal situation and projections for the country are outlined, based
on National Treasury documentation13 and estimates. Provincial
spending estimates for 2015/16 are drawn from Vulindlela on
5 April 2016.
The possibility of higher revenue and funding for the health sector is
explored in the context of the recently published NHI White Paper.
South Africa’s overall spending and revenue are compared with
other upper middle income countries as a benchmark, using data
from the International Monetary Fund (IMF).14 Fiscal sustainability
and space was assessed using various indicators including deficit to
GDP ratio; debt-to-GDP ratio and interest payments as a proportion
of total spending and as a share of GDP. The potential of Government
to take over donor funding progressively was assessed with respect
to potential for government spending increases for HIV and AIDS.
Options to achieve greater technical and allocative efficiency in the
HIV and AIDS response are also presented.
20 5
Table 2: Interventions, technical efficiency (TE) factors and enablers included in the main analysis for the HIV investment case
Programme area
1. Interventions
Care and treatment
Medical male circumcision
(MMC)
Comprehensive condom
programming
Key population interventions
Prevention of mother-to-child
transmission of HIV (PMTCT)
HIV counselling and testing
(HCT)
Social and behaviour change
communication (SBCC)
Other biomedical prevention
2. Technical efficiency (TE) factors
ART
R
HIV Counselling and Testing
(HCT)
BA
EM
3. Critical enablers
e A number of organisations responsible for SBCC campaigns were involved in a government tender submission process at the time of analysis, so we anonymised
the campaigns in order not to influence the tender process.
f SASA! is a community mobilisation intervention to prevent violence and reduce HIV-risk behaviours piloted in Uganda.
206
Intervention/ technical efficiency (TE) factor/ Impact represented in model
enabler
Cotrimoxazole ART uptake
ART at current guidelines ART uptake in children and eligible adults (CD4 <500)
Universal test and treat ART uptake in children and all HIV-positive adults
HIV Counselling and Testing (HCT) uptake
General population MMC MMC uptake in highly sexually active men
Early infant male circumcision (EIMC) EIMC uptake
Condom availability Condom use
Male and female condom education Condom use
Pre-exposure prophylaxis (PrEP) for sex workers PrEP uptake for sex workers
PMTCT (triple ART initiation in pregnant women) ART uptake in pregnant women
Infant testing at birth Uptake of infant testing at birth
PM
Infant testing at 6 weeks Uptake of infant testing at 6 weeks
General population HCT HCT uptake
Testing of pregnant women HCT uptake in pregnant women
Testing of adolescents HCT uptake in adolescents
16 6
SBCC campaign 1e HCT uptake in adolescents
Multiple sexual partners
20 IL
SBCC campaign 2 Condom use
SBCC campaign 3 Condom use
HCT uptake
Y T MMC uptake
PrEP for discordant couples PrEP uptake
A N
PrEP for adolescents PrEP uptake for adolescents
M U
GP down-referral Mortality on ART
Infectiousness on ART
ART retention
4 ED
Home-based ART ART cost
Community-based adherence supporters Mortality on ART
Infectiousness on ART
ART retention
O
Adherence clubs Mortality on ART
Infectiousness on ART
ART retention
G
ART cost
Point-of-care CD4 testing ART uptake
Provider-initiated HCT
Mobile HCT
Home-based HCT HCT uptake
Workplace HCT
O
HCT invitations to pregnancy partners
Gender-based-violence intervention, e.g. SASA!f Multiple sexual partners
Life skills and vocational training for adolescent girls Condom use in adolescents
Risk reduction for alcohol and substance users Condom use
Risk reduction for substance users Condom use
School-based HIV/STI risk reduction Multiple sexual partners
Condom use
Teacher support Multiple sexual partners
Parental monitoring Multiple sexual partners
Condom use in adolescents
School feeding Condom use in adolescents
Positive parenting Multiple sexual partners
Supporting adolescent orphan girls to stay in school Age of sexual debut
State-provided child-focused cash transfers Age disparate sex
S A H R 20 1 6
 H IV and A IDS financing

Key findings Table 3: Incremental cost-effectiveness of interventions and

intervention packages per scenario
Resources for South Africa’s HIV response have increased signi-
ICER/(cost/
ficantly over the last 10 years, and major progress has been made
Rank LYS)* Scenario
in reducing new infections and keeping people alive. The HIV Condom provision Cost-saving
allocations made by the South African government have grown from Male medical Cost-saving
R1.2 billion in 2004/515 to R17.5 billion in 2016/17, representing circumcision
a more than 14-fold growth in nominal public spending. However, ART at current R1 201
guidelines
there are still many ways in which the HIV response can be Constrained
PMTCT R1 474
optimised in order to ensure that the country meets its national and optimisation
Infant testing at 6 R2 683
international commitments and targets, and puts its substantial HIV weeks
investments to best use. This chapter focuses on health sector costs; Universal treatment R2 760
more detail on costs for other sectors such as education and social SBCC campaign 1 R7 847
(HCT, reduction MSP) Unconstrained
services has been or will be presented elsewhere.10
SBCC campaign 2 Cost-saving optimisation
(condoms)

PM
Overall, scaling up condom availability and medical male
General population R13 358
circumcision (MMC) were the most cost-effective options – the model
HCT
in fact suggests that they were cost-saving overall, since both of them SBCC campaign 3 R19 692
prevent significant numbers of new infections, which translate into (condoms, HCT,

16 6
MMC)
savings in treatment costs (Table 3). In terms of cost-effectiveness,
HCT for sex workers R28 727
these two options were followed closely by ART at current guideline

20 IL
Infant testing at birth R31 638
price (with an eligibility threshold of 500 CD4 cells/mm3, and
PrEP for sex workers R107 165
prevention of mother-to-child HIV transmission (PMTCT) coverage of
HCT for adolescents R219 417
Y T
women not on lifelong ART. The currently available budget left space
for additional interventions under the ‘constrained optimisation’
PrEP for young
women
R286 581
A N
scenario – including infant testing at six weeks; improving linkage Early infant male R988 614 783
circumcision
to care and escalating initiation under a policy of universal ‘test and
M U

treat’ (UTT); and scaling up a mass-media campaign aimed at social * ICER (cost/LYS) = Incremental cost-effectiveness ratio as cost per life year
and behaviour change (with a broadcast message of increasing saved
4 ED

HIV counselling and testing (HCT) among adolescents and reducing Source: Authors’ calculations. See also references 10 and 11.
multiple sexual partners (MSP)). The constrained optimisation
scenario almost allowed the country to reach the 90-90-90 targets As a result of UTT being included in all scenarios other than the
O

by 2021, although progress towards the second target was only baseline scenario, the total number of patients on ART (the main
88% (percentage of diagnosed HIV-positive people initiated on cost driver of the country’s HIV programme) did not differ much
G

ART) instead of 90%. Moreover, although UTT is an expensive among the scenarios. From a starting point of 3.3 million people
programme, it must be seen in the light of the long-term cost-saving on treatment at the end of 2015 in the public sector (or 3.6 in both
R

stemming from the number of HIV cases averted. the private and public sectors), the baseline scenario, in which ART
is offered only to people with CD4 cell counts <500 CD4 cells/
BA

The remaining interventions were not affordable under the current

mm3, scales up ART dramatically and continuously over 20 years,
budget and are therefore only included in the ‘unconstrained
O

to a total of 7.2 million by 2035 (Figure 1 overleaf). As a result of

optimisation’ scenario, in addition to the package of interventions in
reduced HIV transmission under UTT, all other scenarios flatten out
EM

the ‘constrained optimisation’ scenario. This included the scaling-up

of two additional different mass-media campaigns aimed at social
and behaviour change (and both increased condom usage and
self-efficacy,g HCT among the general population and MMC), and
increasing HIV testing in the general population as well as among
female sex workers to 90%. The least cost-effective options (once
all the others have been scaled up) were interventions targeting
infants (such as birth testing and, in particular, early infant male
circumcision, the benefits of which fall mainly beyond the 20-year
projection period); further increasing HIV testing in adolescents once
90% testing coverage of the general population has been reached;
and PrEP for both sex workers and young women.
after about 10 years, at levels around 6.5 million patients on ART.
Table 4 provides projections of the total number of patients
remaining on ART, new patients starting ART, condoms being
used, MMCs, and HIV tests for each scenario over the current
Medium-term Expenditure Framework (MTEF) (i.e. from 2016/17 to
2018/19). While some programmes such as condom provision and
MMC were scaled up similarly under all scenarios, the coverage for
other programmes such as HCT differed dramatically among the
scenarios. A further 90-90-90 scenario was also constructed but
was removed here because of its close similarities to the constrained
optimisation scenario.

g Condom self-efficacy is defined as one’s belief in one’s ability to be able to

use a condom.

S A H R 20 1 6 207
Figure 1: Total number of patients on ART, including private sector8,16

6
Patients on ART (Millions)

PM
1

0
2016 2018 2020 2022 2024 2026 2028 2030 2032 2034

Baseline Constrained optimisation Unconstrained optimisation

16 6
20 IL
Table 4: Selected coverage data by scenario for South Africa’s by far the largest contributor to the cost of the entire HIV and AIDS
HIV and AIDS programme, 2016/17–2018/19 (public
and private health sector)
Y T programme, with between 56% and 77% of total cost – mirroring
findings from previous expenditure analyses of the South African
A N
Constrained Unconstrained HIV and AIDS programme.17
Year Baseline optimisation optimisation
M U

In both the baseline and the constrained optimisation scenarios, the

Total remaining on ART
2016/17 4 184 854 4 315 322 4 323 917 cost of the programme correlated with the growing number of people
4 ED

2017/18 4 580 194 4 809 905 4 838 683 on ART, while the unconstrained optimisation scenario is much more
2018/19 4 936 373 5 307 556 5 349 098 expensive than all other scenarios, with costs substantially higher
New patients starting ART than the currently available budget from the three main funders:
South African Government, PEPFAR and GFATM. In the unconstrained
O

2016/17 525 802 661 688 670 599

2017/18 501 313 609 192 630 500 optimisation scenario, costs do not decrease below baseline levels
G

2018/19 462 014 613 831 627 901 but instead almost triple over 20 years, owing to the scale-up of
Number of condoms in circulation less cost-effective interventions in the second half of the ranked
R

2016/17 337 308 240 481 541 212 470 949 722 list in Table 3. In contrast, the constrained optimisation scenario
2017/18 341 080 893 485 688 017 475 133 498 becomes less expensive than the baseline scenario by 2027 and the
BA

2018/19 346 113 637 491 680 366 481 562 685 constrained optimisation scenario by 2030, with increased savings
Number of medical male circumcisions
over baseline every year thereafter. In short, the model continues to
O

2016/17 285 233 509 308 529086

suggest that more aggressive earlier intervention will decrease costs
2017/18 274 317 531 432 553 930
EM

in the long term. If Government chooses to spend more later, it will

2018/19 265 146 540 445 564 655
spend more in total. If Government spends more now, the impact on
Number of HIV tests
health outcomes over 20 years will be greater, but this will also result
2016/17 11 077 811 11 596 035 18 592 290
in reductions in total spending over the long run.
2017/18 11 214 877 15 432 238 28 002 021
2018/19 11 328 301 16 440 258 31 510 815
Outcomes

Source: Authors’ calculations. See also references 10 and 11.
The different intervention packages included in the scenarios result
in different costs of the overall HIV and AIDS programme (Figure 2).
Of particular note is that the cost of the South African HIV and AIDS
programme is projected to continue to increase year-on-year under
each of the scenarios, including the baseline scenario in which no
additional interventions are scaled up and all existing interventions
remain at baseline coverage. Across all scenarios, the cost of the
ART component of the Care and Treatment programme area was
Figure 3 shows the projected HIV incidence, prevalence and number
of AIDS deaths under each scenario. From an incidence of 0.70% in
2015/16 in the baseline scenario, incidence continued to decrease
at a constant pace until 2019, then stabilised at 0.47–0.42% over
the remaining 15 years. In both optimisation scenarios, incidence
continued to drop dramatically throughout the projection period,
to 0.15% in the constrained and 0.12% in the unconstrained
optimisation scenario, respectively, by 2035. All scenarios will
reduce incidence by at least half over 20 years when compared with
the baseline scenario, to between 0.12% and 0.17% by 2034/35.
Of note is that none of the scenarios managed to reduce incidence

h The actual number of condoms assumed to be used to protect sex acts in the
model are a fraction of this number, about 29%.

20 8 S A H R 20 1 6
 H IV and A IDS financing

Figure 2: Total cost of the National HIV/AIDS programme in South Africa, by scenario*

45

40

35

30
Billions ZAR

25
22.08
21.38 21.08

20

15

10

PM
5

0
2016 2020 2024 2028 2032

Baseline Constrained optimisation Unconstrained optimisation Budget constraint

16 6
* Even though the cost of inpatient care per patient on or off ART was included in the calculation of incremental cost-effectiveness, it is excluded here as this

20 IL
cost is borne by the general hospital budget, not the HIV/AIDS budget.

* Expressed in real 2014/15 prices.

Figure 3: HIV incidence, prevalence and total AIDS deaths, by

Y T to below 0.1%, the level proposed by Granich et al.18 as necessary
A N
scenario for ‘virtual elimination’ of HIV – even though both scenarios came
Total HIV incidence close.
M U

1.6%
1.4% Total AIDS deaths followed a similar pattern, with a decline in all
1.2%
scenarios from the 2015/16 level of 160 065 deaths per year with
4 ED

1.0%
0.8% the largest decrease, to 47 421 deaths per year in 2034/35. In
0.6%
0.4%
both the unconstrained optimisation, and constrained optimisation
0.2% scenario deaths fell to 49 831 per year.
O

0.0%
1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033
As a result of the changes in both incidence and mortality,
Constrained optimisation Unconstrained optimisation Baseline
G

prevalence continued to increase from the 2015/16 level of 12.9%

in the baseline scenario to a maximum of 13.6% in 2034/35, and
R

Total HIV prevalence to decline in all other scenarios to between 10.8% in the constrained
16% and 10.1% in the unconstrained optimisation. Increasing ART
BA

14%
coverage is likely to have played a significant role in this, as the
12%
10% ART scale-up options contributed the greatest number of life years
O

8%
saved in the respective scenarios.
6%
EM

4%
2%
Cost-effectiveness
0%
1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033 In terms of total life years saved over the baseline, the unconstrained
Constrained optimisation Unconstrained optimisation Baseline optimisation scenario was more effective than the constrained
optimisation scenario, but comes at a higher price (Table 5). While
both scenarios increase life years saved by 20–22% compared with
Total AIDS deaths
the baseline over 20 years, the unconstrained optimisation scenario
350 000
300 000
increases costs by 31%, in contrast to the marginal cost differences
250 000 of 1.14% in the constrained optimisation scenario. As a result, the
200 000
constrained optimisation scenario is much more cost-effective, at
150 000
100 000
an incremental cost-effectiveness ratio of R442 per life-year saved
50 000 (compared to R10 963 for the unconstrained optimisation scenario).
0
1985 1989 1993 1997 2001 2005 2009 2013 2017 2021 2025 2029 2033

Constrained optimisation Unconstrained optimisation Baseline

S A H R 20 1 6 209
Table 5: Summary of cost, outcomes and cost-effectiveness over sourced from the Budget Review.11 Worth noting is also that debt-
20 years, by scenario service cost is the fastest-growing expenditure item in the budget,
increasing at an annual average of 11.4%.
Constrained Unconstrained
Cost/Outcome Baseline optimisation optimisation
Total life years lost due 79 983 916 64 266 044 62 674 622 Economic growth
to AIDS
National revenue growth is highly dependent on economic growth,
Life years saved - 15 717 872 17 309 294
Change in baseline - -20% -22%
which has declined annually over the past five years to 2015/16
Total cost 610 617 799 (Figure 4), and has only exceeded 3% in one year, in the low growth
(R, billions) decade following the global recession of 2008. Lower economic
Incremental cost (R, - 6.95 189.76 growth is leading to lower increases in Government budgets.
billions)
Growth is projected to increase slightly over the next three years
Change in baseline - 1.14% 31.12%
but may not reach 3% in this Medium-term Expenditure Framework.
Incremental cost per - R442 R10 963
life year saved
Figure 4: South Africa’s annual GDP growth

PM
The investment case was limited to data available by January 2015
(with limited updates thereafter), and will be subjected to updates 4.0

and adaptations in the next rounds. 3.5

3.0

16 6
Affordability and fiscal space 2.5

Although the investment case findings clearly show the most cost- GDP growth (Percentage)
2.0

20 IL
effective option, these still require significant additional funding 1.5

in the medium term, while the SA Government faces real revenue 1.0
Y T
constraints that may limit its ability to implement the most cost-
effective option. The South African Budget 2016 encompassed
0.5
A N
0.0
further weakening of the fiscal position, requiring an increase in tax -0.5
M U

rates and expenditure reductions in order to stabilise the national -1.0

deficit.19 In reducing expenditure, Government has made efforts to -1.5
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
protect funding for the social service delivery sectors such as health,
4 ED

Financial year
basic education and social development. This is shown in Table 6,
Source: Compiled by the authors based on Budget Reviews 2011–
2016.13,19,20,25
Table 6: Consolidated national budget 2016, R million*
O

Medium-term estimates Percentage Average

G

Revised of total annual

estimate MTEF MTEF
2016/17 2017/18 2018/19
Function 2015/16 allocation growth
R

Basic education 213 676 228 803 245 414 264 969 17.6% 7.4%
BA

Health 159 377 168 393 183 629 198 556 13.1% 7.6%
Defence, public order and safety 171 522 181 519 192 444 203 644 13.7% 5.9%
O

Defence and state security 49 900 52 344 54 063 56 373 3.9% 4.1%
Police services 82 648 87 508 94 095 100 225 6.7% 6.6%
EM

Law courts and prisons 38 974 41 667 44 285 47 047 3.2% 6.5%
Post-school education and training 64 158 68 715 74 715 80 493 5.3% 7.9%
Economic affairs 187 796 211 962 217 965 231 091 15.7% 7.2%
Industrial development and trade 29 550 31 844 31 938 35 314 2.4% 6.1%
Employment, labour affairs and social security funds 65 915 73 127 75 270 77 358 5.4% 5.5%
Economic infrastructure and network regulation 73 613 87 105 90 493 97 460 6.5% 9.8%
Science, technology, innovation and the environment 18 718 19 886 20 263 20 959 1.5% 3.8%
Human settlements and municipal infrastructure 178 233 182 631 199 821 216 215 14.2% 6.7%
Agriculture, rural development and land reform 25 249 26 417 27 744 29 147 2.0% 4.9%
General public services2 97 450 73 652 77 770 82 611 5.6% -5.4%
Executive and legislative organs 12 485 13 378 13 988 14 768 1.0% 5.8%
General public administration and fiscal affairs 67 802 41 597 44 701 46 491 3.2% -11.8%
Home affairs 7 247 7 391 7 052 8 935 0.6% 7.2%
External affairs and foreign aid 9 916 11 286 12 029 12 417 0.8% 7.8%
Social protection 154 353 167 479 180 634 194 945 12.9% 8.1%
Allocated by function 1 251 815 1 309 571 1 400 135 1 501 671 100.0% 6.3%
Debt-service costs 129 111 147 720 161 927 178 556   11.4%
Contingency reserve - 6 000 10 000 15 000    
Consolidated expenditure 1 380 926 1 463 291 1 572 062 1 695 227   7.1%

* Numbers stated in this table are in nominal terms (i.e. not adjusted for inflation).
Source: National Treasury, 2011.19

210 S A H R 20 1 6
 H IV and A IDS financing

Health spending is in turn highly dependent on economic growth. The fact that the actual increases in health budgets seen in Figure 4
Based on current GDP and existing ratios of expenditure, the authors are lower than this arises from the revenue growth being largely
estimate that an average of 1% growth in GDP would generate a used to reduce the deficit and pay for higher interest rates.
R1.5 billion real increase in public health spending annually, 2%
would generate R3 billion, 3% R4.5 billion, etc. (based on GDP*% Fiscal policy : national revenue and public spending
growth in GDP*non-interest expenditure/GDP*health spending/ When the global economic recession reached South Africa in 2008,
non-interest expenditure; in this case for 2016/17, a 1% increase growth slowed and, as can be seen in Figure 5, national revenue
in GDP would generate a R11.6 billion increase in-non-interest decreased markedly by 2010/11, but national expenditure levels
expenditure, of which R1.5 billion might be for health services.) were largely maintained as part of a counter-cyclical fiscal stance

Figure 5: Total government revenue and expenditure, 1995/96–2018/19*

1 400

1 200

PM
1 000 Revenue
Real 2015/16 R billion

16 6
Expenditure
800

20 IL
Non-interest expenditure
600

400 Y T
A N
200
M U

0
/96 /98 /00 /02 /04 /06 /08 /10 /12 /14 /16 /18
95 97 99 01 03 05 07 09 11 13 15 17
4 ED

Financial Years

Source: Compiled by the authors based on Budget Reviews 2011–2016.13,19,20,25

O

* Adjusted for inflation, expressed in real 2015/16 prices Rand billion

G

Figure 6: Real annual increase in total government spending (non-interest*; Rand billion)
R

180 30%
BA

160 25%
O

140 20%
EM

120
15%
Real 2015/16 R million

100
10%
80
5%
60
0%
40
-5%
20

0 -10%

-20 -15%

-40 -20%
/03 /05 /06 /07 /08 /09 /10 /11 /12 /13 /14 /15 /16 /1 7 /18 /19
02 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18
Financial year

Annual increase in non-interest expenditure (2015 R billion) Percentage change

Source: Compiled by the authors based on Budget Reviews 2011–2016.13,19,20,25

* Non-interest rather than total expenditure is used because it better reflects spending on government services rather than debt payments which vary; a wider
selection of information is available in the Budget Reviews.

S A H R 20 1 6 2 11
that was intended to protect social spending.20 Figure 5 shows a
sharp decline in the revenue line from 2009/10, after which the
expenditure line far exceeded the revenue line. The lower revenue
line, higher deficit (gap between revenue and expenditure lines) and
higher total expenditure line, partially due to higher interest costs, all
reflect limited fiscal space (despite national spending exceeding one
trillion Rand). Nevertheless, some of the increase seen in non-interest
spending, which funds services, reflects increased allocations pro-
vided to the HIV and AIDS Investment Case in Budget 2016.
Fiscal space can be increased by increasing revenue or decreasing
expenditure. Both of these have been done in Budget 2016.
National revenue will reach 26.9% of GDP on the main budget
in the medium term, and consolidated national revenue (including
social security funds and public entities) will reach 30.5% of GDP.
In both Budget 2015 and Budget 2016, various tax rates have
been increased (personal, fuel levy, excise taxes on alcohol and
cigarettes) and some new forms of taxation have been announced
(e.g. tax on sugar-sweetened beverages).19

Figure 6 shows year-on-year real spending growth in non-interest
expenditure in the main budget. Growth in total government
spending was strong in the six years before the 2008 economic
recession, but has been followed by considerably lower spending
growth since 2010/11. There is no real total year-on-year spending
Table 7 compares South Africa’s total public expenditure and revenue
with a basket of income comparable to upper middle-income (UMIC)
countries.21 South Africa’s spending is comparable to the median,
but several comparator countries have slightly higher revenue and
expenditure (e.g. Brazil, Argentina, Botswana and Turkey). Note

growth anticipated in 2016/17, with some recovery into 2017/18,
with an average total spending growth (non-interest) of R8.5 billion
per annum across government over the next three financial years.
Note that if the health sector were to receive 10–15% (15% is the
PM
that increasing fiscal space does not necessarily imply that spending
would be allocated to health or to HIV specifically.

16 6
Abuja Declaration target) of R8.5 billion non-interest spending
growth, this would amount to an increase of R850 million to R1.3

20 IL
billion.

Table 7:
Y T
General government revenue, expenditure and deficit as a percentage of GDP
A N
Expenditure Revenue Deficit
M U

Countries as % of GDP as % of GDP as % of GDP

  2008 2010 2012 2008 2010 2012 2008 2010 2012
Turkmenistan 10.9 14.1 14.7 20.9 16.1 21.0 10.0 2.0 6.4
4 ED

Costa Rica 16.1 19.0 18.3 15.9 13.6 13.7 -0.3 -5.4 -4.6
Peru 18.8 20.3 19.6 21.3 20.2 21.7 2.6 -0.1 2.1
Dominican Republic 19.3 16.5 20.7 15.9 13.6 14.0 -3.4 -2.8 -6.8
O

Kazakhstan 27.1 22.5 22.4 28.3 23.9 26.9 1.2 1.5 4.5
Mauritius 23.8 25.1 23.3 21.0 21.9 21.4 -2.8 -3.2 -1.8
G

China 20.4 22.8 24.8 19.7 21.3 22.6 -0.7 -1.5 -2.2
Thailand 21.2 23.2 24.9 21.4 22.4 23.1 0.1 -0.8 -1.8
R

Panama 25.7 27.1 26.6 26.1 25.2 25.1 0.4 -1.9 -1.5
Mexico 25.6 26.7 27.2 24.7 22.4 23.5 -1.0 -4.3 -3.7
BA

Gabon 18.7 22.8 27.4 29.6 25.4 29.0 10.9 2.7 1.5
Colombia 26.6 29.4 28.3 26.4 26.1 28.4 -0.3 -3.3 0.1
O

Malaysia 28.2 27.8 29.5 24.6 23.1 25.9 -3.6 -4.7 -3.6
EM

Jamaica 38.6 33.2 29.9 27.5 26.8 25.8 -11.1 6.3 -4.1
Lebanon 34.7 29.7 31.3 24.7 22.2 22.6 -10.0 -7.6 -8.7
South Africa 30.1 32.4 32.6 29.6 27.5 28.3 -0.5 -4.9 -4.3
Namibia 26.8 32.7 34.0 31.0 28.1 32.7 4.2 -4.6 -1.3
Bulgaria 35.2 36.7 34.4 38.0 32.7 34.0 2.9 -4.0 -0.5
Romania 37.0 38.6 35.4 32.2 32.2 32.9 -4.8 -6.4 -2.5
Botswana 46.9 39.9 35.7 39.4 32.5 35.9 -7.5 -7.5 0.2
Turkey 34.5 36.7 36.3 31.8 33.3 34.5 -2.7 -3.4 -1.8
Azerbaijan 31.1 31.7 36.7 51.1 45.7 40.5 20.0 14.0 3.8
Belarus 48.8 42.1 38.9 50.7 41.6 40.5 1.9 -0.5 1.7
Venezuela 34.9 31.6 40.0 31.4 21.2 23.4 -3.5 -10.4 -16.6
Ecuador 34.5 34.6 40.4 35.1 33.3 39.5 0.6 -1.3 -0.9
Brazil 38.3 39.9 40.4 36.7 37.1 37.7 -1.6 -2.8 -2.8
Iraq 57.3 49.6 43.3 56.4 45.4 47.4 -0.9 -4.2 4.1
Argentina 37.9 38.5 44.3 34.3 37.2 40.3 -3.6 -1.4 -4.0
Hungary 49.2 49.9 48.9 45.5 45.6 46.9 -3.7 -4.4 -2.0
Serbia 44.8 46.4 49.3 42.8 42.5 42.1 -2.0 -3.9 -7.2
Median SA comparator 30.6 31.6 31.9 29.6 26.5 28.3 -1.0 -5.2 -3.6
Medium upper middle income 34.2 32.0 33.9 30.3 27.8 29.5 -3.9 -4.2 -4.4

Source: International Monetary Fund, 2014.14

2 12 S A H R 20 1 6
 H IV and A IDS financing

Figure 7: Public health expenditure trend (real Rand million 2015/16 prices)

200 000

180 000

160 000

140 000
Real 2015/16 R million

Provincial and National DoH

120 000
Public (all departments)
100 000
Consolidated 2016 Budget Review

80 000

60 000

40 000

PM
20 000

0
/96 /98 /00 /02 /04 /06 /08 /10 /12 /14 /16 /18
95 97 99 01 03 05 07 09 11 13 15 17

16 6
Financial year

20 IL
Source: Compiled by the authors.

Figure 8: Health spending annual growth – two projections (real Rand million 2015/16 prices)
Y T
A N
18 000
M U

16 000

14 000
4 ED

12 000
Real 2015/16 R million

10 000
O

8 000

6 000
G

4 000
R

2 000
BA

0
O

-2 000
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
EM

Financial year

Real increase consolidated health expenditureuse Real increase provincial and national

Source: Compiled by the authors based on Budget Reviews 2011–2016, Estimates of National Expenditure 2010–2016, and Estimates of Provincial Revenue
and Expenditure 2010–2016.13,19,20,25

S A H R 20 1 6 213
Figure 9: Government and donor funding for HIV/AIDS-dedicated programmes (R billion real 2014/15 prices)*

25 000

20 000

DoH HIV spending excluding

Real 2015/16 R million

opportunistic infections
15 000
Donor

Total

10 000

5 000

PM
0
/08 /09 /10 /11 /12 /13 /14 /15 /16 /17 /18 /19
07 08 09 10 11 12 13 14 15 16 17 18
20 20 20 20 20 20 20 20 20 20 20 20

Financial year

16 6
Source: Compiled by the authors based on Estimates of National Expenditure 2010–2016, Estimates of Provincial Revenue and Expenditure 2010–2016, and
the Partnership Framework Implementation Plan agreement with PEPFAR.

20 IL
* The declining trend of donor spending reflects the bilateral Partnership Framework Implementation Plan agreement with PEPFAR which envisaged a funding
decline from US$450 million to US$250 million over five years. However, in practice, donor funding is likely to be higher in Rand terms because of currency
depreciation and additional funding from PEPFAR and GFATM for targeted HIV interventions.
Y T
* Funding to treat opportunistic infections in general health services is excluded here to make the numbers more comparable to the cost estimates shown in the
investment case.
A N
Health budget trends
M U

Health’s share of the budget is currently 13.1% (Table 5) and not far being distributed out to health departments. These estimates draw
4 ED

from the 15% called for in the Abuja Declaration. Figure 7 shows on in-year preliminary provincial projections for 2015/16 which
trends in public health spending, expressed in real Rand 2015/16 may overestimate the year’s spending outcome. Nevertheless, both
prices, and using three different spending measures. The simplest estimates suggest a considerable slowdown in health expenditure
measure is the sum of health spending by provincial and the national in 2016/17, which will need to be managed, and partial recovery
O

Departments of Health; the consolidated measure is used in the Budget in 2017/18 and 2018/19. Published provincial numbers from all
G

Review and incorporates public entities such as the South African nine provinces for Budget 2016 will be available from May 2016.
Medical Research Council (MRC) and National Health Laboratory
HIV and AIDS spending and funding
R

Service (NHLS); the ‘public all departments’ estimate is the widest

and incorporates health spending in the Departments of Defence Government spending on HIV and AIDS has tripled in real terms
BA

and Correctional Services, among others. All these measures show since 2007/08, as shown in Figure 9, while donor funding is
that real growth was quite strong until 2011/12 (exceeding 5% projected to decline in terms of the bilateral agreement with
O

per annum), but slowed substantially from 2012/13 and especially PEPFAR.22 In practice, however, the donor funding trajectory may
EM

in the recent years, when it started to level off in real terms. At the be more positive in the short term, given the strong US Dollar and
time of writing, provincial budgets had not yet been gazetted for additional allocations from PEPFAR and the GFATM for specific
budget 2016. The consolidated estimate shows somewhat stronger programmes.
growth going forward than do the other two estimates, because its
Annual real growth in government expenditure on HIV and AIDS
methodology assumes that provincial surpluses will be allocated out
(Figure 10) is expected to average R913 million per annum over
over time.
the medium term. This represents a significant commitment by
Figure 8 presents year-on-year real increases in health budgets using government, noting the revenue constraint and that total real
two projections of forward growth. The lower projection covers only government non-interest expenditure growth across all departments
provinces and the National Department of Health, and is based on is anticipated to average R8.5 billion per annum over the MTEF
estimates provided by provinces earlier in the budget process, which (Figure 6) and between R627 million and R2.0 billon per annum for
will change when final provincial 2016 budgets are published. health services overall (Figure 8).
Whereas health expenditure increased by an average R10 billion
per annum in real terms for the four years to 2012/13, spending
is projected to slow over the medium term. This lower estimate of
growth projects 0.4% or an average of R627 million per annum
increase over the medium term. The higher estimate, based on
consolidated expenditure, estimates real growth of 1.3% per annum
or averaging R2.0 billion per annum over the medium term. This
higher estimate includes assumptions about provincial surpluses

214 S A H R 20 1 6
 H IV and A IDS financing

Figure 10: Annual real growth in government HIV and AIDS has been rising and will reach 46.2% by 2018/19. While this in itself
spending on dedicated programmes R billion is still lower than is the case in several developed countries, South
2 500 Africa pays higher interest rates, and as interest as a proportion of
total government spending increases to 11.7% in 2016/17, it could
2 000 soon overtake health expenditure. Government’s interest payments
as a proportion of GDP will now reach 3.5%, higher than the upper
Real 2015/16 R million

1 500 limit of 3% of GDP recommended by the Organisation for Economic

Co-operation and Development (OECD). The annual deficit (i.e. the
1 000 amount by which expenditure exceeds revenue) reached its peak at
6.4% of GDP in 2009/10 and is projected at 4.3% in 2015/16,19
500 higher than the upper limit recommended, for example, in the
European Union (EU) where it is 3%.23 Annual debt payments are
0 projected to rise from R88 billion in 2012/13 to R179 billion in
/09 /10 /11 /12 /13 /14 /15 /16 /17 /18 /19
08 09 10 11 12 13 14 15 16 17 18 2018/19.19
20 20 20 20 20 20 20 20 20 20 20
Financial year

PM
Rising debt-to-GDP ratio, interest payments and high deficits are
Government HIV spending excluding opportunistic infections
considered to be indicators of risk in the ability of governments to
make debt payments and are of concern to Government.24 These
Source: Compiled by the authors based on Estimates of National Expenditure
2010–2016 and Estimates of Provincial Revenue and Expenditure have led to two sovereign ratings downgrades (i.e. independent

16 6
2010–2016. scorings of the risk of governments defaulting on debt payments),
which have in turn led to higher borrowing costs. To reduce fiscal

20 IL
It is clear that HIV and AIDS takes up a considerable share of risk, the Government increased taxes (personal income, fuel levy,
limited budgetary space for health, particularly in the 2016/17 excise taxes and others) in Budget 201525 and Budget 2016, and
year. However, ART is not the only item for which spending growth Y T imposed spending ceilings, spending cuts (R25 billion in personnel
is required – wage pressures are substantial in the South African cuts across the whole-of-government Budget 2016) and undertook
A N
context in terms of the 2015 wage agreement which covers three reprioritisation to fund new priorities, such as the zero-increase in
years exceeding inflation by several percentages. Primary health tuition fees and increased student financial aid at higher education
M U

care volumes of patients are increasing and there are backlogs institutions. Despite these efforts, the indicators of debt sustainability
in improving conditions of health facilities, all of which require in South Africa appear to imply that fiscal space for increased
4 ED

additional resources. health, and specifically HIV and AIDS spending, is likely to be
further constrained.
Sustainability and government debt
O

Fiscal space in South Africa is currently limited by the low economic

growth and high deficit circumstances. The level of government debt
G

and deficits is an important sign of fiscal sustainability. Figure 11

shows four indicators of debt sustainability. The net debt-to-GDP ratio
R
BA

Figure 11: Indicators of debt sustainability in South Africa*

O

50%
EM

40%

30%
Percentage of GDP

Interest/GDP

Deficit/GDP
20%
Interest/Exp

Total loan debt/GDP

10%

0%

-10%
/96 /98 /00 /02 /04 /06 /08 /10 /12 /14 /16 /18
95 97 99 01 03 05 07 09 11 13 15 17

Financial year

Source: Compiled by the authors based on Budget Reviews 2011–2016.13,19,20,25

* The increase in interest payments/GDP ratio from 2.3% of GDP to 3.5% of GDP is somewhat lower than the increase of net loan debt from 22% to 46% of
GDP, because interest rates – although rising – are lower than in 2008/09, but could be at risk of rising further; debt payments take up 11.7% of the budget
in 2016/17.

S A H R 20 1 6 215
Potential to raise additional revenue through NHI
Should funds not be sufficient for the 90-90-90 scenario, additional
funding may become available over time through new financing
mechanisms through NHI or through other mechanisms to raise
national revenue. The recently published White Paper on NHI26
suggests that public funding for health services will rise by
approximately 2% of GDP over 15 years, from 4% of GDP to 6.2%
of GDP, mainly through increased taxation. This could, in the long
term, raise sufficient funding to fully fund the 90-90-90 scenario
and for complete donor sustainability. However, NHI will take
several years to be fully functioning and to generate the revenues
anticipated, particularly in the fiscal climate portrayed in Budget
2016.19
Technical and allocative efficiency
Achieving high levels of technical and allocative efficiency is critical
to sustainability, especially in a constrained fiscal environment.
Substantial savings have been achieved through a well-researched
16 6
and negotiated procurement process resulting in South Africa
20 IL
achieving among the lowest prices for ARVs globally, which,
together with the shift to nurse-based treatment, has substantially
lowered the unit costs of ART. There may be potential for even
Y T
greater efficiencies through measures such as adherence clubs and
the Central Chronic Medicine Delivery and Dispensing programme
A N
which will facilitate less-frequent facility visits, integration of services
M U
and operations at scale. However, an increasing proportion of
patients requiring second-line treatment and several years of
decreasing prices may herald a lower limit on unit costs for ART
4 ED
treatment being approached after many years of reducing costs.
Nonetheless, through improved chronic medicine delivery and
dispensing, integration and other forms of efficiency savings and
O
rationalisation, it is likely that future reforms could achieve greater
technical efficiency and value for money in health service delivery
G
platforms and for the HIV programme as well.27,28
R
Discussion
BA
N
The analysis undertaken suggests that while the 90-90-90 strategy
O
is hard to achieve, it is likely to be affordable and has indeed already
EM
been partially funded in Budget 2016.19 However, the precise costs
of the scenario in the short to medium term will vary depending on
the pace of scale-up of the most cost-effective interventions such as
condoms, circumcision, ART and other interventions shown in the
upper half of Table 3. Too rapid a scale-up might be unfeasible,
particularly given human resource constraints, whereas if scale-up
is too slow, the scenario may revert closer to the baseline scenario
and reduction in the rates of new infection and deaths may be
inadequate.
Both Budget 2016 and Budget 2015 reflect a message of fiscal
constraint and reduced fiscal space. Government has tried to
create some fiscal space by increasing taxation and reducing
expenditure (e.g. R25 billion in personnel savings). Some of these
funds have been used to fund and reprioritise funds towards the HIV
and TB Investment Cases in Budget 2016.19 Additional funds of
approximately R1.8 billion were allocated towards these over three
years in Budget 2016, despite the tight fiscal position.29 These funds
were allocated because the Investment Case showed that substantial
216 S A H R 20 1 6
further improvements in health outcomes could be achieved through
the constrained optimisation scenario, noting that HIV and TB still
contribute massively to the national burden of disease.
The budget process appears to have been proactive in considering
and at least partially funding the proposed recommendations of
the HIV and AIDS Investment Case; this forms a good basis for the
adoption of the 90-90-90 strategy and progressive implementation
of the HIV Investment Case.
However, there will be various hurdles to overcome, such as
managing the increase in health personnel costs due to the 2015
wage agreement, which is expected to result in an 7.4% annual
growth in wages across government.19 In addition, there will be a
need to reconcile rising HIV and AIDS budgets with the personnel
hiring limitations announced across government as part of the
PM
fiscal constraint in Budget 2016 – a specific exclusion for HIV
and AIDS-related personnel may be required to address this. If this
is not achieved, there may be funds available, but not sufficient
human resources to implement the 90-90-90 strategy, noting also
that South Africa has a significantly lower number of doctors than
do most income-comparable upper middle-income countries.30
More contracting with private general practitioners as well as public
clinics, as envisaged in the NHI policy, might also assist.19 Rising
HIV and AIDS budgets in the context of low growth in health budgets
represents somewhat of a dilemma, but may still be worthwhile
given the high proportion which HIV and AIDS contributes to the
overall burden of disease.
Achieving allocative and technical efficiency is important given the
fiscal and other resource constraints. Comparing the investment case
scenarios (see Figures 1–3), the constrained optimisation scenario
compares favourably with the unconstrained optimisation scenario
for outcomes such as incidence, prevalence and lives saved, but is
cheaper in the long term and should therefore be considered the
most cost-effective option for Government. Although the investment
case suggests a degree of allocative efficiency at baseline,
several key prevention interventions are still at low coverage rates
(e.g. MMC, condoms and the sex worker programmes have only
recently expanded coverage, and an adherence strategy including
adherence clubs and a chronic medicines dispensing programme
is yet to be rolled out), and the 2012 South African National HIV
Prevalence, Incidence and Behaviour Survey suggests that safe
sexual behaviour is not being maintained.31
Within the constrained optimisation scenario, various sub-options
could be developed to ascertain how rapidly ART, condom,
circumcision and other targets might be raised. If the 90-90-90 targets
are to be met, universal testing and treatment must be progressively
rolled out, increasing testing to over 12 million tests per year for
the foreseeable future, using a wider range of testing modalities to
detect a larger proportion of infected persons (home-based testing,
mobile testing, provider-initiated counselling and testing, etc.), and
initiating a larger number of people on ART per year.
Depending on the speed with which the UTT programme is rolled
out and whether donor funding does in fact decline (as specified in
the Partnership Framework Implementation Plan (PFIP)) or is actually
maintained, there may still be budgetary shortfalls to implement
the strategy. However, the research suggests that Budget 2016
already contributes towards implementation of the strategy, and the

experience of previous CD4 count threshold changes has been that
they tend to lead to progressive and gradual rather than sudden,
large increases in uptake.
The constrained optimisation scenario involves an optimal allocative
distribution that focuses funds on the most cost-effective interventions.
Implementing this will not necessarily be easy, as there are always
calls (in some cases potentially justifiably) to implement a range
of less cost-effective or proven interventions. Part of this dilemma
arises from the difficulty of proving effectiveness, particularly for
a potentially large set of enabling interventions. This is one of the
methodological limitations of this investment case analysis. Many of
these other interventions make sense from other perspectives, but do
not meet the very rigorous criteria used here. As more interventions
are added and government and donor funds are used for additional
interventions and purposes, the scenario moves closer to the more
expensive unconstrained optimisation approach, with higher costs
and a requirement for further additional funding. In addition, the
costed model assumes that the current high degree of technical
16 6
efficiency in terms of medicine prices and staff distribution can be
sustained, and it is possible that the country may face changing
20 IL
cost pressures, e.g. increasing medicine prices following currency
depreciation.
Y T
Scaling up HIV and AIDS services at a time of fiscal constraint will be
A N
difficult. Confronting these kinds of challenges is consistent with the
experience of health services in many OECD countries (e.g. Ireland,
M U
Greece, England) which have been through a period of fiscal
constraint during the 2008 global recession and have introduced
4 ED
a wide and varied set of efforts to control costs, achieve technical
efficiency gains and source cheaper input costs. South Africa faces
the added high quadruple burden of disease,32 an escalating HIV
and AIDS response, and less advanced health services.
O
Affordability will also depend on the degree to which donor funding
G
will have to be replaced. In the context described here, where
increases in HIV and AIDS funding already comprise a significant
R
share of total annual health budget increases, it is likely that
simultaneous full replacement of donor funding will be difficult. Full
BA
domestic sustainability, in the sense of fully replacing donor funding,
O
will become easier once economic growth becomes stronger or once
the number of persons on ART levels off (as is projected for around
EM
2026 in both optimisation scenarios). In this context, simultaneous
replacement of donor funds is likely to imply greater scrutiny of
the merit of the services to be absorbed into the public service.
However, it is worth noting that the entire level of donor funding
for health is relatively small (0.11% of GDP). Even if donor funding
had to be replaced in its entirety, this does not imply a huge fiscal
pressure. Complete replacement is not envisaged at the present
time, with substantial PEPFAR and GFATM allocations continuing
through the medium term, noting the importance of the South
African contribution to ending AIDS globally. Practical experience
of the sustainability transition in South Africa within the first one to
two years of reducing PEPFAR funds has shown the complexity of
handing over responsibility for a complex set of services and non-
governmental organisations (NGOs) widely distributed throughout
the country. This practical experience suggests that sustainability
transitions should be carefully planned and managed. Fiscal
sustainability has in several cases proven to be considerably simpler
than programmatic transition of services.
S A H R 20 1 6
H IV and A IDS financing
NHI (and other related potential financing reforms) could potentially
increase public health spending from 4% to approximately 6.2% of
GDP over a 15-year period26 (as envisaged in the NHI White Paper
assuming economic growth of 3.5%), once additional revenue
sources have been put into place. NHI would have the effect both of
raising additional revenue and increasing the health sector’s share
of the budget above the current 13.1% and closer to the 15% called
for in the Abuja Declaration.
Conclusions
The national budget, reflected in Budget 2016, is under fiscal con-
straint and has limited fiscal space. Attempts have been made to
create fiscal space by increasing taxation and reducing national
PM
spending. Some of the additional funds sourced from the contingency
reserve and through reprioritisation have been allocated to the HIV
investment case, including the UTT strategy, given its apparent cost-
effectiveness and ability to make a substantial impact on national
health outcomes.
However, for the 90-90-90 strategy to work, its human resource
requirements will have to be addressed in a climate where
restrictions on post-filling have been reported in several provinces.
The annual additional costs of ART expansion consume a significant
portion of the available additional funds in the national health
budget, which faces considerable limitations. The rising short-term
costs of the HIV programme (ART being the largest contributor to
HIV and AIDS spending, accounting for between 56% and 77% of
total cost), together with ever-rising personnel costs resulting from
the 2015 wage agreement, imply pressure on the rest of the health
service with a likely continued focus on efficiency savings and more
cost-efficient service platforms.
Given these pressures, the transition plan for donor-funding
programmes will require scrutiny to make best use of limited and
declining donor funding. However, the level of donor funding in
South Africa is relatively small and compensating for the decline
would not incur huge fiscal pressure. Despite the PFIP, the two largest
donors, PEPFAR and GFATM, have committed to supporting HIV and
AIDS service delivery in South Africa with substantial allocations in
the medium term. Over the past few years, Government has worked
closely with PEPFAR on the PFIP transition. It is evident that transition
planning and sustainability – both fiscal and programmatic – is a
difficult process that requires close collaboration with all relevant
stakeholders, including the NGO sector.
Given the constrained fiscal climate, it is important to achieve high
levels of technical and allocative efficiency in the delivery of HIV
and AIDS services. The programme has already reached fairly high
levels of technical and allocative efficiency (e.g. substantial savings
in ARV procurement, and nurse-initiated management of ART) with
real unit costs dropping substantially. It is important for Government
and the private sector to continue to achieve greater efficiencies and
value for money in HIV and AIDS service delivery and other parts of
the health service as an integral part of financing reforms.
In summary, the total cost of the national HIV and AIDS programme
will increase, notwithstanding the mix of interventions chosen,
because of South Africa’s generalised epidemic and Government’s
pre-existing commitment to fund lifelong ART to existing patients.
2 17
In the context of the current fiscal constraints, it is in the hands of
Government to decide when total costs should start to decrease –
bearing in mind that spending more now will lead to a decrease in
total spend.

Recommendations
The following recommendations arise from the research:

➢➢ A move towards universal UTT, and by implication, the 90-90-

90 targets, appears to be affordable, if hard to reach, with
the increased HIV prevention and treatment funding allocation
in the 2016 Budget assuming that the historical pattern of
growing HIV and AIDS budgets will continue over the medium
to long term. Therefore, the constrained optimisation scenario

PM
should be implemented, which will entail implementation of
UTT, and scale-up of interventions that have been identified as
highly cost-effective, such as MMC and condom distribution.
However, it is uncertain whether some of the highly cost-

16 6
effective interventions can be logistically and practically
scaled up even faster.

20 IL
➢➢ The HIV investment case findings underscore the importance
of investing more now in HIV and AIDS to reduce overall
Y T
spending and to achieve greater impact over the next 20
A N
years. In the context of NHI and declining donor funding, it
is recommended that Government also intensify its efforts to
M U

control costs and safeguard and further expand technical and

allocative efficiencies in programme delivery, such as through
4 ED

community-level testing and adherence clubs.

➢➢ NHI is likely to increase fiscal space to the benefit of health

services including HIV and AIDS. It has the potential to fully
O

address sustainability in the longer term, including phasing

down of donor funding. Therefore, the NHI reforms should
G

be supported, particularly the proposals to raise additional

revenue to fund NHI. Given the difficult fiscal space over
R

the medium term, development partners should be cautious

about unplanned reductions in donor funding without having
BA

a transition plan that is closely co-ordinated with the SA

Government.
O

➢➢ The investment case methodology has been useful in

EM

determining the most cost-effective interventions and budget

requirements to combat the HIV and AIDS epidemic in South
Africa. Together with the TB Investment Case, it was used in the
2016 budget process to successfully secure additional funding
for the HIV and AIDS and TB programmes. The application
of this approach may provide useful lessons for other health
programmes.

Acknowledgements
The authors wish to acknowledge contributions from Teresa Guthrie,
Lise Jamieson, Gavin Surgey, Refiloe Thokoa and Shaneel Ragoo.

218 S A H R 20 1 6
 H IV and A IDS financing

References
1 Joint United Nations Programme on HIV/AIDS (UNAIDS).
90-90-90 – an ambitious treatment target to end the epidemic.
Geneva: Joint United Nations Programme on HIV/AIDS;
2014.
2 La Pelle NR, Zapka J, Ockene J. Sustainability of Public
Health Programs: The Example of Tobacco Treatment
Services in Massachusetts. Am J Public Health. 2006 August;
96(8):1363–9.
3 Durairaj V, Evans D. Fiscal space for health in resource-poor
countries. World Health Report (2010) Background Paper, 41.
Geneva: World Health Organization; 2010.
4 Heller P. Understanding fiscal space. International Monetary
Fund, IMF Policy discussion paper. Washington, DC:
International Monetary Fund; 2005.
19 National Treasury (South Africa). Budget Review 2016.
Pretoria: National Treasury; February 2016.
20 National Treasury (South Africa). Budget Review 2010.
Pretoria: National Treasury; 2010.
21 World Health Organization. World Health Statistics. Geneva:
World Health Organization; 2014.
22 United States President’s Emergency Fund for AIDS Relief
(PEPFAR). Partnership Framework Implementation Plan in
Support of South Africa’s National HIV, STI & TB Response
2012/13–2016/17 between The Government of the
Republic of South Africa and The Government of the United
States of America. 2012. [Internet]. [cited 28 March 2016].
URL: http://www.pepfar.gov/documents/
organization/196651.pdf

5 Venter F. HIV Treatment in South Africa: The challenges of an
increasingly successful antiretroviral programme. In: Padarath
A, English R, editors. South African Health Review 2012/13.
Durban: Health Systems Trust; 2013.
PM
23 European Commission. Economic stability and growth pact.
2016. [Internet]. [cited 28 March 2016].
URL: http://ec.europa.eu/economy_finance/economic_
governance/sgp/corrective_arm/index_en.htm

16 6
6 United Nations. Political Declaration on HIV/AIDS: 24 Sachs M. The new fiscal guidelines and a “rule-of-thumb”.
Intensifying our Efforts to Eliminate HIV/AIDS. Resolution National Treasury proposals in the 2015 Medium Term

20 IL
65/277 of the 65th Session of the UN General Assembly, Budget Policy Statement. Pretoria: National Treasury; 2015.
New York, 10 June 2011. [Internet]. [cited 28 March 2016].
URL: http://www.treasury.gov.za/comm_media/
7 Schwartländer B, Stover J, Hallet T, et al. Towards an
Y T presentations/Fiscal%20Principles.pdf.
improved investment approach for an effective response to
HIV/AIDS. Lancet. 2001;377:2031–41. 25 National Treasury (South Africa). Budget Review 2015.
A N
Pretoria: National Treasury; February 2015.
8 South African National Department of Health. National
M U

Strategic Plan for HIV, TB and STIs (2012–2016). Pretoria: 26 South African National Department of Health. White Paper
National Department of Health; 2012. on National Health Insurance for South Africa, Version 40.
December 2015. [Internet]. [cited 28 March 2016].
4 ED

9 Global Fund to Fight AIDS, Tuberculosis and Malaria. URL: http://www.health-e.org.za/wp-content/

Strategic investments for HIV programs: Information Note. uploads/2015/12/National-Health-Insurance-for-South-Africa-
Geneva: Global Fund to Fight AIDS, Tuberculosis and White-Paper.pdf
Malaria; 2015.
27 World Health Organization. More money for health and more
O

10 South African National Department of Health, and South health for the money. In: World Health Report 2010. Geneva:
African National AIDS Council. South African HIV and TB World Health Organization; 2010.
G

investment case – Summary Report Phase 1. March 2016.

28 Organisation for Economic Co-operation and Development
11 South African National Department of Health and South (OECD). Fiscal sustainability of health systems – bridging
R

African National AIDS Council. South African HIV and TB health and finance perspectives. Paris: Organisation for
investment case – Reference Report Phase 1. March 2016. Economic Co-operation and Development; 2015.
BA

12 Johnson L. THEMBISA version 1.0: A model for evaluating 29 National Treasury (South Africa). Estimates of National
the impact of HIV/AIDS in South Africa – Working Paper. Expenditure. Pretoria: National Treasury; 2016.
O

Cape Town: Centre for Infectious Disease Epidemiology and

Research, University of Cape Town; 2014. 30 World Health Organization. World Health Statistics. Geneva:
EM

World Health Organization; 2015.

13 National Treasury (South Africa). Budget Review. Pretoria:
National Treasury; 2014. 31 Human Sciences Research Council of South Africa (HSRC).
South African National HIV Prevalence, Incidence and
14 International Monetary Fund. Government Finance Statistics Behaviour Survey, 2012. Pretoria: HSRC Press; 2015.
2014. [Internet]. [cited 28 March 2016].
URL: http://elibrary-data.imf.org/FindDataReports. 32 Mayosi B, Flisher A, Lalloo U, et al. The burden of
aspx?d=33061&e=170809 non-communicable diseases in South Africa. Lancet.
2009;374(9693):934–47.
15 National Treasury (South Africa). Trends in intergovernmental
finances: 2000/01–2006/07. Pretoria: National Treasury;
2004.
16 South African National AIDS Council (SANAC). Progress
Report on the National Strategic Plan for HIV, TB AND STIs
(2012–2016). Pretoria: South African National AIDS Council;
2014.
17 South African National AIDS Council (SANAC). The National
AIDS Spending Assessment (2007/08 to 2010/11). Pretoria:
South African National AIDS Council; 2012.
18 Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG.
Universal voluntary HIV testing with immediate antiretroviral
therapy as a strategy for elimination of HIV transmission: a
mathematical model. Lancet. 2009;373(9657):48–57.

S A H R 20 1 6 219
220
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Towards a transparent pricing system in
South Africa: trends in pharmaceutical
18
logistics fees

Authors:
Varsha Bangalee i
Fatima Suleman i

PM
16 6
S 20 IL
outh Africa has instituted various mechanisms to render the pricing of Despite efforts to increase
pharmaceuticals more transparent, including the Single Exit Price (SEP) that
Y T
clarifies the price at which a manufacturer may sell a medicine to logistics transparency in the supply
A N
service providers or medicine dispensers. The SEP consists of an ex-manufacturer chain, prices reflected in
price, a logistics fee and Value Added Tax. However, as more countries look to South
South African medicine price
M U

Africa for lessons from its pricing policies, an understanding of the manufacturer’s
price, logistics fees and their relationship has become increasingly necessary to registries may not be a true
4 ED

support the principle that the SEP leads to more transparent prices. reflection of prices negotiated
This chapter provides a descriptive analysis of the pricing dynamics between the between manufacturers and
ex-manufacturer’s price and the logistics fee; a determination of the logistics fee
logistics service providers or
O

relationship to the number of manufacturers of a product; and an examination of

logistics fees among different therapeutic classes as well as the relationship to the distributors/wholesalers.
G

essential medicine status of a product within the therapeutic class.

R

The findings reveal that despite efforts to increase transparency in the supply chain,
prices reflected in South African medicine price registries may not be a true reflection
BA

of prices negotiated between manufacturers and distributors/wholesalers.

O

Initiatives to conduct larger, in-depth pharmaco-economics evaluations are

EM

required for a deeper understanding of market trends, particularly in terms of the

ex-manufacturer’s price and logistics fee: how they behave in different therapeutic
medicine classes and in response to changes in the patent status of medicines. These
findings should guide policy decisions and importantly, gauge market changes in
response to the various policies.

i Discipline of Pharmaceutical Sciences, School of Health Sciences, Universit y of KwaZulu- Natal

22 1
Introduction
The current landscape of the South African healthcare system has
to a large extent stemmed from the country’s previous political
dispensation. This history has resulted in gross inequality in access
to and affordability of health care in an already severely under-
resourced system grappling with a high disease burden.1 Post-
apartheid efforts to resolve this tenuous situation revolved around the
restructuring of the South African healthcare sector, which resulted
in the publication of the National Drug Policy in 1996.2 Among
the economic objectives of this policy has been the need to reduce
the cost of medicines in both the private and public sectors.2 To
meet these objectives, the policy document importantly included
the establishment of a ‘Pricing Committee’ tasked to monitor and
regulate medicine prices. The policy also highlighted the need
for “total transparency in the pricing structure of pharmaceutical
manufacturers, wholesalers, providers of services, such as dispensers
of drugs, as well as private clinics and hospitals”.2 Importantly,
these policies were intended to apply only to the private sector, as
16 6
medicines procurement in the public sector continued to be based on
20 IL
a national competitive tender process, limited to locally registered
products.3
Y T
Previously in the private sector, medicine price inflation, medicine
price transparency, and medicine price uniformity represented
A N
significant problems in an unregulated medicines market.4 The loss
of benefits to consumers resulting from the high levels of discounting
M U
and payment of incentives within the pharmaceuticals supply
chain had raised serious concerns in the National Department of
4 ED
Health (NDoH) and made it difficult to determine the true price
of a medicine.5 The introduction of government medicine pricing
interventions aimed at reducing the prices of medicines and
O
controlling the mark-ups instituted by the various stakeholders along
the entire supply chain from the manufacturer to the final medicine
G
dispenser, saw the prohibition of said discounts and rebates in the
pharmaceutical sector; mandatory offering of generic substitution;
R
the application of a Single Exit Price (SEP) from manufacturers
(which included a logistics fee for logistic service providers such
BA
as wholesalers or distributors); and a separate dispensing fee for
retailers.3,6,7
O
EM
After much challenge and repeated litigation in the South African
courts, the SEP was introduced in 2004, and was determined for
each medicine on the basis of the net value of sales, including
discounts from the previous year.3,8 Pharmaceutical manufacturers
make submissions to the NDoH for SEPs for new medicines. This
price is determined by the manufacturer and signifies a fixed price
at which manufacturers and importers have to sell medicines,
without an opportunity to offer discounts.9 The ex-manufacturer
price, logistics fee and Value Added Tax (VAT) constitute the three
components of the SEP. The SEP is adjusted on an annual basis and
these maximum annual increases are regulated.10
The final logistics fee, as submitted in the manufacturer application
for SEP or SEP adjustments, is available on a price list found
on the NDoH website. The logistics fee is determined through
negotiation between the manufacturer or importer and the logistic
service provider.9 The process and contracts are not made
public. Wholesalers and distributors are paid a logistics fee by
manufacturers, from the SEP; however, whether all logistic service
providers are able to negotiate the same fee or whether this fee is as
reflected in the medicines database is not evident.3
222 S A H R 20 1 6
Fundamentally, the objectives of attaining price transparency are
to improve economic efficiency; obtain accurate price information
to assist policymakers and researchers; empower buyers to
negotiate more strategically; and to hold pharmaceutical firms more
accountable for prices.11 Previous editions of the South African
Health Review have covered the development and implications
of pharmaceutical pricing policies.12–16 The most recent Health
Policy and Legislation chapter in the Review (2013/2014) also
briefly mentioned the progress of legislation in this area.17 Previous
Mediscor Medicines Reviews provide some information on generic
medicine use, and the effect of newly launched and expensive
medicines in the private sector market, as well as changes in SEP
for a basket of medicines.18,19 However, none of these reviews
PM
examined the impact of policy implementation on the prices of
medicines, or whether transparency has been achieved. Thus no
information exists as to the effect of SEP adjustments on logistics
fees, or whether increases in SEP reflect an increase in both the
ex-manufacturer price and logistics fee increases, on an annual
basis, as a result of increasing costs of doing business for both
manufacturers and wholesalers or distributors.
South Africa has undergone a number of policy changes
pertaining to supply chain and pharmaceutical pricing.12–17
Improved understanding and knowledge of the realities of the ex-
manufacturer price, and logistics fees and their relationship have
become increasingly necessary, especially in the light of published
policy, requesting comment for the regulation of the logistics fee
component of the SEP.20 In addition, a Gazette notice has been
issued for comment on suggested changes to what is perceived as
a bonus or a perverse incentive,21 which could impact on what is
being charged as a logistics fee, and might actually be considered
a discount. Should this Gazette be implemented, logistics fees will
have to be disclosed and be non-discriminatory.
Another proposed policy to reduce medicine prices is International
Benchmarking.3 The methodology implies that South African
medicine prices will be compared with those of a basket of countries.
The selection of the countries was based on a number of factors, one
being that the prices of the products in those countries were publicly
available. Should other countries want to include South Africa in
their basket of countries for benchmarking, South Africa would be
an attractive option due to the availability of the Medicines Pricing
database.
Finally, there is a move to introduce universal health coverage in South
Africa through National Health Insurance (NHI).22 Currently, in the
public sector, the government is responsible for providing essential
medicines for the South African population. Essential medicines can
be defined as those medicines that satisfy the priority healthcare
needs of the population, developed with careful consideration of
disease prevalence in South Africa, evidence of medicine efficacy
and safety, and comparative cost-effectiveness.23,24 Essential
medicines are not charged to patients as a separate fee in the public
sector. As mentioned, equity in health care for all South African
citizens was of fundamental importance in developing the National
Drug Policy, and the implementation of an Essential Medicine List
(EML) played a pivotal role in achieving this. Under NHI, the EML
may not operate solely in the current public sector but be included
under NHI-funded plans, which will incorporate a unified set of
 Pharmaceutical logistics

treatment guidelines and clinical pathways. While there is still
some way to go before the two sectors operate under a unified
NHI system, it would be interesting to understand how a medicine
deemed essential in the public sector is priced in terms of the SEP
(including the logistics fee) in the private sector under the current
system.
As a surrogate to determine transparency, the primary objectives of
this study were therefore to examine pricing dynamics between the
ex-manufacturer price and the logistics fee; to determine the logistics
fee relationship to the number of manufacturers of a product; and
to examine logistics fees among different medicine classes, as well
as the relationship to the essential medicine status of a product
within medicine classes. This investigation is also important for other
African countries referring to South Africa’s experience and lessons
The ex-manufacturer price, logistics fee and the SEP inclusive of
VAT for each sample medicine were recorded as at 20 December
2013. These results were investigated statistically using correlation
analysis to determine the relationship between the number of
manufacturers and the logistics fee as well as to make descriptive
comparisons in relation to medicine class and the logistics fee. The
essential medicine status as listed in the most recently published
Standard Treatment Guidelines and Essential Medicines List (EML)
for two levels,24,32,33 was recorded for each surveyed medicine to
elaborate on this relationship to the logistics fee.
The annual logistics fee as a percentage of the SEP of the originator
and lowest priced generic was compared to the consumer price
index (CPI). This was done for the years 2009–2013. The CPIs in
percentage, as obtained from Statistics South Africa, were 7.26

learnt in implementing pricing policies. African countries are seeking
to institute pricing interventions in order to improve the availability,
affordability and acceptability of medicine access,25,26 especially in
the supply and distribution chain.27
PM
(2009); 4.1(2010); 5.01(2011); 5.75 (2012) and 5.77 (2013).34
The CPI “expresses the current prices of a basket of goods and
services in terms of the prices during the same period in a previous
year, to show effect of inflation on purchasing power”.35 The CPI is a

16 6
measure of inflation. In Canada, the Canadian Patented Medicines
Prices Review Board sets maximum introductory prices for newly

20 IL
Methodology patented medications, and regulates the prices of medicines by
A cross-sectional descriptive study was undertaken to examine calculating a consumer price index adjustment factor.36,37 The CPI is
Y T
the SEPs for a basket of medicines over a five-year period. Data
used in the study were retrieved from the South African Medicine
also one of the measures that the Minister of Health should consider
when reviewing the SEP on an annual basis.38
A N
Price Registry on private sector prices for originator and generic
M U

medicines from 10 December 2009 to 20 December 2013.28

Results
The research was designed to focus on a set of acute and chronic
The changes in the SEP components for the originator and lowest-
4 ED

conditions that have been identified to cause significant morbidity

priced generic medicines were tracked for 50 medicines (see Table
and mortality globally. These include cardiovascular diseases,
1 for list of medicines).
diabetes, asthma, respiratory tract infections and mental illness.
O

The global core list of medicines generated by the World Health

Of these, 16 medicines did not have any generic competition. The
Organization and Health Action International (WHO/HAI) Medicine
relationship between the changes in ex-manufacturer price, logistics
G

Pricing Survey,29 plus medicines (in the same dosage form) in each
fee and SEP over the five-year period showed that the majority of
core medicine class in the South African Medicines Formulary,30
medicines surveyed could be grouped into one of two categories,
R

were selected for detailed analysis to elicit logistics fee comparisons

i.e. Trend 1 (Table 2) and Trend 2 (Table 3), which was demonstrated
between medicine classes.
BA

using quinapril as an example. Both tables reveal an anticipated

The SEP is made up of the ex-manufacturer price, logistics fee and steady increase in the SEP over the study period. However, they
O

VAT. VAT is charged at a standard 14% across the board and is differed with regard to changes in the ex-manufacturer price and
calculated from the sum of the ex-manufacturer price and the logistics fee components. Table 2, showing the trend observed for
EM

logistics fee and added to the combination of these two prices. 65.1% of medicines (of which 73.6% were originator medicines),
The ex-manufacturer price, logistics fee and the SEP for all selected revealed that it was common for the ex-manufacturer price to increase
medicines were collected and expressed in South African Rand. in proportion to the SEP, while the logistics fee remained constant or
These prices were obtained from the locked database and no further was slightly increased. Table 3, showing the trend apparent for only
price adjustments for that year were possible, i.e. all SEP adjustments 20.1% of medicines (of which 47.1% were originator medicines),
had been made for that year. The relationship between the three revealed that increases in the ex-manufacturer price were met with
variables over the five-year period was plotted for all originator proportional decreases in the logistics fee. The remaining 14.8%
medicines and the corresponding lowest-priced generic option, of medicines displayed trends that were different from both Table 2
where available in the dataset specific to that strength. To ensure and Table 3. These trends were not included as they also differed
commonality and consistency of results, the lowest-priced generic from each other, but they are available on request.
as at 10 December 2009 was chosen for each of the originator
medicines in order to display trends throughout the designated study
period. Data for the following originator medicines: indomethacin,
amoxicillin, trimipramine, cefotaxime and co-trimoxazole, were not
available for the entire study period and were therefore excluded.
The pricing data for paracetamol syrup (schedule zero) were not
included as schedule zero medications are currently exempt from
pricing regulations in South Africa.31

S A H R 20 1 6 223
Table 1: Summary of trends for 50 medicines surveyed from 10 December to 20 December 2013

Medicine Class Medicine Patent status Trend 1 Trend 2 Neither

Trend 1 or 2
Short-acting beta 2 agonists Terbutaline 0.5mg/dose INH Originator x
Lowest-priced generic None available
Fenoterol 100mcg/dose INH Originator x
Lowest-priced generic None available
Salbutamol 100mcg/dose INH Originator x
Lowest-priced generic x
Beta1 selective beta blockers Nebivolol 5mg tab Originator x
Lowest-priced generic x
Metoprolol 100mg tab Originator x
Lowest-priced generic None available
Bisoprolol 5mg tab Originator x
Lowest-priced generic x

PM
Acebutolol 200mg cap Originator x
Lowest-priced generic None available
Atenolol 50mg tab Originator x
Lowest-priced generic x

16 6
Proton pump inhibitors Rabeprazole 20mg tab Originator x
Lowest-priced generic None available

20 IL
Pantoprazole 40mg tab Originator x
Lowest-priced generic x
Y T
Esomeprazole 20mg tab Originator
Lowest-priced generic
x
None available
A N
Lansoprazole 30mg cap Originator x
Lowest-priced generic x
M U

Omeprazole 20mg cap Originator x

Lowest-priced generic x
4 ED

HMG CoA reductase inhibitors Simvastatin 20mg tab Originator x

Lowest-priced generic x
Atorvastatin 10mg tab Originator x
Lowest-priced generic x
O

Fluvastatin 80mg tab Originator x

Lowest-priced generic None available
G

Lovastatin 40mg tab Originator x

Lowest-priced generic None available
R

Pravastatin 40mg tab Originator x

BA

Lowest-priced generic x
N

Rosuvastatin 5mg tab Originator x

O

Lowest-priced generic x
Sulphonylureas Gliclazide 80mg tab Originator x
EM

Lowest-priced generic x
Glimepiride 4mg tab Originator x
Lowest-priced generic x
Glipizide 5mg tab Originator x
Lowest-priced generic None available
Glibenclamide 5mg tab Originator x
Lowest-priced generic x
Fluoroquinolones Ciprofloxacin 500mg tab Originator x
Lowest-priced generic x
Moxifloxacin 400mg tab Originator x
Lowest-priced generic x
Levofloxacin 250mg tab Originator x
Lowest-priced generic x
Gemifloxacin 320mg tab Originator x
Lowest-priced generic None available
Norfloxacin 400mg tab Originator x
Lowest-priced generic x
Ofloxacin 400mg tab Originator x
Lowest-priced generic x

224 S A H R 20 1 6
 Pharmaceutical logistics

Medicine Class Medicine Patent status Trend 1 Trend 2 Neither

Trend 1 or 2
Acetic acid derivatives Diclofenac 50mg tab Originator x
Lowest-priced generic x
Ketorolac 10mg tab Originator x
Lowest-priced generic None available
Angiotensin-converting enzyme Enalapril 5mg tab Originator x
inhibitors Lowest-priced generic x
Fosinopril 20mg tab Originator x
Lowest-priced generic x
Trandolapril 2mg cap Originator x
Lowest-priced generic None available
Perindopril 4mg tab Originator x
Lowest-priced generic x
Ramipril 1.25mg tab Originator x

PM
Lowest-priced generic x
Quinapril 5mg tab Originator x
Lowest-priced generic x
Captopril 25mg tab Originator x

16 6
Lowest-priced generic x
Benazepril 10mg tab Originator x

20 IL
Lowest-priced generic None available
Lisinopril 5mg tab Originator x
Lowest-priced generic x
Long-acting Benzodiazepines
Y T
Diazepam 5mg tab Originator
Lowest-priced generic
x
x
A N
Flurazepam 30mg cap Originator x
M U

Lowest-priced generic None available

Chlordiazepoxide 25mg tab Originator x
Lowest-priced generic None available
4 ED

Tricyclic antidepressants Amitriptyline 25mg tab Originator x

Lowest-priced generic x
Clomipramine 25mg tab Originator x
O

Lowest-priced generic x
Dosulepin 25mg tab Originator x
G

Lowest-priced generic x
Imipramine 25mg tab Originator x
R

Lowest-priced generic x
Lofepramine 70mg tab Originator x
BA

Lowest-priced generic None available

Third-generation Cephalosporins Ceftazidime 500mg inj Originator x
O

Lowest-priced generic x
EM

Ceftriaxone 1g inj Originator x

Lowest-priced generic x

Note: INH – inhaler, tab – tablet, cap – capsule, inj – injection.

Table 2: Distribution of SEP, ex-manufacturer fee and logistics Table 3: Distribution of SEP, ex-manufacturer price and logistics
fee over five years, where the logistics fee is constant fee over five years, where there is an inverse relationship
(quinapril – originator) to the logistics fee (quinapril – generic)

Ex-manufacturer Ex-manufacturer
Year price Logistics fee SEP Year price Logistics fee SEP
2009 78.35 5.09 95.12 2009 41.02 4.35 51.72
2010 78.35 5.09 95.12 2010 41.02 4.35 51.72
2011 85.95 5.59 104.36 2011 41.02 4.35 51.72
2012 85.95 5.59 104.36 2012 43.72 2.62 52.83
2013 90.94 5.91 110.41 2013 46.25 2.78 55.89

All prices are in Rand. All prices are in Rand.

S A H R 20 1 6 22 5
Table 4: Median SEP components as at 20 December 2013a

Disease Medicine Class Medicine Name/Strength/ Median Median No. of EML

Dosage Form Log/SEP Ex-Man/ Manufacturers
(%) SEP (%)
Asthma Short-acting beta 2 agonists Terbutaline 0.5mg/dose INH 2.97 84.76 1 N
Fenoterol 100 mcg/dose INH 7.76 79.97 1 N
Salbutamol 100mcg/dose INH 5.37 82.37 3 Y
Cardiovascular Beta1 selective beta blockers Nebivolol 5mg tab 9.61 78.12 2 N
disease Metoprolol 100mg tab 6.22 81.5 1 N
Bisoprolol 5mg tab 8.78 78.95 6 N
Acebutolol 200mg cap 3.98 83.75 1 N
Atenolol 50mg tab 10.94 76.79 10 Y
Ulcer Proton Pump Inhibitors Rabeprazole 20mg tab 10.22 77.51 1 N
Pantoprazole 40mg tab 10.07 77.66 7 N
Esomeprazole 20mg tab 2.97 84.76 1 N

PM
Lansoprazole 30mg cap 7.90 79.83 9 N
Omeprazole 20mg cap 10.44 77.29 7 Y
Cardiovascular HMG CoA Reductase Inhibitors Simvastatin 20mg tab 8.78 78.95 18 Y
disease Atorvastatin 10mg tab 9.61 78.12 10 N

16 6
Fluvastatin 80mg tab 6.22 81.5 1 N
Lovastatin 40mg tab 13.16 74.57 1 N

20 IL
Pravastatin 40mg tab 13.16 74.57 4 N
Rosuvastatin 5mg tab 8.78 78.95 3 N
Diabetes Sulphonylureas Y T Gliclazide 80mg tab 8.37 79.35 8 Y
Glimepiride 4mg tab 8.78 78.95 9 N
A N
Glipizide 5mg tab 5.36 82.37 1 N
Glibenclamide 5mg tab 11.19 76.54 4 Y
M U

Infectious disease Fluoroquinolones Ciprofloxacin 500mg tab 8.78 78.95 17 Y

Moxifloxacin 400mg tab 9.09 78.64 6 Y
Levofloxacin 250mg tab 10.97 76.76 5 N
4 ED

Gemifloxacin 320mg tab 13.16 74.57 1 N

Norfloxacin 400mg tab 7.64 80.09 4 N
Ofloxacin 400mg tab 10.97 76.76 3 N
O

Pain/inflammation Acetic Acid Derivatives Diclofenac 50mg tab 10.92 76.83 6 Y

Indomethacin 25mg cap 10.44 77.29 7 Y
G

Ketorolac 10mg tab 8.32 79.41 1 N

Infectious disease Sulphonamide and Trimethoprim Co-trimoxazole 240mg/5mL susp 9.06 78.64 8 Y
R

Combination
Pain/inflammation Anilides Paracetamol 120mg/5mL syr 11.28 76.45 4 Y
BA

Cardiovascular Angiotensin-converting enzyme Enalapril 5mg tab 10.17 77.54 4 Y

disease inhibitors Fosinopril 20mg tab 11.49 76.2 3 N
O

Trandolapril 2mg cap 9.69 78.03 1 N

EM

Perindopril 4mg tab 7.98 79.75 4 N

Ramipril 1.25mg tab 10.97 76.76 2 N
Quinapril 5mg tab 5.17 82.56 2 N
Captopril 25mg tab 12.64 75.09 8 Y
Benazepril 10mg tab 6.22 81.5 1 N
Lisinopril 5mg tab 10.97 76.76 8 N
Central nervous Long-acting Benzodiazepines Diazepam 5mg tab 12.06 75.68 4 Y
system Flurazepam 30mg cap 7.25 80.48 1 N
Chlordiazepoxide 25mg tab 7.25 80.48 1 N
Depression Tricyclic Antidepressants Amitriptyline 25mg tab 10.97 76.76 4 Y
Clomipramine 25mg tab 7.8 79.93 3 N
Dosulepin 25mg tab 11.49 76.24 1 N
Imipramine 25mg tab 10.97 76.76 2 N
Lofepramine 70mg tab 8.16 79.57 1 N
Trimipramine 25mg tab 13.16 74.57 1 N
Dothiepin 75mg tab 13.59 74.14 2 N
Infectious disease Aminopenicillin Amoxycillin 500mg cap 8.38 79.35 16 Y
Infectious disease Third-generation Cephalosporins Ceftazidime 500mg inj 13.61 74.1 2 Y
Cefotaxime 500mg inj 12.3 75.42 4 Y
Ceftriaxone 1g inj 8.77 78.95 13 Y

226 S A H R 20 1 6
 Pharmaceutical logistics

Table 4 reflects the median logistics fees and median ex-manufacturer
price expressed as a percentage of the SEP for each medicine in the
selected class, together with the total number of manufacturers and
EML status as at 20 December 2013.
The results reveal that there were large variations in the logistics fee
components between all classes of medicines, and that the median
spread of the logistics fee increased as the number of medicines
available in each class increased. Overall, a weak correlation
exists between the number of manufacturers and the logistics fee for
each medicine in a class (Pearson’s correlation coefficient r=0.09);
however, this does not necessarily indicate that logistics fees are
not levied as a means of introducing final price competition. This
phenomenon may actually be class-dependent, as it was noted
that medicines with the highest logistics fee component were also
The findings revealed that for the majority of surveyed medicines
(74.4%; n=61), the logistics fee/SEP percentage (as indicated in
the medicines price database) was generally above the CPI for each
year. Of the remaining medicines that were below the CPI (25.6%,
n = 21), all except four were originator medicines.
Of the 258 medicines surveyed, four medicines, namely fosinopril,
bisoprolol, pantoprazole and moxifloxacin, also had clones
manufactured by the originator company. Table 5 shows the
differences in the SEP components of these medicines as at 20
December 2013.
Apart from bisoprolol, both the ex-manufacturer price and the
logistics fee for the originator medicine were higher than those for
the respective clone, but the percentage of logistics fee and ex-

the medicines that had limited competition (1–2 manufacturers)
in certain medicine classes only, i.e. short-acting beta2 agonists,
fluoroquinolones, tricyclic antidepressants and third-generation
cephalosporins.
PM
manufacturer price of the SEP remained the same or quite similar.
The ex-manufacturer price and the logistics fee for the highest-priced
generics for each of the medicines in Table 5 were lower than those
for the originator and the clone.

16 6
Medicines on the EML represent those that had the highest number
Discussion

20 IL
of different manufacturers in every medicine class surveyed. In
most instances, they also had median logistics fees higher than the
The price of medicines has long been established as an important
logistics fee of other medicines in their group, with the exception
Y T measure in ensuring medicine accessibility.39 however, the pricing of
of the following medicine classes: tricyclic antidepressants,
medicines is reliant on policies unique to each country. South Africa’s
A N
fluoroquinolones, HMG CoA reductase inhibitors and short-acting
efforts in trying to achieve accessible and affordable medicines in
beta2 agonists.a
the private sector have been described as anticompetitive by several
M U

Overall, the ex-manufacturer price and logistics fees relative to the industry players.40,41 Despite the benefits of increased transparency,
SEP varied widely across all medicine classes studied. The results empirical evidence has shown that highly regulated markets with
4 ED

show that 54.4% of the median logistics fee segment were less than low medicine prices may have unintended consequences.42–44
10%. As a medicine class, third-generation cephalosporins had the Price regulation, specifically price ceilings, may result in perverse
highest median logistics fee segment at 12.3%.
O

Table 5: Price component comparisons of originator, clones and the highest-priced generic medicines (20 December 2013)
G

Ex-
Logistics Log/ SEP Ex-man/SEP
Medicine manufacturerer’s VAT SEP Unit SEP
R

fee (lc) (%) (%)

fee
Fosinopril 20mg tab
BA

Originator 169.34 25.54 27.28 222.16 7.41 11.49 76.22

Originator generic 149.79 23.08 24.2 197.08 6.57 11.71 76
O

Highest-priced generic 124.38 7.46 18.46 150.31 5.01 4.96 82.75

EM

Bisoprolol 5mg tab

Originator 74.04 7.58 11.43 93.05 3.1 8.15 79.57
Originator generic 74.04 7.58 11.43 93.05 3.1 8.15 79.57
Highest-priced generic 39.93 5.99 6.43 52.35 1.75 11.44 76.28
Pantoprazole 40 tab
Originator 306.64 39.75 48.49 394.89 14.1 10.07 77.65
Originator generic 191.25 25.82 30.39 247.45 8.84 10.43 77.29
Highest-priced generic 184.46 23.90 29.17 237.54 8.48 10.06 77.66
Moxifloxacin 400mg tab
Originator 334.13 30.98 51.12 416.23 41.62 7.44 80.28
Originator generic 241.21 28.95 37.82 307.98 30.79 9.39 78.32
Highest-priced generic 243.14 27.02 37.82 307.98 30.79 8.77 78.95

All prices are in Rand.

a INH – inhaler, tab – tablet, cap – capsule, susp – suspension, syr – syrup,
inj – injection, Log – logistics fee, Ex-man – Ex-manufacturer, EML – essential
medicines list.
All manufacturer medicines on the NDoH tender list were considered for
the study in the same strength, dosage form and pack size as the originator
medicine.
VAT averaged 14% of the SEP for all medicines surveyed

S A H R 20 1 6 227
economic effects for businesses.45 Consequently, business may be
forced to take other actions to recover their lost profits. This may have
been the case in South Africa, post-SEP implementation, when firms
possibly altered the logistics fee to recover profits lost from changes
in the ex-manufacturer price, or created market incentives by paying
higher logistics fees to create an economic incentive to market
their products. It was previously cited that originator companies
with no other generic competition often paid low or no logistics
fees to wholesalers who were desperate to stock their products. This
placed generic companies at a disadvantage, as wholesalers would
often ‘squeeze’ them for higher logistics fees to make up for the
loss sustained in dealings with originator companies.46 However,
the occurrence of this may be class-dependent, as observed in the
current study.
The results of this study indicate that the number of manufacturers
was not a determinant of the logistics fee component of the SEP for
the majority of the medicine classes surveyed, and that EML status
generally resulted in higher logistics fee components. Furthermore,
16 6
the dynamics between the ex-manufacturer price and the logistics fee
do not follow expected market trends, according to which they should
20 IL
ideally increase collectively as they are both exposed to the same
inflationary pressures over time. These findings confirm arguments
Y T
that the ex-manufacturer price and logistics fee reflected in the
medicines database are not the actual and accurate representation
A N
of the fees negotiated by manufacturers and wholesalers.
M U
The results reflected in Tables 2, 3 and 4 are consistent for a country
like South Africa, where although the SEP is transparent, the ex-
4 ED
manufacturer price and the logistics fee component of this price are
not; therefore, the mark-ups in the distribution chain are not very
clear. Manufacturers could also be using a higher logistics fee to
incentivise wholesalers and distributors to stock their products and
O
thus create the push for their products down the chain. The logistics
G
fee has previously been quoted as generally being between 10%
and 15% of the final price in an unregulated market.43 Slightly more
R
than half of the medicines in this study had a reported logistics fee of
less than 10%. The results show that despite the similarity in the type
BA
of products (dosage form and storage conditions), medicines still do
not attract the same logistics fees.
O
As mentioned, the ex-manufacturer price/cost represents the highest
EM
segment of the final selling price, or in South Africa’s case, the SEP.
According to IMS Health Incorporated, the ex-manufacturer price
is associated with manufacturers, particularly originators, needing
to recover costs associated with initial research and development,
as well as regulatory approval, marketing and production, among
other factors (including a profit margin), which further differ
between types of medicine, manufacturers and countries.47 Generic
manufacturers, however, generally have relatively low development
and manufacturing costs, which was also evident in this study,
even between originator medicines and their clones.47 One would
expect that even though the ex-manufacturer price is likely to differ,
the logistics fee should be the same, as is observed for bisoprolol
tablets. A valid recommendation stemming from this and previous
studies is the implementation of uniform distribution fees for similar
products, with clear stipulation of distribution costs and activities
applied to all stakeholders.7,48
228 S A H R 20 1 6
One would expect that both the ex-manufacturer price and the
logistics fee would increase, as they are both exposed to the same
CPI changes, while the ex-manufacturer prices might increase more
due to international currency fluctuations. In 2014, the Pricing
Committee considered various inflators for different medicines,
whether these were generic medicines (fully imported or locally
produced) or originator medicines.38 The premise was that the cost
pressure for each of these medicines would be different and that
the extent to which each would be affected by inflation and the
exchange rate would also differ.38 This is also evident when looking
at the differences in logistics fees between originator medicines and
their clones as one would expect these to be identical; however, our
findings show that they do differ in certain instances. This could be
to ensure that prices are more competitive than those being set by
the generic medicines.
PM
Results reveal that as a class, no particular medicine group
uniformly displayed high or low logistics fee components. Instead
they displayed a spread of logistics fees depending on either the
EML status of the medicine or the number of manufacturers. The
differences in logistics fees could be attributed to a range of
factors, including differences in product type, product categories in
operation and labour requirements attached to different medicines.
However, this is a further illustration that the logistics fees disclosed
on the database are not the actual fees paid.
There is room for greater transparency with regard to logistics fees
for medicines in South Africa. Allegations of exploitation of the
logistics fee by pharmaceutical companies have led to the proposed
cap on the logistics fee as opposed to a fixed fee.49 This policy will,
however, require monitoring on implementation to ascertain whether
it is feasible. Transparency in this segment of the supply chain should
be strived for, and could possibly be achieved through logistics fee
contracts being made public, or through negotiations between the
National Department of Health and wholesalers and distributors.7
Considering all of the evidence on price transparency, the majority
of the empirical studies have found that greater price transparency
leads to lower and more uniform prices.42 Furthermore, price
competition through discounts in the supply chain is not transparent
or fair, as distributors are not rewarded for services rendered, but for
their ability to negotiate discounts. Such systems are not sustainable
in the long term, as healthcare payers and patients do not capture
the envisaged potential savings from a generic medicines market
where companies compete on price.49
South Africa has already begun the process of implementing several
of the recommendations made by the World Health Organization
in relation to the regulation of mark-ups in the pharmaceutical
supply and distribution chain.44 However, these processes can be
further strengthened by attaining complete transparency in the price
components of the SEP. South Africa currently applies an umbrella
policy to all medicines, but should also consider applying such
policies to select medicine groups only, noting that not all medicines
share the same heath benefit or status, e.g. essential medicines. The
South African EML identifies the minimum medicines that patients
should have access to; these are the “most efficacious, safe and
cost-effective medicine for priority conditions”.23,24 It is therefore
imperative to ensure that these medicines are attainable and
affordable at all times, and that they are subjected to tighter pricing
and margin regulations.
 Pharmaceutical logistics

It is important to note that a potential future role for logistics service

providers exists under NHI. These providers could be used to supply
medicines to public health facilities as a departure from the current
Medicine Depot model. As such, it is necessary for a supply chain
to be sustainable in the private sector in order to ensure that these
systems exist for NHI.

The actual contractual agreements for logistics fees are not in the
public domain and could not be used to compare reported trends
with actual trends.

Recommendations
Research on SEP reveals gaps in the literature regarding how
the various players in the supply chain have adjusted their daily

PM
practices to survive imposed policies. It is therefore recommended
that more qualitative research (documenting the views of the various
stakeholders) be undertaken, as well as quantitative research to
determine whether the logistics fees reflected on the NDoH website

16 6
are a true reflection of the prices actually being paid.

20 IL
The results of this study foreground a dire need for more robust
information on medicine pricing in the South African pharmaceutical
sector to guide further policy decisions, gauge market changes in
Y T
response to the various policies, and ensure transparent pricing.
A N
These results are important in that they aid policymakers in selecting
and implementing policies that will make medicines more inexpensive
M U

for patients, whilst ensuring the viability of the supply chain, rather
than merely instituting an umbrella policy that will interfere with
4 ED

regular market competition and dynamics. While many studies have

looked at benchmarking, very few studies have investigated the
implementation and impact of distribution chain fees. This aspect
O

is also not made transparent to all stakeholders. Whilst the SEP is

transparent, the components other than VAT remain opaque and this
G

is further highlighted by the NDoH’s efforts to regulate the logistics

fee, introduce international benchmarking, remove further discounts
R

and bonuses, and conduct pharmaco-economic evaluations.

BA

N
O
EM

S A H R 20 1 6 22 9
References
1 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D.
The health and health system of South Africa: historical
roots of current public health challenges. Lancet.
2009;374(9692):817–34.
2 South African National Department of Health. National Drug
Policy for South Africa. Pretoria: National Department of
Health;1996. [Internet]. [cited 23 March 2016].
URL: http://www.doh.gov.za/docs/policy/drugsjan1996.pdf
3 Gray A, Suleman F. Pharmaceutical Pricing in South Africa.
Pharmaceutical Prices in the 21st Century. New York: Springer
Publishing Company; 2015:p.251–65.
4 Carapinha & Company. Single Exit Price legislation: A source
of harm to competition. [Internet]. [cited 23 March 2016].
URL: http://www.carapinha.com/single-exit-price-legislation-a-
source-of-harm-to-competition/#sthash.nXKTewtG.dpuf
5 Bangalee V, Suleman F. Has the increase in the availability
of generic drugs lowered the price of cardiovascular drugs in
South Africa? Health SA Gesondheid. 2016;21:60–6.
16 6
6 Williams K. Pharmaceutical price regulation. S Afr J Hum
Rights. 2007;23(1):1–33. [Internet]. [cited 23 March 2016].
20 IL
URL: http://reference.sabinet.co.za/webx/access/
electronic_journals/ju_sajhr/ju_sajhr_v23_n1_a1.pdf
7 Bangalee V, Suleman F. Evaluating the effect of a proposed
Y T
logistics fee cap on pharmaceuticals in South Africa – a pre-
and post-analysis. BMC Health Serv Res. 2015;15:522.
A N
8 Gray AL. Medicine pricing interventions – the South African
M U
experience. Southern Med Review. 2009;2(2):15–9.
9 Republic of South Africa. Medicines and Related Substances
4 ED
Act (101 of 1965). [Internet]. [cited 23 march 2016].
URL: http://www.mccza.com/documents/Integrated%20
Act%20101.zip
10 Pretorius D. The impact of the implementation of single
O
exit pricing for pharmaceuticals in South Africa. Master of
Business Administration, University of the Witwatersrand,
G
Johannesburg. 2011.
11 Kemp K, Schondelmeyer S. Role of price transparency in the
R
pharmaceutical market. In proceedings of Pharmaceutical
Pricing Practices, Utilization, and Costs Conference: Pricing
BA
N
practices in the pharmaceutical market. Washington, USA.
2000. [Internet]. [cited 23 March 2016].
O
URL: http://aspe.hhs.gov/health/reports/drug-papers/
Kemp1.htm#TOC
EM
12 Summers R, Suleman F. Drug Policy. In: Harrison D, Barron
P, Edwards J, editors. South African Health Review 1997.
Durban: Health Systems Trust; 1997.
13 Gray A, Eagles P. Drug policy. In: Barron P, editor. South
African Health Review 1997. Durban: Health Systems Trust;
1997.
14 Gray A. Equity and the provision of pharmaceutical services.
In: Ntuli A, editor. South African Health Review 1998.
Durban: Health Systems Trust; 1998.
15 Gray A, Suleman F. Drug policy – From macro development
to health district implementation. In: Crisp N, Ntuli A, editors.
South African Health Review 1999. Durban: Health Systems
Trust; 1999.
16 Gray A, Matsebula T. Drug pricing. In: Crisp N, Ntuli A,
Clarke E, editors. South African Health Review 2000. Durban:
Health Systems Trust; 2001.
17 Gray A, Vawda Y. Health Policy and Legislation. In:
Padarath A, English R, editors. South African Health Review
2013/2014. Durban: Health Systems Trust; 2014.
23 0 S A H R 20 1 6
18 Mediscor. Mediscor Medicines Review 2013. Johannesburg.
[Internet]. [cited 23 March 2016].
URL: http://www.mediscor.net/MMR/Mediscor%20
Medicines%20Review%202013.pdf
19 Mediscore. Mediscor Medicines Review 2014. Johannesburg.
[Internet]. [cited 23 March 2016].
URL: http://www.mediscor.net/MMR/Mediscor%20
Medicine%20Review%202014.pdf
20 Republic of South Africa. Medicines and Related Substances
Act 101 of 1965: Regulation No. 9830 – Regulations relating
to a transparent pricing system for medicines and scheduled
substances: Logistics fee component of a Transparent Pricing
System. Government Gazette Vol. 567, No. 35699, 18
September 2012. [Internet]. [cited 10 March2016].
URL: http://www.gpwonline.co.za/Gazettes/
PM
Gazettes/35699_18-9_Health.pdf
21 Republic of South Africa. Medicines and Related Substances
Act 101 of 1965: General regulations relating to bonusing
and sampling. Government Notice No. R 642, 22 August
2014. [Internet]. [cited 23 March 2016].
URL: http://www.gov.za/sites/www.gov.za/files/37936_
rg10251_gon642.pdf
22 Republic of South Africa. National Health Insurance for South
Africa. Pretoria: National Department of Health; 10 December
2015. [Internet]. [cited 23 March 2016].
URL: http://www.health-e.org.za/wp-content/
uploads/2015/12/National-Health-Insurance-for-South-Africa-
White-Paper.pdf
23 World Health Organization. WHO Model List of Essential
Medicines: 18th list, April 2013. [Internet]. [cited 23 march
2016].
URL: http://www.who.int/medicines/publications/
essentialmedicines/18th_EML_Final_web_8Jul13.pdf
24 South African National Department of Health. Hospital level
adults: Standard treatment guidelines and essential drugs list.
Pretoria: National Department of Health; 2012.
25 Mhlanga BS, Suleman F. Price, availability and affordability of
medicines. Afr J Prim Health Care Fam Med. 2014;6(1).
26 Shabangu K, Suleman F. Medicines availability and resultant
patient impact at a Swaziland hospital. Afr J Prim Health Care
Fam Med. 2015;7(1):829. [Internet]. [cited 23 March 2016].
URL: http://dx.doi.org/10.4102/phcfm.v7i1.829
27 Tetteh E. Creating reliable pharmaceutical distribution
networks and supply chains in African countries:
Implications for access to medicines. Res Social Adm Pharm.
2009;5(3):286–97.
28 South African National Department of Health. South African
Medicine Price Registry. [Internet]. [cited 23 March 2016].
URL: http://www.mpr.gov.za/.
29 World Health Organization; Health Action International.
Measuring medicine prices,availability, affordability and price
components. 2008. [Internet]. [cited 23 March 2016].
URL: http://www.haiweb.org/medicineprices/
30 Division of Clinical Pharmacology, Faculty of Health Sciences,
University of Cape Town. South African Medicines Formulary.
Cape Town: Health and Medical Publishing Group; 2012.
31 Republic of South Africa. Medicines and Related Substances
Act 101 of 1965: Regulation No. 9965 – Exclusion of certain
medicines from the operation of certain provisions of the Act.
Government gazette Vol. 575, No. 36507, 29 May 2013.
[Internet]. [cited 23 March 2016].
URL: http://www.samed.org.za/Filemanager/userfiles/
News/Regulation%20Gazette%20Medicines%20and%20
Related%20Substances%20Act.pdf
 Pharmaceutical logistics

32 South African National Department of Health. Hospital level
paediatric: Standard treatment guidelines and essential drugs
list. Pretoria: National Department of Health; 2013.
33 South African National Department of Health. Primary health
care level Standard Treatment Guidelines and Essential Drugs
List. Pretoria: National Department of Health; 2014.
34 Statistics South Africa. [Internet]. [cited 23 March 2016].
URL: www.statssa.gov.
35 Business Dictionary.com. [Internet]. [cited 23 March 2016].
URL: http://www.businessdictionary.com/definition/
consumer-price-index-CPI.html
36 Patented Medicines Prices Review Board. 2014 CPI-Based
Price-Adjustment Factors. 2015. [Internet]. [cited 23 March
2016].
URL:http://www.pmprbcepmb.gc.ca/view.
asp?ccid=1145&lang=en#a7
47 IMS Institute for Healthcare Informatics. Understanding the
pharmaceutical value chain. IMS Health Incorporated and its
affiliates. 2014. [Internet]. [cited 23 March 2016].
URL: http://www.imshealth.com/imshealth/Global/
Content/Corporate/IMS%20Health%20Institute/Insights/
Understanding_Pharmaceutical_Value_Chain.pdf
48 Xiphu L, Mpanza N. Medicine prices survey in the Gauteng
Province in South Africa. Pretoria: National Department of
Health; 2004. [Internet]. [cited 23 March 2016].
URL: http://www.haiweb.org/medicineprices/
surveys/200411ZAG/survey_report.pdf
49 Board of Healthcare Funders of Southern Africa. Health sector
inquiry: Pharmaceutical task group’s response to third party
submissions concerning the pharmaceutical sector. [Internet].
[cited 10 March 2016].
URL: https://www.google.co.za/?rlz=1W4CHBB_enZA577#
q=healthcare+sector+inquiry+pharmaceutical+task+group%E

PM
2%80%99s+response+to+third+party+submissions+citation
37 Lexchin J. The siren call of new drugs. Expert Rev
Pharmacoeconomics Outcomes Res. 2003;3(5):513–5.
38 Republic of South Africa. Medicines and Related Substances

16 6
Act 101 of 1965: Regulations relating to a transparent pricing
system for medicines and scheduled substances: Comment

20 IL
notice on the annual adjustment of the single exit price of
medicines and scheduled substances for the year 2015.
Government Gazette No. R 536, 8 July 2014. [Internet].
[cited 23 March 2016]. Y T
URL: http://www.gov.za/sites/www.gov.za/files/37816_
rg10231_gon536.pdf
A N
39 Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R.
M U

Medicine prices, availability, and affordability in 36

developing and middle-income countries: a secondary
analysis. Lancet. 2009;373(9659):240–9.
4 ED

40 Davie EG, Urbach J. Comment to the Department of Health

in response to Government Gazette No. 28214 of 11
November 2005 (Notice No. 2007 of 2005).Determination
O

of a maximum logistics fee. Johannesburg:The Free Market

Foundation of Southern Africa;2006. [Internet]. [cited 23
March 2016].
G

URL: http://www.healthpolicyunit.org/downloads/
logisitcs_fee.pdf
R

41 Buthelezi L. Health rules ‘threaten suppliers’. The Star, Business

Report. 29 August 2011.
BA

42 Austin DA, Gravelle JG. Does price transparency improve

O

market efficiency? Implications of empirical evidence in other

markets for the health sector. 2007. [Internet]. [cited 23
EM

March 2016].
URL: https://www.fas.org/sgp/crs/misc/RL34101.pdf
43 Ball D. The regulation of mark-ups in the pharmaceutical
supply chain. WHO/HAI Project on Medicine Prices and
Availability, Review Series on Pharmaceutical Pricing Policies
and Interventions, Working Paper 3. 2011. [Internet]. [cited
23 March 2016].
URL: http://www.haiweb.org/medicineprices/05062011/
Mark-ups%20final%20May2011.pdf
44 World Health Organization. WHO guideline on country
pharmaceutical pricing policies. Geneva: World Health
Organization; 2013. [Internet]. [cited 23 March 2016].
URL: http://www.ncbi.nlm.nih.gov/books/NBK258631/
45 Knittel CR, Stango V. Price ceilings as focal points for
tacit collusion: evidence from credit cards. Am Econ Rev.
2003;1703–29.
46 Ngozwana S. Policies to control prices of medicines: Does
the South African experience have lessons for other African
countries? In: Mackintosh M, Banda G, Tibandebage P,
Wamae W, editors. Making Medicines in Africa – The
political economy of industrializing for local health.
Basingstoke: Palgrave Macmillan; 2016. p.214.

S A H R 20 1 6 23 1
232
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
 EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM

233
Information
 Information

23 4
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
The development of a National Health
Research Observatory in South Africa:
19
considerations and challenges

Authors:
Nobelungu J. Mekwa i Ashley Van Niekerk i,ii
Edith N . Madela-Mntla i,iii Mohammed Jeenah i

PM
Glaudina Loots i,iv Bongani M . Mayosi i,v

16 6
H 20 IL
ealth research observatories are globally recognised proactive institutions The National Health Research
that provide appropriate evidence-based information to guide policy-making
Y T
decisions in a country, thereby improving health care. The World Health Committee has undertaken to
A N
Organization has recommended the development of national and regional research establish the National Health
and development observatories to ensure relevant, timeous and credible information
Research Observatory as a
M U

on current and emerging health research priorities and impact on health responses
and interventions, including allocation of resources and their scope and location. comprehensive information
4 ED

This chapter describes the vision, mandate, purpose, scope and benefits of a and translation system to
proposed health research observatory, as well as the key challenges, in order to enable the national co-
stimulate awareness and generate local interest among and participation by the
ordination and integration
O

health research community and relevant stakeholders in South Africa.

of research and health
G

The National Health Research Committee (NHRC) has undertaken to establish

the National Health Research Observatory as a comprehensive information and information from the country’s
R

translation system to enable the national co-ordination and integration of research multiple research platforms
and health information from the country’s multiple research platforms.
BA

Potential challenges inherent in this undertaking include legislative inadequacies that

O

could limit the NHRC authority over public entities, and the autonomy of research
EM

institutions such as universities where conflicts of interest may cause and perpetuate
barriers to vital research-related information.

i National Health Research Committee, South African National Department of Health

ii Violence, Injury and Peace Research Unit, South African Medical Research Council and Universit y of South Africa
iii International Council for Science, Regional Office for Africa
iv Health Innovation, Department of Science and Technology
v Department of Medicine, Universit y of Cape Town

235
Introduction
Health research observatories have emerged in a number of countries
such as the Lebanese Observatory for Research, Development and
Innovation; the Lattes Platform in Brazil; and the National Institute for
Health Care and Excellence (NICE) in the United Kingdom. These
institutions function through the secondary use and integration of
existing or routinely gathered research information towards the
support of public health policy decision-making.1 The World Health
Organization (WHO) AFRO Region Consultative Expert Working
Group has recommended the development of national and regional
research and development (R&D) observatories to member countries
to ensure relevant, timeous and credible information on current and
emerging health research priorities and impact on health responses
and interventions, including allocation of resources and their scope
are purely passive is incorrect. Rather, observatories are proactive
investigators, providing information to inform policy-making,
decisions and resource allocation.
Three key terms should be defined in order to understand the
concept of a health research observatory, namely: health research,
health research system, and research for health.
The Global Forum for Health Research (GFHR) defines ‘health
research’ as a process for obtaining systematic knowledge and
technology that can be used to improve the health of individuals or
groups to reduce inequalities in health.10
A ‘health research system’ is defined as a system for planning, co-
ordinating, monitoring and managing health research resources and

and location.2–5
In response to its legislative mandate, South Africa’s National Health
Research Committee (NHRC) convened a summit in July 2011 to set
PM
activities, and for promoting research for effective and equitable
national development.
The term ‘research for health’ connotes that improving health

16 6
priorities for health research and to address the strategic priorities
outcomes requires the involvement of many sectors and disciplines.
of the National Department of Health (NDoH) and the government
The GFHR promotes a shift of focus from ‘health research’ to

20 IL
in South Africa. The summit brought together stakeholders from
‘research for health’, the latter referring to “research undertaken in
government, industry, academia and civil society to identify the
any discipline or combination that seeks to understand the impact on
Y T
key priorities for strengthening health research, innovation and
development over the next three to five years. Notable among the
health of policies and programs; assist in developing interventions
that mitigate impact; and contribute to the achievement of better
A N
seven summit findings is the need:
health and equity”.10
M U

to develop a national system for evidence-based planning,

While health research is a process, the health research system is a
monitoring and evaluation of the effectiveness and impact of
structure within which health research takes place. The observatory is
the health research system on the burden of disease in South
4 ED

therefore an instrument of action that co-ordinates relevant research

Africa.6
into research for health.2–5
It is this need, namely to monitor and evaluate the health research
O

system, that has led to the proposal for the establishment of a The nature and function of health observatories
National Health Research Observatory (NHRO) in South Africa.
According to Pourmalek,11 the health observation concept and
G

South Africa’s National Development Plan (NDP)7 has identified key practice relate closely to the evolution and maturation of health
health and social priorities with a far-reaching development and
R

policy-making. In an editorial entitled “National health observatories:

health systems agenda. Observations indicate that an unco-ordinated Need for stepped up action”, the health observatory is assumed
BA

health research system, limited researcher collaboration, poor control

N

to be a policy-oriented virtual-based national centre aimed at

over funds spent, unnecessary duplication and over-researched performing systematic and ongoing observations on relevant issues
O

fields undermine research efforts to transform the country’s health about population health and health systems, in support of effective
profile. Based on these considerations, the NHRC has undertaken to
EM

and evidence-based health policy, planning, decision-making and

develop the NHRO as a comprehensive information and translation
system that will integrate health information from the country’s
multiple research platforms,6,8 co-ordinate research processes, and
serve to monitor, evaluate and support translation of essential health
research findings in line with NDP goals and priorities.8
What is a health research observatory?
The Liverpool Public Health Observatory uses the term ‘observatory’
to denote an organisation which “stands back from phenomena
and events, providing objective description and analysis, and
forecasting of patterns, interrelationship processes and outcomes”,
thus to improve quality by using evidence.9
Public health observatories tend to be comparatively autonomous
and are therefore able to consider and develop their own locally
sensitive agenda. In terms of the size of their directly employed
staff, public health observatory teams tend to be small, though
highly qualified. Although ‘observing’ is an important component
in the work of observatories, the implication that observatories
action. The health observatory has a focus on ‘high-yield’ health
information on current and emerging population health concerns. The
health observatory’s mission and various functions are shared by a
network of stakeholders with different messages that are proactively
addressed to health policy-makers, managers and service providers,
researchers and academia, private sector and industry, and last but
not least, mass beneficiaries on the ground. The ultimate goal of
the health observatory is cost-effective and equitable improvement
of population health and hence a contribution to socio-economic
development.11
Health observatories vary in geographical scope, focus areas, and
functional and organisational structures.9 Moreover, public health
observatories serve to combine the qualities of academic and State-
based public health by providing high-quality and relevant regional,
national and local health intelligence on a shorter timescale,
enabling rapid responses to health research concerns. Importantly,
the observatory aims to bridge the gap between academia and
policy-makers.12

23 6 S A H R 20 1 6

Pourmalek further states that health observatories use information
from monitoring, evaluation and surveillance systems.11 However,
he cautions that health observatories are not meant to be replicas
or replacements for any part of health information systems, nor
raw or intelligent repositories of health statistics or geographical
information systems. Health observatories contribute to the
identification of health information gaps and improvements in health
information systems.13 Most countries do not have established
national health observatories, while some developing countries have
national observatories or public health observatories and others
have thematic observatories, such as the National Human Resources
for Health Observatory in Sudan.14 In South Africa, the NHRO will
come under the legislated mandate of the NHRC.8 Its core purpose
will be to strengthen the co-ordination and management of research
within the health research system, thus it will fall into the category of
‘thematic observatories’.
Co-ordination of research within the health research
16 6
system in South Africa : the current situation
Health research co-ordination in South Africa falls under the mandate
20 IL
of the NHRC which derives its authority from the National Health Act
(61 of 2003)15 as amended. In terms of this Act, the NHRC is tasked
Y T
to determine the health research to be carried out by public health
authorities; to ensure that health research agendas and research
A N
resources focus on priority health problems; to develop and advise
M U
the Minister of Health on the application and implementation of an
integrated national strategy for health research; and to co-ordinate
the research activities of public health authorities. In this capacity,
4 ED
the NHRC is the primary co-ordinator of health research activities in
South Africa.15
O
Does South Africa need a National Health Research
Observatory?
G
The NHRC has reported that there are deficiencies in the monitoring
R
and evaluation of South Africa’s health research system.16 While
there are existing initiatives that allow for the collection or collation
BA
of information on health, none of these is comprehensive, and they
are limited in terms of the health conditions covered, geographic
O
coverage, the degree to which public or private funding can be
EM
assessed, and in some cases the absence of a standardised system
for reporting research and development data.6 These limitations are
manifest within a setting characterised by insufficient information
policies, formal agreements and data management protocols
between the agencies that manage health information. Such
shortcomings in the information produced by routine national health
information systems with weak structures and performance profiles
have negative effects on the country’s health research system.
Global trends
South Africa is not alone in its attempt to establish a health research
observatory as a means to solve the problems facing the provision
of healthcare delivery and the development of health systems. At
the global level, the African Health Observatory and Knowledge
Management Unit of the WHO AFRO Region supports regional
and country efforts towards strengthening health systems through
the African Health Observatory and a network of national health
observatories.3 The Unit defines its purpose as being to support the
strengthening of the WHO’s capacity in knowledge acquisition,
S A H R 20 1 6
Health Research Observatory
generation, sharing, dissemination and use, including web-related
activities at the Regional Office. This entails providing support to
member states to enhance the evidence for policies and strategies,
and for monitoring health in the Africa Region, while strengthening
the capacity of member states to improve the:
➢➢ availability, quality and use of information;
➢➢ sharing, translation and application of information; and
➢➢ use of information and communication technology for health.3
These support areas involve tasks that fall within the legislated
mandate of the NHRC and that necessitate action that is consistent
with the establishment of the proposed NHRO for the country.
Regionally, the Consultative Expert Working Group (CEWG) of the
WHO AFRO Region held a meeting in Brazzaville in the Republic of
PM
the Congo in 2013 to deliberate on their task assigned by the Sixty-
third World Health Assembly, namely to search for new, innovative
and sustainable sources of funding for research and development
(R&D) addressing the specific health needs of developing countries.
One of the five potential mechanisms identified for implementation
of the recommendations on R&D financing and co-ordination
pointed to a need for co-ordination of research through instituting a
regional R&D observatory and relevant advisory mechanisms under
the auspices of the WHO. In this respect, a network of research
institutions, regional experts and consulting councils would be
established. Such a network would ensure the implementation of
policies at institutional, country and regional levels and improve the
business climate of the African continent to make it more attractive
for investment.3
Sound co-ordination along with national health R&D observatories
will enable the WHO to play a central and more effective role in
improving the co-ordination and support of health R&D directed
at the African Region.3 The establishment of a health research
observatory has great potential for South Africa to improve not only
its health system machinery, but also the regional and global health
research enterprise.
National context
For the NHRO to be relevant to national needs and priorities, it
is important that it be positioned in relation to all key national
strategies and initiatives, as well as other similar intersectoral
initiatives and existing strategies in South Africa’s public domain.
Advocacy for the observatory, which is a fairly new development
in the country, should be strongly mobilised to secure the buy-in of
all key stakeholders. Some of these initiatives and strategies may be
located in other sectors and driven by State and other entities, but
all contribute to research for health. Key among these is the National
Development Plan 2030.7
The National Development Plan 2030
The National Development Plan (NDP 2030) sets out nine long-term
health goals for South Africa. Five of these goals relate to improving
the health and well-being of the population. By 2030, South Africa
should have:
➢➢ Raised the life expectancy of South Africans to at least 70
years
➢➢ Progressively improved TB prevention and cure
237
➢➢ Reduced maternal, infant and child mortality
➢➢ Significantly reduced the prevalence of non-communicable
disease
➢➢ Reduce injury, accidents and violence by 50% from 2010
levels.
The remaining four goals deal with aspects of health systems
strengthening, which are:
➢➢ Complete health system reforms
➢➢ Primary health care teams to provide care to families and
communities
➢➢ Universal health care coverage
➢➢ Posts with skilled, committed and competent individuals.
The planned observatory can add value towards the achievement of
these goals. While the NDP 2030 explicitly acknowledges that there
are no easy solutions for achieving these nine goals, it identifies a set
16 6
of nine priorities that will contribute to the achievement of effective
health systems. Table 1 sets out some of the possible contributions of
20 IL
the proposed NHRO to these priorities.
Key initiatives and stakeholders Y T
The value of access to credible research information in the
A N
development of the health system is highlighted by the Director-
M U
General of the NDoH as follows: “These important challenges
require high-quality data, research, deliberate service development
strategies and a willingness to change”.17
4 ED
‘Research for health’ will contribute to understanding the impact
on health of policies, programmes, processes, actions or events
O
originating in any sector, will assist in the development of inter-
G
Table 1: Contribution of a National Health Research Observatory to the nine priorities of the National Development Plan 2030
R
National Development Plan priority
BA
Address the social determinants that affect health and diseases
Strengthen the health system
O
EM
Improve the health information system
Prevent and reduce the disease burden and promote health
Finance universal health care coverage
Improve human resources in the health sector
Review management positions and appointments, and strengthen Analyse data on management functions and infrastructure needs; map out trends
accountability mechanisms in skills availability and thus influence accountability and evidence-based policy-
and decision-making
Improve quality by using evidence
Meaningful public-private partnerships
23 8 S A H R 20 1 6
ventions to prevent or mitigate such impact, and will support the
achievement of international goals and targets. This covers the full
spectrum of research, spanning generic areas of activity: measuring
the magnitude and distribution of the health problem, understanding
the diverse causes or determinants of the problem, developing
solutions or interventions that will help prevent or mitigate the
problem, implementation or delivery of solutions through policies
and programmes, and evaluating the impact of these solutions on the
level and scale of the problem.2 In line with the call for a multisectoral
and multidisciplinary approach to the functioning of health research
observatories, the NHRC will ensure that the proposed NHRO
will strengthen existing collaborations and draw on initiatives and
research institutions that already provide information on research for
health. These include but are not limited to the following initiatives:
PM
➢➢ The National Health Information Systems (NHIS), which
provides health information and undertakes monitoring
and evaluation of the health of the population and disease
tendencies.
➢➢ Research and Development plans developed by the NDoH
which provide funding that is responsive to changes in the
research environment and that aims to enhance skills levels
and address South Africa’s socio-economic objectives will also
be drawn on.
➢➢ The National Health Research Database (NHRD), developed
by the Health Systems Trust, serves as a repository of health-
related research being conducted in South Africa. The NHRD
enables researchers and research committees to map the
geographic areas in which research is being conducted, and
provides a snapshot of current and past research priorities.
Commissioned and funded by the NDoH, the NHRD is
currently being launched through the nine Provincial Health
Possible contribution of a National Health Research Observatory
Provide an analysis of social factors that play a key role in determining health
status
Identify points of weakness in the health system and their underlying causes and
make recommendations for appropriate solutions
Collate data from a range of sources; stratify, repackage, translate and
disseminate the information in ways that make it accessible for use by different
stakeholders
Contribute to the identification of the types and levels of the burden of disease;
make recommendations for their prevention, reduction and mitigation
Analysis of health care financing; assist in identifying sources, levels and types of
healthcare financing available, and identify gaps in universal coverage
Analysis of the full-time equivalents for health sector human resources to reliably
determine the quality, qualifications and numbers needed for provision of
adequate health care
Analyse all data received and provide feedback for translation of research into
practice; make findings accessible to all stakeholders for improved quality of
health care
Vigilance on events and trends leading to balanced feedback to all sectors will
enable development of meaningful partnerships between public and private
sector stakeholders to help parties engage in using synergies for mutual benefit

Research Committees and is a crucial first step undertaken by
the NDoH to facilitate the development of the NHRO.
➢➢ The Research Information Management System (RIMS),
funded by the Department of Science and Technology (DST)
and hosted at the National Research Foundation (NRF) in
Pretoria, allows users to view the total R&D investment in
specific areas of science and technology across agencies
and to examine the details of research investments within a
specific agency. The system is a strategic tool for research
development and support at institutional and national levels,
and facilitates internal and external monitoring of research
outputs and impact. It provides the country’s science councils
and higher education institutions with two key components of a
research information management system, namely a common
application platform for publicly funded research institutions
to support their research administration processes, and the
information needed to establish a common platform for the DST
to distil data from publicly funded institutions that will inform
16 6
strategic research-related decision-making. Additionally, the
National Bioportal being developed by the DST will focus
20 IL
on the research and development activities needed for the
implementation and expansion of the National Bio-economy
Strategy launched in 2014.18 Y T
A N
➢➢ The National Science and Technology Expenditure Plan is a
means of reporting projected national expenditure on scientific
M U
and technological activities (STAs) over the Medium-term
Expenditure Frameworks (MTEF). The National Department of
4 ED
Health also feeds information on expenditure levels and trends
at national, provincial and local levels.
➢➢ The Department of Environmental Affairs (DEA) conducts
O
research that provides valuable information on environmental
impacts on health and on health issues as they affect the
G
environment. In particular, the Environment Sector Research,
Development and Evidence Framework is a tool developed
R
to provide routine information of interest to policy-makers
in health and industry in terms of how environmental forces
BA
N
influence the health of the South African population.
O
➢➢ The Safety in Mines Research Advisory Committee, under the
auspices of the Department of Energy and Mineral Resources,
EM
annually prepares comprehensive programmes for health
and safety research, including a review of health and safety
performance in the various mining sectors, health and safety
research foci and priorities for these sectors, estimated costs of
specific programmes, and an evaluation of research proposals
made by the Mine Health and Safety Council or any of its
committees.
There is therefore compelling evidence that South Africa has both a
critical need for and has already garnered much of the necessary
information and technical capacities, resources and infrastructure
to implement a health research observatory.6,19 With this context
in mind, it is imperative that all stakeholders within the research
community be brought on board to ensure proper understanding
of the processes for the establishment and maintenance of the
proposed NHRO, and to engage actively in its development as a
tool for improving the yield of research for health outcomes.
S A H R 20 1 6
Health Research Observatory
Proposed model for the NHRO in South Africa
It is envisaged that the NHRO will function directly under the authority
of the NHRC but will be co-ordinated by a steering committee
comprising identified experts as mentors and advisors and research
institutions as feeders of information. There have been strong
motivations for national observatories to be staffed with their own
officials and to support the training of the requisite human resources
to ensure their core functioning.18 Securing skilled leadership would
be critical for the strategic management of the NHRO to ensure
that it serves its intended goals, and the NHRO should be armed
with high-level technical expertise and capacity to achieve the initial
implementation and full operation of the observatory. Specifically,
the human resources complement should comprise a director; three
senior managers to govern operations, data analysis and information
PM
dissemination; two administrators; technicians; managers for data
analysis and information dissemination; a biostatistician and an
epidemiologist. A hosting institution will provide operational staff
for office administration and human resources support. Infrastructure
needs to include office space, information technology and communi-
cations facilities.
Implementation, considerations and challenges
Some of the potential challenges include current legislative
inadequacies that may limit the NHRO’s authority to engage with
public or private health data repositories. The autonomous nature of
research partners, and the variations in and limitations of the existing
approaches and standards for health research data, present further
possible challenges to the successful operation of the observatory.
The institutionalisation of a NHRO is considered a key prerequisite to
its effective operation and ability to function over time.3 The decision
to launch, resource and operate the NHRO should be taken at a
high political level to ensure its establishment as a legally authorised
entity, its effective implementation, and its sustainability. Because
the NHRO is being considered by the NDoH within the context
of international momentum for the implementation of national,
regional and global health observatories,4,5 the NHRC has sought
to align the focus and scope of the NHRO with existing government
policy and health sector needs within current legislative mandates,
specifically the National Health Act (61 of 2003)15 through the
NHRC mandate.8,19 Such alignments will support the administrative
actions that are required to ensure the effective implementation of
the observatory.19
However, ensuring that the NHRO will be aligned with the
information needs of policy- and decision-makers may be difficult,
given the complex nature of health systems and services, the multiple
levels and requirements of government, the diverse management
involved, and the types of decision-making that may need to be
conducted.19 The following measures are likely to consolidate this
alignment:
➢➢ Establishment of an observatory under a government policy
that extends beyond government administrations
➢➢ A guarantee that the observatory has the necessary resources
and an independent budget
➢➢ A transparent management system for both the use of
resources and the information gathered and processed by the
observatory.19,20
239
Consensus on NHRO scope and functions
The proposed NHRO may generate many expectations from a range
of interest groups with regard to its purpose, objectives, functions
and responsibilities. The NHRO may therefore be mistakenly
perceived as an alternative or replacement for routine information,
monitoring and surveillance systems, thus generating concerns about
its implementation, especially among those groups already involved
in similar monitoring systems.19 The NHRO implementation plan
should therefore specify its key dimensions through some form of
engagement process with partners and stakeholders.3 The formation
of advisory meetings, task teams and technical collaboration
agreements is needed to aid the buy-in and sharing of accountability
or ownership of joint tasks. Such a plan should also consider and
where possible specify the extent and boundaries of the data

PM
system co-ordination, collation, analysis and liaison capacities, and
difficulties that may impede implementation. The plan should also
be framed around a phased implementation of an approach that
utilises existing and effective monitoring or surveillance systems.8,19

16 6
Furthermore, the development and management of the NHRO may

20 IL
be perceived by partners, including government departments and
managers, as an additional activity for busy staff, implying increased
workloads with no added value. It is therefore imperative that a
Y T
cost-benefit analysis of the observatory be generated to support the
A N
engagement with partners on its implementation.19
M U

Information systems, data limitations and human

resources
4 ED

The general launch of the NHRO and its capacity to compile and
analyse information and generate reports would be limited by
the difficulties inherent in operationalising a new structure of this
O

kind.19,20 Limitations in the provision of information produced by

national routine health information systems with weak structure and
G

performance can be expected to hinder the NHRO’s performance

and outputs, and the improvement of these, if at all feasible, may
R

take longer than expected. Despite such challenges, there exist

BA

important opportunities through technical collaboration that would

N

aid in governing the development of policy guidelines, instruments

O

or measures, and indicators.

EM

Conclusion
The NHRC acknowledges the existence of gaps in available
information regarding South Africa’s health research system as a
whole. Such gaps include information pertaining to expenditure on
health and disease-related research and development as outlined
in the 2011 NHRC Summit Report.6 Efforts to track and map
health research investments may be restrained by the complexity,
incompleteness and resource-intensity of information systems;
however, the NHRC has carefully considered global experience and
WHO recommendations and is proposing the establishment of a
NHRO along lines that will be relevant to South Africa’s context
and needs. Driven by the NHRC’s mission, namely to elevate health
research that is aligned with both the NDP and the WHO’s global
interest in research for health, this chapter articulates the manifold
local, regional and global benefits to be rendered by the envisaged
NHRO. These benefits should generate lasting interest among the
research community to ensure a functional and sustainable structure
for co-ordination of South Africa’s health research system.

240 S A H R 20 1 6
 Health Research Observatory

References
1 Peer N, Padarath A, Cadegan M, Padayachee T, English R.
National Health Research Observatory: A Literature Review.
Unpublished report. Pretoria: National Health Research
Committee; 2014.
2 World Health Organization. The WHO Strategy on Research
for Health. Geneva: World Health Organization; 2012.
[Internet]. [cited 5 February 2016].
URL: http://www.who.int/phi/WHO_Strategy_on_research_
for_health.pdf
3 World Health Organization. Overview – African Health
Observatory and Knowledge Management Unit (Regional
Office for Africa). [Internet]. [cited 5 February 2016].
URL: https//www.afro.who.int/en/clusters-a-programmes/
ard/African-health-observatory-a-knowledge-management/
about.html
15 Republic of South Africa. National Health Act (61 of 2003).
Government Gazette Vol 469, No. 26595. 23 July 2004.
[Internet]. [cited 13 April 2016].
URL: http://www.gov.za/sites/www.gov.za/files/a61-03.pdf
16 Senkubuge F, Mayosi B. The State of the National Health
Research System in South Africa. In: Padarath A, English R,
editors. South African Health Review 2012/13. Durban:
Health Systems Trust; 2013.
17 South African National Department of Health. Annual
Performance Plan 2014/15–2016/17. Pretoria: National
Department of Health; 2014.
18 South African National Department of Science and
Technology. National Bio-economy Strategy. Pretoria:
National Department of Science and Technology; 2013.
[Internet]. [cited 13 April 2016].

PM
4 World Health Organization. Report of the AFRO Consultation URL: http://www.innovus.co.za/media/Bioeconomy_
of Experts on the CEWG Recommendations on Research Strategy.pdf
and Development: Financing and Coordination. Brazzaville,
19 Gattini CH. Improving the Structure and Performance of
Congo: WHO Africa Region; 2013.
National Health Information Systems, Operational Approach

16 6
5 World Health Organization. A Global Health R&D and Strategic Recommendations. Santiago de Chile: Office of
Observatory – Developing a case for its development: the Pan American Health Organization/Regional Office of the

20 IL
Department of Public Health Innovation and Intellectual World Health Organization; 2009.
Property, Draft Working Paper 1; May 2013. [Internet]. [cited
20 Gattini CH. Implementing National Health Observatories
13 April 2016]. Y T Operational Approach and Strategic Recommendations.
URL: http://www.who.int/phi/documents/dwp1_global_
Technical Series on Information for Decision-Making - PWR
health_rd_observatory_16May13.pdf
A N
CHI/09/HA/02. Santiago de Chile; Office of the Pan
6 Mayosi BM, Mekwa JN, Blackburn J, Coovadia H, Friedman American Health Organization/Regional Office of the World
M U

IB, Jeenah M, et al. Strengthening research for health, Health Organization; 2009.
innovation and development in South Africa: Proceedings
and recommendations of the 2011 National Health Research
4 ED

Summit. Pretoria: National Health Research Committee; 2012.

7 Office of the Presidency, Republic of South Africa/National
Planning Commission. National Development Plan 2030:
Our Future – make it work. Pretoria: National Planning
O

Commission; 2012.
G

8 National Health Research Committee. National Health

Research Observatory Proposal Discussion Paper. Pretoria;
NHRC Observatory Working Group; 2015.
R

9 Hennings J, Wilkinson S. What is a public health

BA

observatory? J Epidemiol Community Health.

2003;57(5):324–326.
O

10 World Health Organization/ Global Health Workforce

Alliance. Global Forum for Health Research. [Internet]. [cited
EM

13 April 2016].
URL: http://www.who.int/workforcealliance/members_
partners/member_list/gfhr/en/
11 Pourmalek F. National health observatories: Need for stepped-
up action. theHealth. 2012;3(3):63–64.
12 Richards T. European observatory will promote better health
policy. British Medical Journal. 1999;318:352.
13 Gattini CH. Implementing National Health Observatories:
Operational Approach and Strategic Recommendations.
Santiago de Chile. Office of the PAHO/WHO Representation
in Chile, Pan American Health Organization, Regional Office
of the World Health Organization. 2009. [Internet]. [cited 4
April 2012].
URL: http://new.paho.org/chi/images/PDFs/national%20
health%20observatories_final.pdf
14 The National Human Resources for Health Observatory –
Sudan. World Health Organization Global Health Workforce
Alliance. [Internet]. [cited 13 April 2016].
URL: http://www.who.int/workforcealliance/members_
partners/member_list/nhrhobs_sudan/en/

S A H R 20 1 6 24 1
242
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Health and Related Indicators 20

Authors:
Candy Day i
Andy Gray ii

PM
16 6
20 IL
Contents
Introduction 244
Data sources and collection
Y T 249
A N
Demographic indicators 250
Socio-economic and risk factor indicators 254
M U

Health status indicators 257

Mortality 257
4 ED

Disability 260
Infectious disease 262
Malaria 264
Tuberculosis 266
O

HIV and AIDS 269

Reproductive health 273
G

Contraception, sexual behaviour, sexually transmitted infections

and termination of pregnancy 273
R

Maternal health 275

BA

Child health 278

N

Nutrition 282
O

Non-communicable diseases 286

Risk behaviour and determinants of health 291
EM

Injuries 295
Health services indicators 297
Health facilities 297
Health personnel 300
Health financing 307
Conclusion 311
Acknowledgements 311
Appendices 311
Maps 311
Selected data sources and results for WHO Core indicators 320
Indicator definitions for data tables presented in this chapter 332
References 342

i Health Systems Trust

ii Division of Pharmacology, Discipline of Pharmaceutical Sciences, Universit y of KwaZulu- Natal

243
Introduction
Just as 2015 saw the target date set for the Millennium Development
Goals (MDGs) being reached, with a global effort to track progress
towards achieving those ambitious goals, so 2016 is the first year
for a new series of such goals, with an even more ambitious scope.
In September 2015, the United Nations General Assembly hosted
the Sustainable Development Summit in New York, which endorsed
a new set of Sustainable Development Goals (SDGs).a The range
of the SDGs has been expanded. A total of 17 SDGs have been
set, ranging from “end poverty in all its forms everywhere” (Goal
1) to “promote peaceful and inclusive societies for sustainable
development, provide access to justice for all and build effective,
accountable and inclusive institutions at all levels” (Goal 16), with
a commitment to “strengthen the means of implementation and
3.b - Support the research and development of vaccines and
medicines for the communicable and non-communicable
diseases that primarily affect developing countries, provide
access to affordable essential medicines and vaccines, in
accordance with the Doha Declaration on the TRIPS Agreement
and Public Health, which affirms the right of developing
countries to use to the full the provisions in the Agreement on
Trade-Related Aspects of Intellectual Property Rights regarding
flexibilities to protect public health, and, in particular, provide
access to medicines for all
3.c - Substantially increase health financing and the recruitment,
development, training and retention of the health workforce in
developing countries, especially in least developed countries

revitalize the global partnership for sustainable development” (Goal
17). SDG3 is specific to Health: “Ensure healthy lives and promote
well-being for all at all ages”. As with the MDGs, each SDG has
a series of targets. The targets for SDG3 are extensive, and each
PM
and small island developing states
3.d - Strengthen the capacity of all countries, in particular
developing countries, for early warning, risk reduction and

16 6
represents a complex set of sub-targets:b management of national and global health risks.

20 IL
3.1 - By 2030, reduce the global maternal mortality ratio to less There has been a robust debate about how best to set measurable
than 70 per 100 000 live births indicators for the health-related SDG targets. Murray has argued
Y T
3.2 - By 2030, end preventable deaths of newborns and
children under 5 years of age, with all countries aiming to
that four major design features should be considered:1 that each
indicator should not only measure the intended effect, but also be
A N
important for population health (in order to avoid diverting scarce
reduce neonatal mortality to at least as low as 12 per 1 000
resources to an outcome that is only tangentially related to the
M U

live births and under-5 mortality to at least as low as 25 per

target); that each indicator be easily interpreted and communicated;
1 000 live births
that each indicator produce valid, timely, local and comparable
4 ED

3.3 - By 2030, end the epidemics of AIDS, tuberculosis, malaria measurements in an affordable manner; and that, wherever
and neglected tropical diseases and combat hepatitis, water- possible, each indicator should be disaggregated by age, gender,
borne diseases and other communicable diseases and sub-national location. Meeting these standards is incredibly
O

difficult when a target is a composite of many sub-targets (such as

3.4 - By 2030, reduce by one third premature mortality from
the target to “end AIDS, tuberculosis, malaria and neglected tropical
non-communicable diseases through prevention and treatment
G

diseases” as well as “combat hepatitis, water-borne diseases and

and promote mental health and well-being
other communicable diseases”).
R

3.5 - Strengthen the prevention and treatment of substance

If such a complex development can be reduced to one dimension, it
abuse, including narcotic drug abuse and harmful use of alcohol
BA

would be that the SDGs have focused greater attention on efforts to

3.6 - By 2020,c halve the number of global deaths and injuries tackle non-communicable diseases (NCDs), while still maintaining the
O

from road traffic accidents visibility of major communicable diseases (and adding the politically
EM

charged issue of hepatitis, where new treatments for hepatitis C

3.7 - By 2030, ensure universal access to sexual and reproductive
health-care services, including for family planning, information
and education, and the integration of reproductive health into
national strategies and programmes
3.8 - Achieve universal health coverage, including financial
risk protection, access to quality essential health-care services
and access to safe, effective, quality and affordable essential
medicines and vaccines for all
3.9 - By 2030, substantially reduce the number of deaths and
illnesses from hazardous chemicals and air, water and soil
pollution and contamination
3.a - Strengthen the implementation of the World Health
Organization Framework Convention on Tobacco Control in all
countries, as appropriate
have been developed but are largely unaffordable). Target 3.4
combines a focus on chronic non-communicable diseases, while
adding mental health. Target 3.a focuses on tobacco control, while
3.5 targets substance abuse and alcohol. There is also an emphasis
on tracking progress towards attaining universal health coverage
(UHC), for which the South African variant is National Health
Insurance (NHI). The Global Sustainable Development Report 2015
has drawn attention to the ‘interlinkages’ between the goals, the
targets, sectors and issues addressed.2 The Report also noted that,
as much as the MDGs had posed data and monitoring challenges
for many countries, the SGDs amplified those challenges. There
are, however, increased opportunities for engagement between
researchers and operational actors, in exactly the way that Health
Systems Trust and the Health Review were first conceptualised.3

a https://sustainabledevelopment.un.org/sdgs
b Target numbering is reproduced as it appears in the source.
c It is not clear why only this target is to be achieved by 2020, and the others
by 2030, but it is included as per the source.

24 4 S A H R 20 1 6
 Health and Related Indicators

Work is still under way in South Africa to hone the local indicator set (HIV and AIDS, sexually transmitted infections, tuberculosis,
to match the new global imperative. The official 2015 country report malaria, neglected tropical diseases, outbreaks, epidemic diseases),
on the MDGs has been released by Statistics South Africa.4 This reproductive, maternal, newborn, child and adolescent health
showed that none of the MDG4 indicators (under-5 mortality) for (including sexual health, reproductive rights and immunisation),
which there were data were achieved. The same applied to MDG5 non-communicable diseases (including chronic disease, health
(maternal and reproductive health). However, some but not all of promotion, nutrition, mental health and substance abuse), injuries
the targets set for MDG6 (AIDS, tuberculosis, malaria) were met. and violence and the environment.
Interestingly, no data were provided on one of the most challenging
of the MDG8 targets, measuring access to essential medicines
(8E: In co-operation with pharmaceutical companies, provide
access to affordable essential drugs in developing countries). In
this regard, the global report stated that “global and regional data
are lacking”.5 It noted that “availability varies widely across the
countries surveyed”, and recommended improved monitoring of the
availability of essential medicines, as well as the prices actually paid

PM
by patients in developing countries. This example is illustrative of the
challenge facing the choice of indicators for the new SDGs.

A useful summary of global progress towards the health-related

16 6
MDGs and their transition to the SDGs was provided by the WHO in
2015.6 This report clearly identifies the challenges facing countries

20 IL
as they re-orientate their programmes to add the focus on NCDs:
“Achieving the SDG target for NCDs will require major interventions
Y T
to deal with a context characterized by ageing populations, rapid
unplanned urbanization and globalization of markets that promote
A N
inactivity and unhealthy diets, and will focus on the development and
M U

implementation of strong national plans that emphasize prevention

and treatment access for all”. This edition of the Health Review
Indicators chapter, while maintaining its comprehensive scope, is
4 ED

focused specifically on the data needed to monitor NCDs, with the

SDG targets in mind.

Although their initial development predates the establishment of

O

the SDGs, the WHO Global Reference List of 100 Core Health
G

Indicators7 provides a useful starting point for national indicator

choices.d The List is not intended to be prescriptive, but to provide a
R

reference for countries to use, “in accordance with their own health
priorities and capacity”. However, the List is also uniquely relevant to
BA

the SDGs. Table 1 shows those WHO 100 Core Health Indicators for
which South Africa currently does not have data readily available.
O

Indicators have been listed in this table where it is considered that

EM

there are no or limited data published or available in the public

domain, particularly from locally generated data sources. It does not
imply that no data exist or that the indicators cannot be calculated
or estimated using a proxy measure, but rather that additional data
requests, calculation or analysis are required, or that data quality
needs improvement before indicators are made publicly accessible.
However, for many others, the data are already collected as part
of the National Indicator Data Set (NIDS). For some, adjustment
to one or more of the data elements will be needed. A snapshot
of data sources available for these indicators in South Africa is
shown in Figure 11, together with a more detailed table at the end
of the chapter (Table 40). The WHO 100 Core Health Indicators
are constructed deliberately by levels, domains and sub-domains.
Derived from the familiar results chain framework, the levels consist
of inputs, outputs, outcomes and impacts. The domains are health
status, risk factors, service coverage and health systems (including
service delivery). The sub-domains include communicable diseases

d This is somewhat of a misnomer, as many of the 100 Indicators are

composites (e.g. in relation to human resources, where separate figures
would need to be tracked for each selected health profession).

S A H R 20 1 6 245
Table 1: WHO 100 Core Health Indicators for which South African data are not readily available or routinely reported
Financing Sub-domain
Health systems Domain
Input Level
Indicator
Current expenditure on
health by government and
compulsory schemes as % of
current health expenditure
Externally sourced funding
as a percentage of current
expenditure on health
Total capital expenditure on
health as a share of current + expenditure on health.
capital expenditure on health
Out-of-pocket payment on
health as a percentage of
current expenditure on health
Birth registration coverage
Information
A N
M U
4 ED
Death registration coverage
O
G
R
Completeness of reporting
by facilities
BA
Health service access
Infrastructure
EM
Output training institutions
Workforce
Service-specific availability
Output
Health systems
Access and
availability
and readiness
International Health
Health security
Regulations (IHR) core
capacity index
24 6
Definition
Current expenditure on health by general government and compulsory
schemes as a share of total current expenditure on health (expressed
as a % of total current expenditure on health). This is the sum of current
health outlays paid for in cash or supplied in kind by government entities
such as the Ministry of Health, other ministries, parastatal organisations
or social security agencies, or by entities running health schemes that are
compulsory by law.
Share of total current expenditure on health funded by external (rest of the
world) institutional units providing revenues to financing schemes.
PM
Total capital expenditure on health as a percentage of current + capital
16 6
Share of total current expenditure on health paid by households out-of-
pocket, expressed as a percentage of total current expenditure on health.
20 IL
Percentage of births that are registered within one month of age in a civil
registration system.
Y T
Percentage of deaths that are registered (with age and sex).
Percentage of facilities that submit reports within the required deadline.
Percentage of population living within 5 km of a health facility.
Number of graduates from health workforce educational institutions
(including schools of dentistry, medicine, midwifery, nursing, pharmacy)
during the last academic year per 1 000 population.
Number of health facilities offering specific services per 10 000 population
and meeting minimum service standards on the basis of a set of tracer
criteria for specific services.
Percentage of attributes of 13 core capacities that have been attained
at a specific point in time. The 13 core capacities are: (1) National
legislation, policy and financing; (2) Coordination and National Focal Point
communications; (3) Surveillance; (4) Response; (5) Preparedness; (6)
Risk communication; (7) Human resources; (8) Laboratory; (9) Points of
entry; (10) Zoonotic events; (11) Food safety; (12) Chemical events; (13)
Radionuclear emergencies.
S A H R 20 1 6
Notes
In principle it should be possible to calculate this
from data on government expenditure (National
Treasury) and medical schemes. The challenge
is to quantify other health expenditure outside
these regulated sources.
Donor funding is relatively low for South Africa,
compared to other African countries. This
indicator could possibly be assessed from
global work by the Institute for Health Metrics
and Evaluation (IHME) on donor assistance
for health.8
It should be possible to calculate this indicator
using data on government expenditure (National
Treasury) although this would not include all
sources (local government, private sector).
Although some estimates exist, there does not
appear to be a robust estimate of this indicator
for SA.
Some information is available in Stats SA
Live Births reports. The Births and Deaths
Registration Amendment Act (18 of 2010)
makes it compulsory to register live births
that take place in the country within 30 days
following birth occurrence. The majority of births
registered in 2014 (59.1%) were registered
within 30 days, although completeness of birth
registration was estimated to be 89.2% making
the coverage for all births somewhat lower.9
Some information on completeness of death
registration is available in Stats SA Causes
of death reports, but not for all age groups.
Completeness of adult death registration (15
years and older) was estimated to be 94% for
2014 but the extent of child death registration is
less certain. Completeness of other variables
such as age and sex are reported for deaths
that are registered.10
This can be calculated by NDoH based on
timeliness of reporting through DHIS. These
results do not however appear to be published
or generally available.
Some GIS work on this topic has been done but
the results have not been made available in the
public domain. A similar indicator is “Children
living far from their usual health facility (%)”,
which is reported annually in the SA Child
Gauge based on analysis of the Stats SA GHS.
Data are potentially available from training
institutions, but are not currently reported.
A proxy measure may be based on the National
Core Standards Assessments and the Ideal
Clinic dashboard initiative:
Fixed PHC facilities scoring 80% and above on
ideal clinic dashboard
There are no available data for this indicator. So
far only the transfer of Port Health to National
control has been reported.

Quality and safety Sub-domain
Domain
Level
Indicator
Perioperative mortality rate
Obstetric and gynaecological Percentage of admissions for (spontaneous or induced) abortion-related
admissions owing to abortion complications to service delivery points providing inpatient obstetric and
gynaecological services, among all admissions (except those for planned
termination of pregnancy).
Maternal death review
coverage (%)
ART retention rate
Intimate partner violence
Outcome
Risk factors
Injury and
violence
prevalence (%)
A N
Early initiation of
Infectious disease NCDs and
nutrition
breastfeeding (%)
M U
People living with HIV who
Service coverage
4 ED
have been diagnosed (%)
O
G
HIV care coverage (%)
R
BA
N
O
HIV viral load suppression
(%)
EM
TB preventive therapy for
HIV-positive people newly
enrolled in HIV care (%)
Percentage of TB patients
with test results for isoniazid
and rifampicin drug
susceptibility
Definition
All-cause death rate prior to discharge among patients having one or more
procedures in an operating theatre during the relevant admission.
PM
Percentage of maternal deaths occurring in the facility that were audited.
16 6
Percentage of adults and children with HIV alive and on ART 12, 24, 36
20 IL
(etc.) months after initiating treatment among patients initiating ART during
a specified time period.
Percentage of currently partnered girls and women aged 15-49 years who
Y T
have experienced physical and/or sexual violence by their current intimate
partner in the last 12 months.
Percentage of infants breastfed within 1 hour of birth in a specified time
period.
Percentage of people living with HIV who have been diagnosed.
This indicator is also one of the 90-90-90 global targets for AIDS
(UNAIDS).
Number and percentage of people living with HIV who are receiving HIV
care, as proxied by receipt of at least one of the following during the
reporting period: clinical assessment (WHO staging) or CD4 count or viral
load or on ART.
Percentage of people on ART who are virologically suppressed (VL level
≤1000 copies/mL).
Number of patients who are started on treatment for latent TB infection
expressed as a percentage of the total number newly enrolled in HIV care
in a specified time period.
Percentage of TB cases with results for diagnostic drug susceptibility
testing for resistance to isoniazid and rifampicin in a specified time period.
S A H R 20 1 6
Health and Related Indicators
Notes
Requires a register of operations (major
surgery only) in hospitals and recording of
survival status at discharge after operation.
The indicator also generates information on the
surgical volume (procedures performed in an
operating theatre per 100 000 population per
year). This is a rough indicator of access.
It is unclear whether the relevant data are
currently collected by routine health systems in
the public sector.
The Saving Mothers reports have some
information on causes of maternal mortality
but no data source is available for admissions
disaggregated in this way.
In theory, the NCCEMD audits all maternal
deaths in facilities that are reported to the
secretariat, but there are no specific data in this
regard. Few home deaths are noted and not all
private sector facilities may be covered.11
Although these data are collected in Tier.Net,
there are concerns about data quality. The
availability of data may vary between districts.
No current data source in SA.
No current data source in SA.
Numerator: Number of people living with HIV
who have been diagnosed.
Denominator: Estimated number of people living
with HIV.
The denominator could be estimated from
prevalence surveys; DHIS/Tier.Net can
provide the number on ART but this would not
include patients who are diagnosed but not yet
receiving treatment.
It is not clear whether the necessary data are
available in SA, which would allow for tracking
of a unique identifier allowing for calculation of
the number of people receiving care according
to clinical assessment or CD4 / viral load
testing.
Although these data are collected in Tier.
net, there are concerns about data quality.
Theavailability of data may vary between
districts. Data on this indicator have not yet
been published.
It is not compulsory that latent TB is tested for
in South Africa before initiating IPT. All HIV-
positive patients who do not have active TB can
receive IPT – even without a test for latent TB
(TST test) – although a TST is recommended
(National Consolidated Guidelines 2015).12
DHIS does include an indicator “HIV positive
new client initiated on IPT rate”.
No data are currently available but could
probably be determined using the number
of all TB patients from the TB register for the
denominator, and data from the National Health
Laboratory Services for the numerator.
Data are available on GeneXpert testing (RIF
resistance only), but may it be more difficult to
collate data for INH and RIF testing.
247
 Sub-domain
Domain
Level
Indicator
Second-line treatment
coverage among multidrug-
resistant tuberculosis (MDR-
TB) cases (%)
Intermittent preventive
therapy for malaria during
pregnancy (IPTp) (%)
Percentage of population
sleeping under insecticide-
treated nets (%)
Indoor residual spraying
(IRS) coverage (%)
Coverage of preventive
chemotherapy for selected
neglected tropical diseases
(%)
Demand for family planning
Service coverage
Repro, maternal, child,
adolescent
satisfied with modern
methods (%)
M U
Percentage of children
under 5 years of age with
4 ED
suspected pneumonia taken
to a health facility
Children with diarrhoea
receiving oral rehydration
solution (ORS) (%)
G
AIDS-related mortality rate
Health status
Impact
Infectious disease
(per 100 000 population)
R
BA
N
O
EM
Prevalence of hepatitis B
surface antigen
Malaria parasite prevalence
among children aged 6–59
months
Source: Compiled from WHO 100 Core Health Indicators list and multiple data sources reviewed for this chapter.
24 8
Definition
Percentage of notified TB patients estimated to have MDR-TB who were
detected with MDR-TB and enrolled on second-line anti-TB treatment in a
specified time period.
Percentage of women who received three or more doses of intermittent
preventive treatment during antenatal care visits during their last
pregnancy.
Percentage population in malaria-endemic areas who slept under an ITN
PM
the previous night.
Percentage of population at risk protected by IRS during a specified time
period.
16 6
20 IL
Percentage of the population living in endemic areas requiring
preventive chemotherapy that received treatment for at least one of the
selected neglected tropical diseases (schistosomiasis, soil-transmitted
Y T
helminthiases, lymphatic filariasis, onchocerciasis).
A N
Percentage of women of reproductive age (15-49 years) who are sexually
active and who have their need for family planning satisfied with modern
methods.
Percentage of children under 5 years of age with suspected pneumonia
(cough and difficult breathing NOT due to a problem in the chest and
a blocked nose) in the two weeks preceding the survey taken to an
appropriate health facility or provider.
Percentage of children under 5 years of age with diarrhoea in the last two
weeks receiving ORS (fluids made from ORS packets or pre-packaged
O
ORS
Estimated number of adults and children who have died due to AIDS-
related causes in a specific year, expressed as a rate per 100 000
population.
Prevalence of hepatitis B surface antigen (HBsAg)-positive, adjusted for
sampling design.
Percentage of children aged 6–59 months in the population with malaria
parasites in blood.
S A H R 20 1 6
Notes
No indicator like this is currently reported, but it
may be possible to obtain data from EDR.web,
combined with denominator data on number
found to have MDR-TB.
The indicator ‘MDR-TB started on treatment’
provides the number of MDR-TB patients who
started treatment. Updated data could be
requested from the TB Control Programme of
NDoH.
The World Malaria Report 2015 indicates that
this intervention has not been adopted as policy
in SA.
The World Malaria Report 2015 indicates that
this intervention has not been adopted as policy
in SA.
The World Malaria Report 2015 indicates that
SA claimed 100% coverage for the population
at risk in 2014, although local data on this topic
do not appear to be published; they may be
available on request from the NDoH malaria
programme.
No data collected in SA for this indicator.
The DHIS does include an indicator ‘Deworming
dose 12-59 months coverage’.
Essentially the inverse of ‘Unmet need for family
planning’. Potentially available from surveys
such as the Demographic and Health Survey,
but there are no recent data for SA.
There are no available data for SA, and this
indicator poses significant challenges, even
when included in a household survey.
These data are not currently collected by DHIS,
but some old data may be extracted from
previous Demographic and Health Surveys,
although the 2003 survey was considered
unreliable.
Empirical data from different HIV surveillance
sources are consolidated to obtain estimates
of the level and trend of HIV infection and of
mortality in adults and children. However, to
obtain the best possible estimates, judgement
must be used as to the quality of the data
and how representative it is of the population.
Adjustments are often needed because of
underreporting/misclassification of HIV and
AIDS deaths. UNAIDS and WHO produce
country-specific estimates of mortality due to
AIDS every year.
Vital registration data in SA reflect significant
under-reporting of deaths due to AIDS. Various
estimates and models are available that provide
the percentage of deaths due to AIDS and these
could be used to calculate this indicator.
Although there is some literature about hepatitis
B prevalence in South Africa, the studies quoted
appear to be from 1970s and 1980s.
SA does not appear to collect any data for this
indicator.
Measured by household survey with rapid
diagnostic test or microscopy applied to all
children aged 6–59 months.
 Health and Related Indicators

Data sources and collection

As before, while this chapter attempts to identify most of the key
international and national data sources and literature on a range of
health indicators, it cannot claim to be exhaustive. The data provided
in this chapter are only a sub-set of those available. More data,
particularly those showing trends over time, are stored in the Health
Statistics Database, which can be accessed on the Health Systems
Trust (HST) website (www.hst.org.za). In addition, a substantial set
of district-level data is presented in the District Health Barometer
reports, which can also be accessed from the HST website.

Although attention is drawn to known data quality or interpretation

issues, it is not possible to verify, adjust and correct every data
source in detail. Caution is therefore advised with regard to which
types of indicators are presented and whether their use is suitable

PM
for the intended purpose.13

The National Department of Health intends to issue Annual Health

Statistics (AHS) each year. To date, only the 2012 edition has been

16 6
published. The 2015 edition has been prepared, but has not yet
been published.

20 IL
In addition to routine sources and annual surveys, several key
surveys will either be in the field during 2016, or are expected
Y T
to release results this year. These data will contribute significantly
A N
to monitoring a range of demographic and health indicators. The
expected new sources include the:
M U

➢➢ Stats SA Community Survey 2016 (with a much larger sample

size than the 2007 survey)
4 ED

➢➢ South Africa Demographic and Health Survey 2016

➢➢ SANHANES-2
O

➢➢ South African National HIV Prevalence, Incidence and

Behaviour Survey Report
G

➢➢ TB prevalence survey
R

➢➢ National Income Dynamics Study Wave 4

BA

➢➢ Study on global AGEing and adult health (SAGE) Wave 2.

N
O

Indicator definitions: The definitions of all indicators appearing

in the tables are given at the end of the chapter on page 332.
EM

Trends and time-series: For most indicators, data are given for
several years, often from multiple different sources. In most cases
these data can thus not be used to assess trends and changes
over time due to possible differences in methodology and data
presentation issues. Even data from regular surveys may not be
comparable over time, or revised data for a historical time series
may be released, as for example with the General Household
Surveys and mid-year population estimates. This may result in
different values being published compared to previous editions.
Therefore, when using time series data, the most recent revisions
should be obtained from the online database and not from
previous printed editions of this chapter.

S A H R 20 1 6 249
Demographic indicators
Context Demographic indicators provide the critical denominator data for many other indicators. A periodic census allows
for the recalibration of such figures. However, later projections from the census struggle to take account of the
effects of large-scale migration, especially where such movements occur over the short-term, or are exacerbated
by crises, either natural or man-made. The Community Survey 2016 is in the field, with a planned increase in the
sample size, and will provide interim demographic indicators.
New data sources Some of the key new sources of national data included in this section are:
• Stats SA Census 2011 series of analytical publications on population dynamics, migration dynamics and
fertility
Internationally, new reports include:
• The State of World Population 2015
• World Report on Ageing and Health
Key issues and trends A key report from the Census 2011 was that dealing with fertility, which provided new estimates of total fertility

PM
rate (TFR), and in particular data on the adolescent fertility rate. Although South Africa is moving through a
demographic transition, it still has to deal with the health issues of a large youth cohort, even as it starts to deal
with the non-communicable disease burden associated with an aging population.

16 6
In 2015, the United Nations Population Fund (UNFPA) report “The altered the population structure of the country, except perhaps
State of the World Population” drew attention to the issue of those in relation to the Indian ethnic group. Although exact figures are

20 IL
requiring humanitarian assistance.14 The report pointed out that
more people were displaced by crises in 2015 than at any time
since the Second World War. It estimated that 59.5 million were Y T
displaced, more than 100 million were in need of humanitarian
A N
assistance, and that natural disasters affected 200 million people
a year. Based on data from the Census 2011, Stats SA issued a
M U
not reported, the trends over time show increasing international
migration, with approximately 100 000 female and 140 000 male
international migrants recorded in 2011 (Figure 1). This appears
to be a significant under-recording of the phenomenon. Based on
data from a long-term panel study undertaken in five relatively
impoverished Johannesburg neighbourhoods, the health status of

report on population dynamics in South Africa.15 The age and sex international migrants and South African respondents is similar.16
structure of any given population is a function of the three major If, as is expected, non-documented international migrants are not
4 ED

demographic phenomena: migration, fertility and mortality. That evenly distributed between provinces, but are accessing health
age and sex structure has a major impact on demands for health services, this calls into question the population data used in the
services, as well as other services (such as education). Migration equitable share calculation, as well as the denominators used for
O

occurs both internally (such as from province to province) and many indicators. In addition, international migrants do pose some
internationally. Although acknowledging that a Census only particular health challenges, as shown by the increased incidence
G

captured those international migrants who declare themselves as of imported malaria, including in provinces other than those which
such, Stats SA concluded that migration does not appear to have are malaria endemic.
R
BA

Figure 1: Trends in international migration to South Africa, 1985–2011

O

160 000
EM

140 000

120 000

100 000
Migrant population

Male
80 000

60 000
Female
40 000

20 000

0
1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

Year

Source: Stats SA Census 2011: Population Dynamics.15

250 S A H R 20 1 6
 Health and Related Indicators

The Stats SA Population Dynamics report noted that fertility seems to
have been the “main contributing factor to the change in population
age-sex structure over time”. Declining fertility has resulted in a “shift
from child population to youth population aged 20–29”, creating
a potential “demographic dividend”. However, it also notes that
“youth unemployment rates, uncertainties about quality of education
and the scourge of HIV and AIDS” may result in the country not
enjoying the benefits of this ‘dividend’. The overall shift in the
population age-sex structure between 1985 and 2011 is depicted
in the population pyramids provided by Stats SA (Figure 2).
Figure 2: Population of South Africa, 1985 and 2011
Age
80+
occurred after the age of 30 years. It also showed that African
and coloured women experienced their first birth earlier than white
mothers, irrespective of province, residence or education. The
adolescent fertility rate (per 1 000 girls aged 15–19 years) is a
new indicator, included in Table 2 and Table 3. The national figure
is 70 per 1 000 adolescents, varying from 60 in Gauteng and the
Western Cape to 80 in other provinces. Differences per population
group are far wider, ranging from 14 in white adolescents to 76 in
African adolescents.
Globally, there is great interest in the effects of ageing populations
on health and thus the need for healthcare services. A World
Health Organization report in 2015 has, however, challenged the
prevailing stereotypes, supporting the contention that “70 is the
new 60”.18 However, this contention has also been challenged as

PM
70-74 Males potentially placing vulnerable older people at risk, and perhaps as
60-64 Females
ill-fitting to low- and middle-income countries. The WHO report also
50-54
included data on changes in national total fertility rates by economic
strata. Although South Africa is an upper middle-income country,

16 6
40-44
its national TFR is still closer to that of low middle-income or even
30-34
low-income countries (Figure 3).

20 IL
20-24

10-14
Figure 3: Fertility rates in low-, middle- and high-income countries,
0-4
8.0 6.0 4.0 2.0 0.0
Y T
2.0 4.0 6.0 8.0
1960–2011
A N
% Population 1985 7
M U

Age
6
80-84
Males
4 ED

70-74
Females 5
60-64
Births per woman

50-54 4
O

40-44

30-34 3
G

20-24
2
10-14
R

0-4
1
BA

15.0 10.0 5.0 0.0 5.0 10.0 15.0

% Population 2011
O

0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Source: ASSA2008 and Census 2011 as cited in Stats SA Census 2011:
EM

Population Dynamics.15 Year

Note: Axes adjusted so that each age-sex bar represents the percentage of High-income Organisation for Economic Co-operation and Development
the total population.
High-income
Upper-middle-income
Stats SA has also issued a specific report on fertility, based on the
Lower-middle-income
Census 2011 data,17 which recorded a national total fertility rate
Low-income
(TFR) of 2.67. Although data quality issues could not be ruled out,
SA TFR
the Census 2011 showed an increase in the TFR for the coloured
population from 2.41 in 2001 to 2.57 in 2011. As before, the TFR
Source: Adapted from Census 2011 Fertility17 and World Report on
for the African population was highest (2.82), while the values for Ageing.18
both the white (1.70) and Indian (1.85) population groups were
below the replacement level. As expected, TFRs were lowest in the
most developed provinces (Gauteng, Western Cape) and highest
in the more rural provinces (Limpopo, Eastern Cape), reflecting the
combined effects of differences in socio-economic status and the
dominance of specific population groups. The Stats SA report also
provided insights into the age of mothers at first birth. It showed
that the majority of first births occurred when women were aged
between 18 and 20 years, and that less than 5% of all first births

S A H R 20 1 6 251
Table 2: Demographic indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Adolescent fertility rate (per 1000 girls aged 15–19 years)
2011 80.0 70.0 60.0 80.0 80.0 80.0 80.0 80.0 60.0 70.0 a
Ageing index
2011 Census 20 19 18 15 18 15 19 19 23  18 b
2015 mid-year 15 20 22 14 15 14 23 17 23  17 c
Age dependency ratio
2011 Census 66.0 52.9 39.0 58.5 67.3 56.0 55.7 54.5 45.0 52.7 d
Annual population growth rate
2011 2001–2011 0.44 0.14 2.68 0.69 0.79 1.83 1.44 1.62 2.52  1.44 b
2015 2014–2015 - - - - - - - - -  1.65 c
Area (square km)
2011 168 966 129 825 18 178 94 361 125 754 76 495 372 889 104 882 129 462  1 220 813 b
Area as a % of total area of South Africa

PM
2011 13.8 10.6 1.4 7.7 10.3 6.3 30.5 8.7 10.6  100.0 b
Average household size
2011 Census 3.7 3.2 3.0 3.9 3.7 3.7 3.7 3.2 3.4  3.4 b
Crude death rate (deaths per 1 000 population)

16 6
2014 unadjusted - - - - - - - - -  8.4 e

20 IL
2015 mid-year - - - - - - - - -  9.6 f
Population – Census and Stats SA mid-year estimates
2011 Census 6 562 053 2 745 590 12 272 263 10 267 300 5 404 868 4 039 939 1 145 861 3 509 953 5 822 734  51 770 561 b
2015 mid-year
Population – DHIS estimates
6 916 200 Y T
2 817 900 13 200 300 10 919 100 5 726 800 4 283 900 1 185 600 3 707 000 6 200 100  54 956 900 c
A N
2015 DHIS 6 692 803 2 763 018 13 267 544 10 688 165 5 654 033 4 235 606 1 182 278 3 702 970 6 245 836  54 432 253 g
2016 DHIS 6 731 182 2 768 642 13 543 184 10 806 538 5 724 448 4 290 010 1 191 995 3 757 769 6 362 257  55 176 026 g
M U

2017 DHIS 6 773 280 2 765 819 13 820 215 10 924 776 5 789 938 4 344 144 1 202 801 3 809 367 6 478 871  55 909 212 g
2018 DHIS 6 815 094 2 773 543 14 088 410 11 039 740 5 849 604 4 395 703 1 212 630 3 858 959 6 589 734  56 623 417 g
4 ED

Population % by province
2011 Census 12.7 5.3 23.7 19.8 10.4 7.8 2.2 6.8 11.2  100.0 b
2015 mid-year 12.6 5.1 24.0 19.9 10.4 7.8 2.2 6.7 11.3  100.0 c
Population density (people per km2)
O

2011 Census 38.8 21.1 675.1 108.8 43.0 52.8 3.1 33.5 45.0  42.4 b
G

2015 mid-year 40.9 21.7 726.2 115.7 45.5 56.0 3.2 35.3 47.9  45.0 c
Public sector dependent population – based on medical scheme coverage reported in the General Household Survey (GHS)
R

2014 GHS 6 097 394 2 296 119 9 292 722 9 358 755 5 149 542 3 587 874 942 269 3 112 069 4 493 087  44 274 032 h
2015 GHS 6 189 999 2 313 496 9 477 815 9 521 455 5 234 295 3 645 599 950 851 3 158 364 4 569 474  45 009 701 h
BA

Public sector dependent population – based on population minus number of beneficiaries reported by Council for Medical Schemes
2014 non med scheme 6 115 606 2 394 063 9 959 696 9 430 704 5 196 166 3 626 168 982 490 3 127 784 4 785 456 45 244 189 i
O

Total fertility rate

2011 Census 2.9 2.5 2.3 2.7 3.3 2.9 2.8 2.8 2.3  2.7 j
EM

2015 mid-year - - - - - - - - -  2.6 c

2015 mid-year 2011–2016 3.0 2.3 2.1 2.9 2.9 2.5 2.4 2.6 2.2  - c

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Census 2011 Fertility.17 National value estimated from graph since not included in report. Values multiplied by 1 000 to convert from rate per individual
adolescent.
b Census 2011.19
c Stats SA Mid-year Estimates. 2015 mid-year estimates.20
d Census 2011 Population dynamics.15
e Stats SA Causes of death 2014.10 Data have been updated with late registrations processed in 2015. Not adjusted for under-reporting - completeness of
death registration for children uncertain, completeness for adults estimated at 94%.
f Stats SA Mid-year Estimates. 2015 mid-year estimates.20 CDR assumption used in population projections.
g DHIS Population Estimates 2002–2018.
h Stats SA GHS 2014.21 Calculated using provincial medical scheme coverage (GHS 2014) and Stats SA mid-year estimates for the relevant year.
i Medical Schemes 2014–15.22 Calculated from total number of beneficiaries subtracted from total population (Stats SA mid-year estimates for the relevant
year).
j Census 2011 Fertility.17

2 52 S A H R 20 1 6
 Health and Related Indicators

Table 3: Demographic indicators by population group

African Coloured Indian White Other All Ref

Adolescent fertility rate (per 1000 girls aged 15–19 years)
2011 76.0 71.0 20.0 14.0 - 70.0 a
Ageing index
2011 Census 14 17 34 84 23  18 b
2015 mid-year 13 19 36 91 -  17 c
Population
2011 Census 41 000 938 4 615 401 1 286 930 4 586 838 280 454  51 770 561 b
2015 mid-year 44 228 000 4 832 900 1 362 000 4 534 000 -  54 956 900 c
Population % by population group
2011 Census 79.2 8.9 2.5 8.9 0.5  100.0 b
2015 mid-year 80.5 8.8 2.5 8.3 -  100.0 c
Public sector dependent population
2013 GHS 37 717 446 3 736 679 716 494 1 058 549 - 43 233 305 d

PM
2014 GHS 38 778 133 3 811 882 689 310 1 052 479 -  44 274 032 d
2015 GHS 39 539 832 3 851 821 698 706 1 047 354 -  45 009 701 d

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):

16 6
a Census 2011 Fertility.17 National value estimated from graph since not included in report. Values multiplied by 1 000 to convert from rate per individual
adolescent.

20 IL
b Census 2011.19
c Stats SA Mid-year Estimates. 2015 mid-year estimates.20
d Calculated using medical scheme coverage (Stats SA GHS 2013 and 2014)21,23 and Stats SA mid-year estimates for the relevant year.
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 2 53
Socio-economic and risk factor indicators
Context Although a focus on the determinants of health has been central to the Primary Health Care approach, which is
entrenched as underpinning South African health policy, this focus has been given even more prominence by the
Sustainable Development Goals (SDGs), and its renewed attention to intersectoral action.
New data sources Nationally, new data have been reported in the:
• Stats SA Quarterly Labour Force surveys, 2015 (Q3)
• Stats SA Education and Gender, 2004–2014
• Stats SA Census 2011 Profile of Educational Attainment
• Stats SA Census 2011 Income Dynamics
• Department of Water Affairs 2014 Blue Drop Report
Internationally, data of interest have been reported in the:
• UNDP Human Development Report 2015

PM
• UNICEF Unless we act now: The impact of climate change on children
Key issues and trends Although an updated Blue Drop Report (with data from the 2014 audit) was finally released, no Green Drop
Report has yet been issued. The Blue Drop Report is poorly constructed and difficult to interpret. Similarly,
updated data on air pollution are difficult to access and interpret.

16 6
Key socio-economic indicators, such as the unemployment rate, provide evidence of the persistent gaps that exist
between population groups and provinces and also the impact of lower than expected economic growth.

20 IL
The United Nations Development Programme’s annual Human A key measure of socio-economic status is the unemployment rate,
Y T
Development report places countries in a hierarchy, based on the
Human Development Index.24 In 2015, South Africa was placed in
reported on a quarterly basis by Stats SA. The most recent figures
show that unemployment increased by 626 000 in quarter 1 of
A N
the ‘medium development’ strata, at position 116, together with El 2015, decreased by 305 000 in quarter 2, but then increased
M U

Salvador and Viet Nam. The Human Development Index value for again by 188 000 in quarter 3.27 Overall, the national official
South Africa continues to improve steadily. unemployment rate in quarter 3 was 25.5%, but 34.4% when
measured by the expanded definition. It is against this sustained
4 ED

Climate change has the potential to have significant impacts on

high level of unemployment that the increased access to child care
the environment, which will in turn impact on population health.
grants needs to be seen. The Child Gauge 2015 reported that, by
In 2015, the United Nations Children’s Fund (UNICEF) published
March 2013, over 11.7 million children were receiving a Child
a report examining the potential impact of climate change on
O

Support Grant; 500 000 children a Foster Child Grant and 127 000

children’s health, in particular.25 An obvious example, with direct
children a Care Dependency Grant.28
G

relevance to South Africa in 2015/16, would be the effects of

increased incidence of drought on water supply and sanitation Stats SA has also issued a number of detailed reports based on
R

services. Severe storms, resulting in floods and landslides, can also further analyses of the Census 2011 data. This includes reports on
affect access to safe water and sanitation. After considerable delay, income dynamics and education attainment.29-31 These provide
BA

the Department of Water and Sanitation released the Blue Drop compelling evidence of the persistence of poverty in South Africa,
Report 2014 in early 2016.26 The report claimed that the National where 15.5% of households in 2011 (down from 23.2% in the 2001
O

Blue Drop score (measuring the performance of individual potable Census) reported no income at all. They also showed persistent
EM

water suppliers) has “improved substantially” since 2009; but also
that the “drop in performance in general in 2014 is perturbing and
water services authorities and their providers need to regain the
progress made in 2012”. The 2014 audit assessed 152 Water
Service Authorities, providing services via 1 036 treatment systems.
Only 44 Blue Drops (indicating excellence) were awarded to 20 of
the 152 Water Service Authorities. Overall, it was claimed that 60%
of the water supplied daily was supplied with Blue Drop excellence.
Critically, no updated report on waste water treatment (the Green
Drop report) was issued. Stats SA has reported on sanitation and
refuse removal as part of the General Household Survey 2014.21
The percentage of households with access to ‘improved sanitation’
(i.e. a flush toilet connected to a public sewerage system or septic
tank, or a pit toilet with a ventilation pipe) is one of the WHO
100 Core Health Indicators and was 79.5% nationally in 2014.
Nationally, only 4.9% of households had no sanitation or relied on
the bucket system in 2014, but the percentage was still high in the
Northern Cape (9.1%), Eastern Cape (8.5%), Free State (7.9%) and
Mpumalanga (7.1%).
gaps between the educational attainment status of Whites and both
Coloureds and Africans. Lack of educational attainment has an
increasingly important effect on employment status, as unskilled and
semi-skilled jobs are lost from the economy.
Air quality is also a focus on the SDGs (target 3.9 reads: “By
2030, substantially reduce the number of deaths and illnesses
from hazardous chemicals and air, water and soil pollution and
contamination”) and a measure of air pollution is included in the
WHO 100 Core Health Indicators (defined as “Annual mean
concentration of particulate matter of less than 2.5 microns of
diameter (PM2.5) [μg/m3] (or of less than 10 microns [PM10] if
PM2.5 is not available) in cities”). Recent data on this indicator are
difficult to access. The 2012 PM10 data presented here are from
the WHO Global Health Observatory, although trend information
by city areas is available in the 2014 Department of Environmental
Affairs Annual Air Quality Governance Lekgotla.32

254 S A H R 20 1 6
 Health and Related Indicators

Table 4: Socio-economic indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Air pollution level in cities (particulate matter [PM])
2012 PM10 - - - - - - - - -  56.0 a
Drinking Water System (Blue Drop) Performance Rating
2012 82.1 73.6 98.1 92.1 79.4 60.9 68.2 78.7 94.2  87.6 b
2014 72.0 75.0 92.0 86.0 62.0 69.0 68.0 63.0 89.0  79.6 c
Education level: percentage of population 20 years and older with no schooling
2013 no schooling 5.9 4.4 2.0 7.8 10.4 10.6 7.8 8.3 1.2  5.5 d
2014 no schooling 5.5 4.2 2.0 7.1 10.1 9.3 6.9 7.4 2.1  5.2 e
Human development index (high value = best)
2013 - - - - - - - - -  0.663 f
2014 - - - - - - - - -  0.666 f
Human development index rank (1 = best)
2013 - - - - - - - - -  117 f

PM
2014 - - - - - - - - -  116 f
Literacy rate
2014 90.4 92.3 97.6 89.8 84.8 85.8 89.4 89.6 97.9  93.1 g
Percentage of households by type of housing

16 6
2014 formal 64.3 83.8 78.9 74.8 93.6 88.1 83.6 78.0 82.5  79.4 e

20 IL
2014 informal 7.8 14.3 19.2 8.1 3.9 7.6 10.8 21.0 14.8  12.9 e
2014 traditional 27.7 1.8 0.3 17.0 2.4 4.3 1.9 0.9 0.0  6.8 e
Percentage of households using electricity for cooking (%)
2013 GHS
2014 GHS
71.5
74.9
Y T
88.8
89.4
84.6
84.9
75.5
77.5
53.6
57.0
75.6
76.6
83.9
85.3
81.1
81.9
88.3
89.2
 78.4
 79.8
d
e
A N
Percentage of households with access to piped water
2013 GHS 80.5 95.9 95.9 86.2 77.5 86.7 96.1 88.3 98.7  89.9 d
M U

2014 GHS 78.5 95.3 96.4 86.5 79.6 87.1 95.8 87.2 98.9  90.0 e
Percentage of households with no toilet / bucket toilet
4 ED

2013 GHS 10.0 7.7 1.8 5.5 7.2 6.3 7.4 5.0 3.6  5.1 d
2014 GHS 8.5 7.9 1.9 4.8 5.4 7.1 9.1 5.1 4.5  4.9 e
Percentage of households with telephone (telephone in dwelling or cell phone)
O

2013 GHS 89.4 94.1 98.0 95.5 95.7 96.8 86.4 94.0 93.0  95.0 d
2014 GHS 91.1 95.1 98.2 96.9 96.4 96.8 89.8 93.8 94.8  95.9 e
Population using safely managed sanitation services (%)
G

2013 GHS 71.2 83.3 90.2 73.9 50.0 62.7 81.7 70.0 94.8  77.9 d
R

2014 GHS 78.1 83.8 90.9 75.7 54.0 64.3 83.7 66.7 94.6  79.5 e
Poverty prevalence (%)
BA

2011 Census food poverty line 40.5 31.6 26.8 37.4 41.5 35.3 28.2 33.4 23.2  32.7 h
2011 FPL rebased - - - - - - - - -  21.7 i
O

2011 LBPL rebased - - - - - - - - -  37.0 j

2011 UBPL rebased - - - - - - - - -  53.8 k
EM

Unemployment rate (official definition)

2013 Q3 30.8 34.0 24.3 20.9 17.8 26.6 28.0 26.6 23.4  24.7 l
2014 Q3 29.1 32.2 24.6 20.8 15.9 26.6 28.7 25.2 22.9  24.3 m
2015 Q3 29.2 31.5 28.6 20.5 18.8 26.2 34.8 25.4 20.6  25.5 n

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Global Health Observatory. http://gamapserver.who.int/gho/interactive_charts/phe/oap_exposure/atlas.html [accessed 11/2/2016].
b Blue Drop 2012.33
c Blue Drop 2014.26 No report has been produced for 2013.
d Stats SA GHS 2013.23
e Stats SA GHS 2014.21
f Human Development Report 2015.24
g Gender & Education Vol 2.31
h Census 2011 Poverty.29 Census results considered less accurate compared to specific income/poverty surveys. Income data from Census 2011 significantly
overestimated the proportion of households that claimed to have no income, resulting in higher levels of poverty.
i Poverty Trends 2006–2011.34 Derived from the Income and Expenditure Survey (IES) 2010/2011. The food poverty line (FPL) is the level of consumption
below which individuals are unable to purchase sufficient food to provide them with an adequate diet. Food poverty line rebased – equates to 10.9 million
people in 2011.
j Poverty Trends 2006–2011.34 Lower-bound poverty line – equates to 18.6 million people in 2011.
k Poverty Trends 2006–2011.34 Upper-bound poverty line – equates to 27.1 million people in 2011.
l Stats SA Labour Force Survey.35 Quarter 3, 2013 Report.
m Stats SA Labour Force Survey.35 Quarter 3, 2014 report.
n Stats SA Labour Force Survey.27 Quarter 3, 2015 report.

S A H R 20 1 6 2 55
Table 5: Socio-economic indicators by population group

African Coloured Indian White All Ref

Education level: percentage of population 20 years and older with no schooling
2014 no schooling 6.4 2.2 2.0 0.2  5.2 a
Literacy rate
2014 91.6 96.9 97.3 99.9  93.1 b
Percentage of households using electricity for cooking (%)
2014 GHS 76.9 90.5 94.7 91.3  79.8 a
Percentage of households with access to piped water
2014 GHS 88.1 98.7 99.4 96.3  90.0 a
Percentage of households with no toilet / bucket toilet
2014 GHS 5.8 2.3 0.0 0.0  4.9 a
Poverty prevalence (%)
2011 Census food poverty line 37.5 21.7 13.0 10.8  32.7 c
2011 upper-bound poverty line 54.0 27.6 3.4 0.8  45.5 d

PM
Unemployment rate (official definition)
2014 Q3 27.2 22.9 11.9 7.7  24.3 e
2015 Q3 28.8 22.8 12.5 5.9  25.5 f

16 6
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2014.21

20 IL
b Gender & Education Vol 2.31
c Census 2011 Poverty.29 Census results considered less accurate compared to specific income/poverty surveys. Income data from Census 2011 significantly
overestimated the proportion of households that claimed to have no income, resulting in higher levels of poverty.
d Y T
Poverty Trends 2006–2011.34 Derived from the Income and Expenditure Survey (IES) 2010/2011. The lower-bound poverty line (LBPL) includes non-food
items, but requires that individuals sacrifice food in order to obtain these, while individuals at the upper-bound poverty line (UBPL) can purchase both
adequate food and non-food items. The Rand value of each line is updated annually using CPI prices data.
A N
e Stats SA Labour Force Survey.35 Quarter 3, 2014 report.
f Stats SA Labour Force Survey.35 Quarter 3, 2015 report.
M U
4 ED
O
G
R
BA

N
O
EM

256 S A H R 20 1 6
 Health and Related Indicators

Health status indicators

Mortality
Context Despite improved access to antiretroviral treatment, South Africa’s mortality data still show the impact of HIV,
described by Stats SA as “the most catastrophic loss of life” and as “unprecedented in recent recorded history”.
New data sources Nationally, new data have been reported in the:
• Stats SA Mortality and causes of death in South Africa, 2014
• Stats SA Census 2011 Estimation of Mortality in South Africa
• Rapid Mortality Surveillance Report 2014
Internationally, reports of interest include:
• Global Burden of Disease Study 2013 – diseases and injuries among children and adolescents
• Global Burden of Disease country profiles on morbidity and mortality (healthdata.org)
Key issues and trends Mortality statistics drawn from the civil registration system continue to show the sustained gains that have resulted

PM
from overall improvements in health status, but are perhaps most closely related to expanded access to ART.
Mortality data are increasingly available at district municipality level rather than only at provincial level, and
can even be disaggregated by local municipality. However, the completeness and quality of data may vary
substantially between areas, complicating the comparison of mortality rates.

16 6
A recent issue from the Global Burden of Disease Study 2013 (GDB) 21.8% of deaths. This included 779 deaths specifically recorded as

20 IL
has reported on the causes of mortality among adolescents and due to multidrug-resistant tuberculosis (MDR-TB) and 77 deaths due
children.36 It showed that, in 2013, the leading causes of death to extensively drug-resistant tuberculosis (XDR-TB). The data were
Y T
were lower respiratory tract infections (among younger children),
diarrhoeal diseases (among older children) and road injuries
presented not only by province, but also by district municipality. The
report stated that disaggregated data by local municipality were
A N
(among adolescents). The persistence of some of these causes in available on request.
particular locales was striking: Nigeria was responsible for 12%
M U

The question of how many patients on antiretroviral treatment (ART)

of global deaths from lower respiratory tract infections and 38%
are still succumbing to their disease (or other unrelated causes)
of global deaths from malaria; India accounted for 33% of global
is difficult to answer. Based on data from six ART centres, where
4 ED

deaths from neonatal encephalopathy. Similarly, half of the global

patient records were linked with vital registration data based on the
deaths from diarrhoeal diseases occurred in only five countries:
unique identity number, it was shown that deaths noted in patient
India, the Democratic Republic of the Congo, Pakistan, Nigeria and
files were recorded in vital registration records 94% of the time, but
O

Ethiopia. Although lower respiratory tract infections remained the

that only 35% of deaths recorded in vital registration records also
leading global cause of death and adolescents and children, there
appeared in patient records.38 It was therefore concluded that any
G

was a 57.6% median reduction in global DALY counts and 58.8%

estimates of ART mortality based on patient records only were likely
median reduction in global DALY rates between 1990 and 2013.
R

to be biased.
Similar changes were seen for those aged younger than 5 years,
which are a testament to the global attention paid to child health Although now somewhat dated, the estimates of mortality in South
BA

in the MDG era. The Institute for Health Metrics and Evaluation Africa derived from the Census 2011 are still interesting, especially
(IHME) has provided intriguing graphical representations of the as they reflect changes in relation to AIDS-related mortality over
O

GBD data for individual countries, showing the changes in causes time.39 The report also provided estimates of the under-5 mortality
EM

of morbidity and mortality.37 Figure 4 shows the changes between
1990 and 2013 in the number of years lived with disability (YLD)
due to leading causes (disaggregated by communicable, maternal,
neonatal, and nutritional diseases, non-communicable diseases and
injuries). Over that time period, the most dramatic change was in
HIV and AIDS, which moved from position 70 to position 1, a shift
in excess of 12 000%. Other notable shifts include a 35% increase
in YLDs due to diabetes and a 29% decrease in YLD due to iron-
deficiency anaemia.
The 2014 update to the Stats SA report “Mortality and causes
of death in South Africa” (P0309.3) was released in December
2015.10 These data are drawn from the civil registration system
and are based on 453 360 reported deaths, showing a sustained
downward trend since the peak in 2006 (Figure 5). Of these, 78.4%
were reported within 72 hours of the death. The overall leading cause
of death remained infections and parasitic diseases, responsible for
rate (44.0 per 1 000 live births) and maternal mortality ratio (580
per 100 000 live births), but these differed markedly from estimates
prepared from civil registration data. Nonetheless, Stats SA were
of the opinion that, overall, “the findings suggest that the country
has made significant progress towards achievement of the MDG
targets”.
The fourth annual report of data from the Rapid Mortality
Surveillance (RMS) database was released in December 2015 and
tracks several high-level indicators of mortality, after correcting for
the incompleteness of reporting.40 A steady improvement in birth
and identity registration has improved the completeness of the
population register, although this has exposed apparent under-
recording in the vital registration (cause of death) data.

S A H R 20 1 6 2 57
Figure 4: Leading causes of YLDs in South Africa, 1990 and 2013, and percent change, 1990–2013

1990 ranking 2013 ranking % change 1990-2013

Low back & neck pain 1 1 HIV/AIDS 12 792%

Depressive disorders 2 2 Low back & neck pain 23%

Iron-deficiency anemia 3 3 Depressive disorders 11%

Sence organ diseases 4 4 Sence organ diseases 8%

Skin diseases 5 5 Skin diseases 1%

Anxiety disorders 6 6 Iron-deficiency anemia -29%

Tuberculosis 7 7 COPD 22%

COPD 8 8 Tuberculosis 10%

Intellectual disability 9 9 Anxiety disorders 3%

PM
Migraine 10 10 Diabetes 35%

11 11 Migraine 6%

16 6
Diabetes

HIV/AIDS 70 14 Intellectual disability -13%

20 IL
Communicable, maternal, neonatal and
Non-communicable diseases Injuries
nutritional diseases
Y T
A N
Source: IHME Global Burden of Disease 2013 Country Profile for South Africa (healthdata.org).
M U

Notes: YLDs are years lived in less than ideal health. This includes conditions that may last for only a few days, as well as conditions that can last a lifetime.
Rankings are based on YLDs per 100 000, all ages, not age-standardised.
The small burden of HIV and AIDS in 1990 accounts for the dramatic relative increase in burden from this cause.
4 ED

Figure 5: Number of registered deaths by year of death, 1997–2014

O

700 000
G

600 000
R
BA

500 000
O
Number of deaths

EM

400 000

300 000

200 000

100 000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Stats SA 317 727 366 477 382 530 417 042 456 054 503 160 558 258 578 217 599 267 614 014 605 949 597 781 582 956 550 401 514 938 492 062 473 384 453 360

Year of death

Source: Stats SA Census 2011: Mortality.39

258 S A H R 20 1 6
 Health and Related Indicators

Table 6: Mortality indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Adult mortality (45q15 – probability of dying between 15–60 years of age)
2010 BoD 52.2 53.7 33.9 52.8 37.7 47.4 43.9 44.5 26.6  42.6 a
2010 Census both - - - - - - - - -  37.4 b
2010 Census female - - - - - - - - -  31.2 b
2010 Census male - - - - - - - - -  43.6 b
2010 RMS 2014 both - - - - - - - - -  43.0 c
2010 RMS 2014 female - - - - - - - - -  38.0 c
2010 RMS 2014 male - - - - - - - - -  48.0 c
2011 RMS 2014 both - - - - - - - - -  40.0 c
2011 RMS 2014 female - - - - - - - - -  35.0 c
2011 RMS 2014 male - - - - - - - - -  46.0 c
2012 RMS 2014 both - - - - - - - - -  38.0 c
2012 RMS 2014 female - - - - - - - - -  32.0 c

PM
2012 RMS 2014 male - - - - - - - - -  44.0 c
2013 RMS 2014 both - - - - - - - - -  36.0 c
2013 RMS 2014 female - - - - - - - - -  30.0 c
2013 RMS 2014 male - - - - - - - - -  42.0 c

16 6
2013 GBD 2013 female - - - - - - - - -  35.3 d

20 IL
2013 GBD 2013 male - - - - - - - - -  45.2 d
2014 RMS 2014 both - - - - - - - - -  34.0 c
2014 RMS 2014 female - - - - - - - - -  28.0 c
2014 RMS 2014 male
Life expectancy at birth (e0)
- Y T- - - - - - - -  40.0 c
A N
2010 BoD 53.8 53.4 63.2 52.9 63.6 56.6 59.3 58.0 68.0  58.8 a
2010 Census - - - - - - - - -  57.9 b
M U

2010 Census female - - - - - - - - -  60.6 b

2010 Census male - - - - - - - - -  55.2 b
4 ED

2010 RMS 2014 both - - - - - - - - -  58.5 c

2010 RMS 2014 female - - - - - - - - -  61.2 c
2010 RMS 2014 male - - - - - - - - -  56.0 c
O

2011 RMS 2014 both - - - - - - - - -  60.5 c

2011 RMS 2014 female - - - - - - - - -  63.2 c
G

2011 RMS 2014 male - - - - - - - - -  57.8 c

2012 RMS 2014 both - - - - - - - - -  61.3 c
R

2012 RMS 2014 female - - - - - - - - -  64.0 c

2012 RMS 2014 male - - - - - - - - -  58.5 c
BA

2013 RMS 2014 both - - - - - - - - -  62.2 c

2013 RMS 2014 female - - - - - - - - -  65.1 c
O

2013 RMS 2014 male - - - - - - - - -  59.4 c

2014 RMS 2014 both - - - - - - - - -  62.9 c
EM

2014 RMS 2014 female - - - - - - - - -  65.8 c

2014 RMS 2014 male - - - - - - - - -  60.0 c
2014 mid-year - - - - - - - - -  62.5 e
2014 mid-year female - - - - - - - - -  64.5 e
2014 mid-year male - - - - - - - - -  60.5 e
2015 mid-year - - - - - - - - -  62.5 e
2015 mid-year female - - - - - - - - -  64.3 e
2015 mid-year male - - - - - - - - -  60.6 e

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Burden of Disease SA 2010.41
b Census 2011 Mortality.39
c RMS 2014.40 Estimates for 2013 are based on RMS data rather than VR data because of apparent significant under-recording of the VR (cause of death)
data.
d Global Burden of Disease 2013.42
e Stats SA Mid-year Estimates. 2015 mid-year estimates.20

S A H R 20 1 6 2 59
Disability
Context Although no new data on disability are available, this section is retained for the sake of completeness.
New data sources Nationally, no new data have been reported.
Internationally, media reports have focused on the gap between life expectancy at birth and the proposed
measure of ‘healthy life expectancy’ (HALE)
Key issues and trends The data shown below are repeated from the previous issue of the Health Review.

Data from the Global Burden of Disease Study 2013 (GBD 2013)
have been used to calculate the gap between life expectancy at
birth and another summary measure, health life expectancy (HALE)
proposed by the University of Washington’s Institute for Health
Metric and Evaluation (IHME).43,44 The latter takes into account the
number of years lived with illness and disability. On average, while
life expectancy at birth has increased, so have the number of years
lived with illness and disability. The gap between HALE and life
expectancy at birth is on average 9.2 years (with 62.3 years lived
in a healthy state out of a life expectancy of 71.5 years (Figure 6).
In South Africa the gap is 8.4 years (with 52 years lived in a healthy
state out of a life expectancy of 60.4 years). South Africa was one
of a few countries which experienced a reduction in life expectancy
and HALE between 1990 and 2013 (Figure 7).

PM
Figure 6: The gap between HALE and life expectancy, highlighting the position of South Africa, 2013

16 6
Years

20 IL
35 40 45 50 55 60 65 70 75 80 85 90

Y T
A N
M U
4 ED
O
G
R

Healthy life Life

BA

expectancy expectancy
O
EM

62.3 71.5 World Average

+9.2

52 60.4 South Africa

+8.4

Source: GBD 2013 DALYs and HALE collaborators, Lancet 2015 and Noack et al. 2015.43,44

Note: The gap between healthy life expectancy (HALE) and life expectancy grows as life expectancy rises. The gap is greatest in Switzerland at 12.8 years,
and narrowest in Papua New Guinea, at six years.

26 0 S A H R 20 1 6
 Health and Related Indicators

Figure 7: Change in HALE and life expectancy for South Africa, 1990–2013

Years
40 50 60 70 80 90

2013
HALE LE
52 60.4

56 64.5
1990

PM
Source: GBD 2013 DALYs and HALE collaborators, Lancet 2015 and Noack et al. 2015.43,44

Note: The majority of countries experienced a rise in life expectancy, with some exceptions: Botswana, Namibia, South Africa, Gabon, Zimbabwe, Swaziland,

16 6
Lesotho, Belarus, Belize, Paraguay and Guyana.

20 IL
Table 7: Disability indicators by province

EC
Cataract surgery rate (per million population)
FS Y T GP KZN LP MP NC NW WC SA Ref
A N
2012 DHIS 962.5 471.2 412.8 685.4 737.4 662.1 448.9 426.4 -  553.2 a
2013 DHIS 882.9 387.4 620.3 700.1 568.8 563.3 993.7 661.4 1 272.4  732.0 b
M U

2014 DHIS 1 052.4 608.1 846.4 758.2 751.1 630.5 883.4 594.3 1 287.3  849.7 c
Prevalence of disability (%)
4 ED

2012 GHS 6.0 7.6 3.5 5.0 5.0 5.4 7.1 7.2 4.6  5.1 d
2012 WHODAS score 2.6 3.1 2.0 3.1 3.2 3.9 3.0 2.4 1.4  2.5 e
2013 GHS 6.2 7.1 3.9 5.9 4.7 5.3 8.3 8.1 4.6  5.4 f
2014 GHS 6.0 7.0 3.7 4.7 4.6 4.6 7.5 7.4 4.6  4.9 g
O

Prevalence of hearing disability (%)

2012 age 15+ 10.8 14.3 7.0 13.6 10.5 10.3 4.0 7.2 9.0  9.5 h
G

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
R

a DHIS.45 2012/13 financial year. WC data were not available in the national DHIS datamart as extracted at the time.
b DHIS.45 2013/14 financial year.
BA

c DHIS.45 2014/15 financial year.

d Stats SA GHS 2012.46 This analysis only includes the percentage of persons aged 5 years and older with a disability. This is because children under five
O

years are often mistakenly categorised as being unable to walk, remember, communicate or care for themselves when it is due to their level of development
rather than any innate disabilities they might have.
EM

e SANHANES-1.47 The WHO–Disability Assessment Scale (DAS) score provides an indication of the overall level of self-reported disability in the 30 days
preceding the interview at the time the survey was conducted. It is expected that the level of disability will increase with age. In SANHANES-1, a very low
level of disability was reported at all ages, including the middle and older age group although the results show a trend of increasing disability with age.
f Stats SA GHS 2013.23
g Stats SA GHS 2014.21
h SANHANES-1.47 Self-reported prevalence of wearing a hearing aid.

S A H R 20 1 6 26 1
Infectious disease
Context Even though the SDGs can be perceived as shifting focus to non-communicable diseases, they also broaden the
focus on communicable diseases beyond the ‘Big Three’ (AIDS, tuberculosis and malaria).
New data sources Nationally, new data have been reported in the:
• Surveillance data, surveillance bulletins and other reports issued by NICD

Internationally, there have been many reports on the Ebola virus disease outbreak, and also on the emerging
threat of Zika virus. However, these have not been covered in the Health Review as their direct and immediate
relevance to South Africa is limited. A national response has been mounted though, especially following the
declaration of Zika as a Public Health Emergency of International Concern (PHEIC), in terms of the International
Health Regulations.
Key issues and trends Significant changes in the way prevalence and incidence data on infectious diseases are collected, analysed and
reported is expected with the creation of the National Public Health Institute of South Africa (NAPHISA). A draft
Bill in this regard has been published for comment, but not yet tabled in Parliament.

PM
As has been noted for some years, no updated notifiable disease other target conditions are diphtheria, pertussis, neonatal tetanus,
data have been issued by the National Department of Health. The total tetanus, measles, rubella, congenital rubella syndrome, mumps,
role currently filled by the National Health Laboratory Service diarrhoea, pneumonia, Japanese encephalitis, and yellow fever.

16 6
(NHLS), and in particular the National Institute for Communicable The intention is to provide data disaggregated by age, geographic
Diseases (NICD), is expected to be taken on by the proposed location (such as by district), sex, and vaccination status. Available

20 IL
National Public Health Institute of South Africa (NAPHISA). The data on prevalence of hepatitis B are either dated50 or based on
most recent report on laboratory-confirmed cases of diseases under small sample sizes.51 The latter study, based on only 201 serum

September 2015.48
Y T
surveillance by NICD covered the period 1 January 2014 to 30 samples, showed a decline in occult hepatitis B infection in the post-
vaccination era in South Africa (after the introduction of the vaccine
A N
to the Expanded Programme on Immunisation in April 1995), but
An example of the expanded scope of global attention is provided
significant disease burden in those who are HIV co-infected. Occult
M U

by the inclusion of an indicator on schistosomiasis treatment in the

hepatitis B infection is defined as the presence of hepatitis B DNA
WHO 100 Core Health Indicators (“Proportion of the population
living in endemic areas requiring preventive chemotherapy that in the hepatocytes or serum of individuals who test negative for the
4 ED

received treatment for at least one of the selected neglected tropical surface antigen (HBsAg) by current available assays. The WHO 100
diseases (schistosomiasis, soil-transmitted helminthiases, lymphatic Core Indicator set also contains a specific measure of the prevalence
filariasis, onchocerciasis)”). In South Africa, more than 4 million of hepatitis B surface antigen.
O

people are estimated to be infected with either Schistosoma The September 2015 edition of the NICD Communicable Diseases
haematobium or Schistosoma mansoni.49 About a quarter of the
G

Communiqué provided a summary of available data on rabies to

country, in the north and east, from the Eastern Cape to Limpopo, that point.52 It showed that in the past 15 years there had been
is at risk. Despite the World Health Organization Resolution 54.19,
R

a total of 171 laboratory-confirmed human rabies cases in South

which called for at least 75% treatment coverage of school-age
Africa, of which almost half (43%) were identified in KwaZulu-Natal.
BA

children by 2010, South Africa has yet to implement a sustained

N

Only one case was identified in Gauteng during this period, and
public health response in this regard.
none in the Western Cape. The January 2016 edition showed that
O

The WHO 100 Core Health Indicators also include a composite eight laboratory-confirmed human rabies cases had been identified
EM

measure of “new cases of vaccine-preventable diseases”. Among in 2015.53

the vaccine-preventable diseases to be tracked is hepatitis B. The

262 S A H R 20 1 6
 Health and Related Indicators

Table 8: Selected infectious disease indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Reported cases of cholera
2013 NICD lab confirmed cases - - - - 1 - - - -  1 a
2014 NICD lab confirmed cases - - 2 - - - - - -  2 b
2015 NICD lab confirmed cases 0 0 0 0 0 0 0 0 0  0 c
Reported cases of measles
2013 NICD lab confirmed cases 2 0 3 1 0 0 0 1 1  8 a
2014 NICD lab confirmed cases 2 1 16 6 0 3 35 0 6  69 b
2015 NICD lab confirmed cases 2 1 2 2 0 0 3 1 4  15 c
Reported cases of rabies
2013 NICD lab confirmed cases 0 2 0 1 3 1 0 0 0  7 a
2014 NICD lab confirmed cases 4 0 0 0 1 0 0 1 0  6 b
2015 NICD lab confirmed cases 1 1 0 1 2 0 0 0 0  5 c

PM
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a NICD surveillance. Communicable Diseases Surveillance Bulletin April 2015.54 Data for Jan–Dec 2013.
b NICD surveillance. Communicable Diseases Surveillance Bulletin April 2015.54 Data for Jan–Dec 2014.
c NICD surveillance. Communicable Diseases Surveillance Bulletin November 2015.48 Data for Jan–Sep 2015.

16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 263
Malaria

Context Although malaria transmission only occurs in KwaZulu-Natal, Mpumalanga and Limpopo, imported cases
present to health facilities in other provinces. South Africa has yet to decide on the provision of chemoprophylaxis
through the public health sector, and in particular for those migrant workers who return to neighbouring countries
over holiday periods, and are at increased risk of contracting malaria.
New data sources Nationally, new data have been reported in the:
• NDoH malaria surveillance
Internationally, reports of interest include:
• WHO World Malaria Report 2015
• Global Technical Strategy for Malaria 2016–2030
Key issues and trends South Africa is committed to eradicating malaria by 2030. As always, it is difficult to reconcile the different
figures reported locally and in global reports. The WHO World Malaria Report now includes the number of
local versus imported cases for some countries; the NDoH figures for 2015 classify cases as local, imported or
unknown.

PM
The World Health Organization’s World Malaria Report 2015 confirmed by microscopy, the number of rapid diagnostic tests
showed that, globally, the number of malaria cases fell from about (RDT) performed, and the number of cases confirmed with an RDT.

16 6
262 million (range: 205–316 million) in 2000 to about 214 million Surprisingly, the estimated number of malaria deaths in 2014 in
(149–303 million) in 2015.55 Globally, malaria incidence fell by South Africa (120) was lower than the reported number of deaths

20 IL
37% over the same period, and by more than 75% in 57 of 106
affected countries. The number of malaria deaths globally also fell
by 48% (from 839 000 (653 000–1.1 million) in 2000 to 438 000
Y T
(236 000–635 000), in 2015. WHO therefore concluded that “the
A N
target of Millennium Development Goal (MDG) 6 ‘to have halted
and begun to reverse the incidence of malaria’ (Target 6C) has
M U
(174) in the global report. South African surveillance data recorded
136 deaths due to malaria in 2015, including deaths that have
occurred in provinces other than KwaZulu-Natal, Mpumalanga and
Limpopo, as shown in Table 9. Of the 11 238 cases recorded in
2015, 5 597 were classified as imported, 5 235 as local and the
remaining 406 of unknown origin (Figure 8). This Figure shows a

been achieved”. Nonetheless, even though the number of malaria marked difference in the relative proportion of local and imported
deaths in children aged under 5 years in the WHO African Region cases between Limpopo and Mpumalanga.
4 ED

had dropped from 694 000 (569 000–901 000) to 292 000

In May 2015, the World Health Assembly adopted the Global
(563 000–948 000) over the same time period, the report pointed
Technical Strategy for Malaria 2016–2030.56 The goals of the
out that “malaria remains a major killer of children, particularly in
Strategy are ambitious: between 2015 and 2030, to reduce malaria
O

sub-Saharan Africa, taking the life of a child every 2 minutes”.

mortality rates globally by 90%, to reduce malaria case incidence
The South African country profile in the World Malaria Report 2015 globally by 90%, to eliminate malaria from at least 35 countries,
G

shows that, of a population of 54 million, it was estimated that in and to prevent re-establishment of malaria in all countries that are
2014 just over 2 million South Africans lived in high transmission now malaria-free. The indicators for the Strategy include some that
R

areas (where there is more than 1 case per 1 000 population), are also in the WHO 100 Core Indicator set, but which South Africa
BA

and 3.2 million in low transmission areas (0–1 cases per 1 000 does not report (specifically where the interventions are not adopted
N

population). The report provided figures from 2000 to 2014 on locally, such as the proportion of the population at risk who slept
O

the number of malaria cases presumed and confirmed in South under an insecticide-treated net the previous night).
Africa, the number of microscopy samples examined, the number
EM

Table 9: Malaria indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Case fatality rate: malaria

2013 DoH surveillance 10.0 2.8 1.4 2.3 1.0 1.0 0.0 2.9 1.2  1.2 a

2014 DoH surveillance 0.0 0.0 1.5 1.2 1.6 0.6 6.7 0.0 2.3  1.2 a

2015 DoH surveillance 4.2 2.4 1.7 1.0 1.5 0.5 5.6 1.8 2.4  1.2 a

Malaria mortality rate (per 100 000 population)

2013 DoH surveillance 0.05 0.07 0.19 0.12 0.43 0.87 0.00 0.08 0.02  0.20 b

2013 VR 0.06 0.29 0.53 0.30 1.05 1.11 0.00 0.61 0.12  0.47 c

2014 DoH surveillance 0.00 0.00 0.22 0.07 1.62 0.78 0.09 0.00 0.07  0.31 b

Reported cases of malaria

2013 DoH surveillance 30 72 1 761 575 2 408 3 796 20 102 87  8 851 a

2013 GBD 2013 - - - - - - - - -  5 629 d

2014 DoH surveillance 33 54 1 929 687 5 679 5 280 15 73 175  13 925 a

2015 DoH surveillance 24 41 1 524 606 5 352 3 494 18 55 124  11 238 a

26 4 S A H R 20 1 6
 Health and Related Indicators

EC FS GP KZN LP MP NC NW WC SA Ref
Reported cases of malaria (per 100 000)

2013 DoH surveillance 0.5 2.6 13.8 5.5 43.6 92.0 1.7 2.8 1.4  16.7 b

2014 DoH surveillance 0.5 1.9 14.9 6.4 100.9 124.8 1.3 2.0 2.9  25.8 b

2015 DoH surveillance 0.3 1.5 11.5 5.5 93.5 81.6 1.5 1.5 2.0  20.4 b

Reported deaths from malaria

2013 DoH surveillance 3 2 24 13 24 36 0 3 1  106 a

2013 GBD 2013 - - - - - - - - -  374 d

2013 VR 4 8 67 31 58 46 0 22 7  247 c

2014 DoH surveillance 0 0 28 8 91 33 1 0 4  165 a

2015 DoH surveillance 1 1 26 6 79 18 1 1 3  136 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):

PM
a DoH Malaria Statistics. Data for Jan–Dec.
b DoH Malaria Statistics. Calculated using Stats SA mid-year population estimates for the relevant year.
c Stats SA Causes of death 2013.57-59 Calculated from Stats SA Causes of Death online database using ICD-10 codes B50–B54 as underlying cause of
death. Includes deaths not recorded by province. Although the 2014 Causes of death report has been released, it does not contain details on deaths due
to malaria and therefore this indicator will be updated once the unit records are made available through Nesstar online database.

16 6
d Murray et al. 2014.60 Modelled estimate as part of the Global Burden of Disease Study 2013.

20 IL
Figure 8: Monthly cases and deaths due to malaria by province, 2015

Y T Date month / P rov / Date month

2015
A N
E lement EC FS GP K ZN LP MP NC NW WC
M U

1500
Number per month

Malaria 1000
cas es
4 ED

500

0
30
O
Number per month

20
Malaria
G

deaths
10
R

0
April

April

April

April

April

April

April

April
Augus t

April
Augus t

Augus t

Augus t

Augus t

Augus t

Augus t

Augus t

Augus t
J une

J une
F ebruary

October
December

J une

December
F ebruary

October
December

J une
F ebruary

October
December

J une
F ebruary

October
December

J une
F ebruary

October
December

J une
F ebruary

October
December

J une
F ebruary

October
December

J une
F ebruary

October
December
F ebruary

October
BA

N
O

E lement_type
Import
EM

Local
Unknown
Uns pecified

Source: DoH Malaria Statistics (surveillance).

S A H R 20 1 6 265
Tuberculosis

Context Although tuberculosis remains a key target for the Sustainable Development Goals (SDGs), there is also increased
awareness of the potential linkages with non-communicable diseases, and in particular, diabetes. In the same
way that HIV fuelled the tuberculosis epidemic, so could the increasing incidence of diabetes.
New data sources Nationally, new data have been reported in the:
• Stats SA Mortality and causes of death in South Africa, 2014: Findings from death notification
Internationally, reports of interest include:
• WHO Global Tuberculosis Report 2015
• Stop TB Partnership Global Plan to End TB 2016–2020
Key issues and trends The Stop TB Partnership’s Global Plan to End TB 2016–2020 has set ambitious 90-(90)-90 targets: to reach 90%
of all people who need TB treatment, including 90% of people in key populations, and to achieve at least 90%
treatment success. Monitoring the first two of these targets requires estimation of the total number of patients with
TB in the general population and then, specifically in ‘key’ populations. Target 2 is therefore a subset of Target 1.
In South Africa, the ‘key’ populations would include people living with HIV, miners and prisoners. The targets

PM
have been articulated somewhat differently by the South African National Department of Health, as screening
90% of vulnerable groups, diagnosing and starting 90% on treatment, and then achieving at least 90% treatment
success.

16 6
Improved diagnostic capacity is still needed for children, and in particular those who are HIV-TB co-infected.

20 IL
Globally, the World Health Organization’s Global Tuberculosis
Report 2015 showed that the Millennium Development Goal (MDG)
target in terms of TB incidence had been met.61 The target was met
Y T
in all six WHO regions, and in 16 of 22 high-burden countries
A N
(including South Africa). South Africa did not meet the MDG
targets for TB prevalence or TB mortality. In 2014, the number of
M U
The 90-(90)-90 targets pose significant challenges to routine data
systems. It has also been argued that a TB elimination strategy
requires considerable investment in local data systems, which
would allow for targeted interventions to address ‘hot spots’ of
transmission.63 Barnhart does point out, however, that targeted
approaches and disease-specific initiatives and funding can be

incident cases in South Africa was only exceeded by those in India, self-defeating, in that they can draw resources away from some
Indonesia, China, Nigeria and Pakistan (in that order). However, areas and weaken the health system, potentially resulting in poorer
4 ED

when expressed as an incidence rate (per 100 000 population all-cause outcomes.64

per year), South Africa’s incidence was only exceeded by that in
As in previous years, there has been increased attention paid to the
Lesotho (and followed closely by Swaziland). In this report, the data
challenges of diagnosing and treating TB in children.65 A survey
O

on TB mortality in South Africa in those not living with HIV were

of practices in paediatric antiretroviral treatment programmes
taken from the Institute of Health Metrics and Evaluation (IHME)
in Africa, Asia, the Caribbean and Central and South America
G

estimates, based on vital registration data adjusted for miscoding

showed that induced sputum and Xpert MTB/RIF were infrequently
of deaths caused by HIV and TB. Globally, there were 123 000
used.66 Reliance on symptom identification is unlikely to be sufficient
R

cases of multi-drug resistant tuberculosis (MDR-TB) reported in 2014,

in co-infected children, resulting in persistent under-diagnosis and
of which almost half were reported in India, the Russian Federation
BA

avoidable morbidity and mortality.

N

and South Africa. The Report also recorded a substantial increase in

the number of Xpert MTB/RIF cartridges procured at reduced prices, As no updated data are available at a provincial level, only the
O

from 550 000 in 2011 to 4.8 million in 2014, of which 51% were 2014 case findings are shown in Table 11 and the 2013 treatment
EM

procured by South Africa. South Africa was also responsible for outcomes in Table 12. Historical data can, as always, be accessed
59% of all people living with HIV who were treated with isoniazid from the HST website.
preventive therapy (IPT) in 2014.

The Stop TB Partnership’s Global Plan to End TB 2016–2020 was

published in 2015.62 Ending the TB epidemic by 2030 is one of the
targets under Goal 3 of the Sustainable Development Goals (SDGs).
The Global Plan to End TB has framed this as the 90-(90)-90 targets:
to reach 90% of all people who need TB treatment, including 90%
of people in key populations, and to achieve at least 90% treatment
success in those diagnosed with TB. In the Plan, South Africa is held
up as an example of progress, with the claim that it “has already
largely integrated its HIV and TB care, seeking to ensure that every
individual diagnosed with HIV is also tested and if necessary treated
for TB, using modern tools”. The reality on the ground is certainly
less rosy, even though the political commitment cannot be faulted.

26 6 S A H R 20 1 6
 Health and Related Indicators

Table 10: TB programme management and other indicators

EC FS GP KZN LP MP NC NW WC SA Ref
Case detection rate (all forms)
2012 Global TB - - - - - - - - -  69 a
2013 Global TB - - - - - - - - -  68 a
2014 Global TB - - - - - - - - -  68 a
HIV prevalence in TB incident cases
2012 Global TB - - - - - - - - -  64.0 a
2013 Global TB - - - - - - - - -  62.0 a
2014 Global TB - - - - - - - - -  61.0 a
Incidence of TB (all types) (per 100 000)
2012 Global TB - - - - - - - - -  892 a
2013 Global TB - - - - - - - - -  860 a
2014 Global TB - - - - - - - - -  834 a
Prevalence of multidrug resistance among new TB cases (%)

PM
2012 NHLS Xpert 6.9 6.2 6.8 8.9 6.6 11.2 5.5 7.1 5.1  7.1 b
2013 NHLS Xpert 6.2 5.7 6.5 8.9 4.9 9.5 5.6 5.4 5.0  6.6 b
2014 NHLS Xpert 6.0 5.6 5.7 8.3 4.9 8.6 5.0 5.2 5.2  6.4 b
Tuberculosis death rate per 100 000 (in HIV-positive people)

16 6
2012 Global TB - - - - - - - - -  130 a

20 IL
2013 Global TB - - - - - - - - -  129 a
2014 Global TB - - - - - - - - -  134 a
Tuberculosis mortality rate per 100 000
2012 vital registration
2013 vital registration
109
95
Y T 120
103
62
56
129
96
77
66
108
90
107
91
106
86
52
44
 93
 77
c
d
A N
2014 vital registration 87 99 49 81 62 80 88 84 40  69 e
Tuberculosis mortality rate per 100 000 (excluding HIV)
M U

2012 Global TB - - - - - - - - -  51 a

2013 Global TB - - - - - - - - -  47 a
4 ED

2014 Global TB - - - - - - - - -  44 a

Tuberculosis prevalence rate per 100 000 population
2012 Global TB - - - - - - - - -  705 a
O

2013 Global TB - - - - - - - - -  706 a

2014 Global TB - - - - - - - - -  696 a
G

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Global TB Report 2015.61
R

b DHB 2014/15.67 Percentage of positive TB tests that are RIF resistant (based only on tests done using GeneXpert technology).
c Stats SA Causes of death 2012.58 Calculated from deaths due to TB (ICD10 A15–A19), plus ICD10 U51 (MDR) and ICD10 U52 (XDR TB) and Stats SA
BA

mid-year population estimates for the relevant year. No adjustment has been made for under-reporting or ill-defined causes. The rate for South Africa
includes deaths that are not allocated to a specific province and will therefore be higher than the average provincial value. Based on the recorded province
of death.
O

d Stats SA Causes of death 2013.59 Calculated from deaths due to TB (ICD10 A15–A19), plus ICD10 U51 (MDR) and ICD10 U52 (XDR TB) and Stats SA
mid-year population estimates for the relevant year. No adjustment has been made for under-reporting or ill-defined causes. The rate for South Africa
EM

includes deaths that are not allocated to a specific province and will therefore be higher than the average provincial value. Based on the recorded province
of death.
e Stats SA Causes of death 2014.10 Includes 779 deaths due to MDR TB and 77 deaths due to XDR TB. Calculated from deaths due to TB (ICD10 A15-A19),
plus ICD10 U51 (MDR) and ICD10 U52 (XDR TB) and Stats SA mid-year population estimates for the relevant year. No adjustment has been made for
under-reporting or ill-defined causes. The rate for South Africa includes deaths that are not allocated to a specific province and will therefore be higher than
the average provincial value. Based on the recorded province of death.

S A H R 20 1 6 267
Table 11: TB case-finding indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Bacteriological coverage rate (%)
2014 TB register 66 65 63 69 72 57 54 50 69  65 a
Proportion of extra-pulmonary TB
2014 TB register 6 12 13 14 13 8 4 8 11  11 a
Reported cases of MDR-TB
2012 Lab diagnosed 2 205 390 1 198 6 630 266 760 373 267 2 072  14 161 b
2014 Lab diagnosed - - - - - - - - -  18 734 c
Reported cases of XDR-TB
2012 Lab diagnosed 477 31 50 754 3 3 72 10 145  1 545 b
Reported cases of TB (PTB new Sm+)
2014 TB register 22 026 5 157 11 944 21 657 4 907 5 150 2 502 4 229 12 530  90 102 a
Reported cases of TB (PTB new Sm+) (per 100 000)
2014 TB register 330.9 187.0 91.9 204.9 87.9 123.2 213.4 115.9 204.4  167.8 a

PM
Reported cases of TB (PTB)
2014 TB register 49 696 15 543 40 845 78 169 15 069 17 309 8 635 19 106 38 615  282 987 a
Reported cases of TB (all types)
2014 TB register 52 734 17 584 46 995 91 382 17 355 18 820 9 001 20 759 43 563  318 193 a

16 6
Reported cases of TB (all types) (per 100 000)

20 IL
2014 TB register 792.3 637.6 361.6 864.4 310.7 450.1 767.6 568.8 710.6  592.5 a
Retreatment ratio (percentage of Sm+ cases that are retreatment)
2014 TB register 4 5 4 5 4 4 10 6 19  7 a

42
Y T
Smear positivity (percentage of PTB cases which are new Sm+)
2014 TB register 29 25 24 28 27 28 20 29  28 a
A N
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
M U

a DoH TB. Based on analysis of patient-level records in ETR.Net as received from NDoH 2013–2015.
b MDR Overview 2014.68
c Global TB Report 2015.61
4 ED

Table 12: TB case-holding indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
O

Outcomes in new smear-positive cohort

G

Cure rate (new Sm+ cases) (%)

2013 TB register 70.5 75.8 84.2 82.8 64.0 73.3 65.6 69.0 80.4  76.8 a
R

Lost to follow up (defaulter) rate (new Sm+ cases) (%)

2013 TB register 7.7 4.3 4.9 4.1 4.5 5.4 8.0 7.1 8.3  5.8 a
BA

Smear conversion rate (new Sm+ cases) (%)

2013 TB register 51.7 78.0 66.0 67.2 59.5 57.3 71.1 46.4 56.6  60.9 a
O

Outcomes in all drug-susceptible TB patients – new and retreatment (ETR.Net)

TB client lost to follow up rate (all TB) (%)
EM

2013 TB register 7.6 5.6 6.3 4.9 4.2 5.0 7.9 7.3 8.6  6.3 a
TB death rate (all TB)
2013 TB register 9.3 11.1 6.3 6.4 11.0 7.5 9.0 10.2 3.8  7.4 a
TB treatment failure (all TB) (%)
2013 TB register 0.4 0.3 0.1 0.2 0.5 0.3 0.3 0.3 0.3  0.3 a
TB treatment success rate (all TB) (%)
2013 TB register 77.0 76.8 82.6 81.8 57.6 76.1 71.8 65.8 82.6  77.9 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DoH TB. Based on analysis of patient-level records in ETR.Net as received from NDoH in 2015.

26 8 S A H R 20 1 6
 Health and Related Indicators

HIV and AIDS

Context Although the dominance of HIV, TB and malaria indicators has not been retained in the Sustainable Development
Goals (SDGs), the impact of HIV in high-burden countries remains important.
New data sources Nationally, new data have been reported in the:
• 2013 National Antenatal Sentinel HIV Prevalence Survey
• National Health Laboratory Service data
Internationally, reports of interest include:
• The One Campaign Tracking Global Commitments on AIDS
• UNAIDS Focus on location and population
• UNAIDS Global Plan Progress Report 2015
• UNAIDS AIDS by the numbers 2015
• HIV Worldwide 1990–2013 Visualization created by IHME for the Journal of the American Medical

PM
Association
Key issues and trends The UNAIDS 90-90-90 targets pose considerable challenges for routine data systems, especially with regard to
the first of these targets.
Delays in the release of key HIV survey data continue to hamper efforts to track progress. The results of the

16 6
October 2013 antenatal HIV survey were released in January 2016. This is a key starting point for many
modelled estimates of the burden of HIV.

20 IL
Timely access to key survey results is invaluable, not only for AIDS by 2030” focused on what is termed the ‘location-population
Y T
researchers, but also to guide local practice. In this regard the
continued delay in releasing the results of the most recent annual
approach’ to implementing the Fast-Track interventions.75 An
example of a population that is routinely missed by HIV programmes
A N
antenatal HIV survey is regrettable. The results of the 2013 National is men. Data from the Hlabisa demographic surveillance site have
Antenatal HIV Prevalence Survey were only published in January shown growing male-female disparities in adult life expectancy,
M U

2016. The national antenatal HIV prevalence was shown to be related to lack of utilisation of HIV testing and treatment among
29.7% (95% confidence interval 28.9–30.2%).69 No statistically men.76
4 ED

significant change in this figure has now been recorded for the
The WHO 100 Core Health Indicators have introduced a number of
last six reported surveys. However, there are persistent differences
measures that require integrated HIV and TB data systems, including
in antenatal HIV prevalence between provinces, and between
the provision of TB preventive therapy for HIV-positive people newly
O

districts. The highest provincial prevalence was recorded in 2013

enrolled in HIV care, HIV test results for registered new and relapsed
in KwaZulu-Natal (40.1%), with the highest district prevalence
G

TB patients, and counts of HIV-positive new and relapsed TB patients

recorded in iLembe (45.9%). Importantly, no decline in antenatal
on ART during TB treatment. Where available, such data are shown
HIV prevalence in the 15–24 year group was detected.
R

in Table 14. Detailed data on the testing and treatment cascade are
Some data from a survey of HIV prevalence in sex workers in difficult to gather. The design of a household survey to be conducted
BA

Johannesburg, Cape Town and Durban was released in December in two sub-districts of the uMgungundlovu Municipality has shown
2015.70 The report was finally made available in March 2016.71 It that two sequential cross-section surveys of 10 000 randomly
O

was announced in March 2016 that pre-exposure prophylaxis with selected individuals aged 15–49 years will be needed in order to
EM

tenofovir-based antiretrovirals would be provided to sex workers,
marking an important intervention for this key group.72
Globally, UNAIDS continues to issue summary data on the HIV
pandemic. The 2015 Progress Report on the Global Plan towards
the elimination of new HIV infections among children by 2015
and keeping their mothers alive showed that, among the 21 target
countries, 1.2 million paediatric infections had been averted since
1996 through the provision of antiretrovirals to pregnant women
living with HIV (PMTCT).73 In this regard, the greatest progress
had been made by South Africa, which reduced such infections by
76%. Early (4–8 weeks post-partum) population-level effectiveness
identify two cohorts to be followed for one year in order to detect a
30% reduction in the HIV incidence rate between surveys with 84%
power.77
Modelled estimates show that South Africa was diagnosing 76% of
HIV-positive adults by 2012.78,79 In 2014/15, 9.6 million HIV tests
were performed, almost achieving the target of 10 million.80 These
data provide further support for expanded access to different testing
options, including home-based testing and self-testing. However,
ensuring that the necessary data are captured from such testing
modalities in order to track progress towards the 90-90-90 targets
will be challenging.

of South Africa’s PMTCT programme showed a 91% reduction in
mother-to-child transmission of HIV by 8 weeks.74 This assessment
also showed high levels of HIV testing during pregnancy (95.5%),
of access to such results (99.8%) and of early infant HIV testing
(98.7%). In 2015, the UNAIDS report on the “Fast-Track to end
The methods for modelling population prevalence have had to be
updated, to take account of the effects on prevalence and incidence
of increasing access to ART.81 Increasingly, such models will rely
on accurate service provision data, disaggregated by all of the
covariates of interest.

S A H R 20 1 6 269
Table 13: HIV prevalence and incidence indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
AIDS sick (number of people with AIDS-defining conditions)
2015 ASSA2008 80 652 41 238 152 552 187 299 46 526 55 965 9 432 51 915 34 743  665 502 a
Antenatal client HIV 1st test positive rate (%)
2014 DHIS 13.1 15.3 16.8 20.4 10.6 21.0 7.6 14.6 6.1  15.2 b
HIV incidence (%)
2012 HSRC age 15-49 - - - - - - - - -  1.7 c
2012 THEMBISA age 15-49 1.5 d
2012 EPP/Spectrum age 15-49 1.5 d
2013 ASSA2008 total population 0.8 0.7 0.5 1.0 0.5 0.8 0.4 0.8 0.3  0.7 a
2013 GBD 2013 total population - - - - - - - - -  0.7 e
HIV prevalence (%) (age 15-49)
2015 ASSA2008 17.3 18.4 16.4 22.8 11.5 19.5 10.4 18.6 8.0  17.0 a
2015 mid-year - - - - - - - - -  16.6 f

PM
HIV prevalence (%) (antenatal)
2012 29.1 32.0 29.9 37.4 22.3 35.6 17.8 29.7 16.9  29.5 g
2013 15-49 years 31.4 29.8 28.6 40.1 20.3 37.5 17.5 28.2 18.7  29.7 h
2013 15-19 years - - - - - - - - -  12.7 h

16 6
2013 15-24 years - - - - - - - - -  19.9 h

20 IL
2013 20-24 years - - - - - - - - -  24.0 h
2013 25-29 years - - - - - - - - -  34.9 h
2013 30-34 years - - - - - - - - -  42.5 h
2013 35-39 years
2013 40-44 years
-
-
Y T -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 42.5
 35.3
h
h
A N
2013 45-49 years - - - - - - - - -  24.4 h
HIV prevalence (%) (total population)
M U

2012 ASSA2008 10.8 12.1 11.2 15.1 7.1 12.7 6.8 12.5 5.2  11.1 a
2012 HSRC all ages - - - - - - - - -  12.2 c
4 ED

2013 4-8 weeks 0.7 1.0 0.7 1.3 0.5 0.6 0.5 1.7 0.4  0.9 i
2015 mid-year - - - - - - - - -  11.2 f
2015 ASSA2008 11.4 12.3 11.1 15.4 7.5 13.0 7.0 12.6 5.2  11.3 a
People living with HIV
O

2012 Spectrum/EPP - - - - - - - - -  6 100 000 j

G

2012 ASSA2008 736 404 355 466 1 222 605 1 602 236 423 400 492 287 78 711 436 670 278 889  5 685 424 a
2015 ASSA2008 796 634 366 895 1 229 068 1 680 200 461 927 520 480 82 723 451 339 289 915  5 967 061 a
R

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a ASSA2008.82
BA

b DHIS.45
c HIV Household Survey 2012.83
O

d Rehle et al. 2015.84

e Murray et al. 2014.60 Based on estimated 396 631 incident cases per total population of 52 982 000 (mid-year).
EM

f Stats SA Mid-year Estimates.20 2015 mid-year estimates.

g Antenatal Survey 2012.85
h Antenatal Survey 2013.69
i PMTCT Survey 2012-13.
j Antenatal Survey 2012.85 Modelled from antenatal HIV survey using the Epidemic Projection Package.

Table 14: Other HIV and AIDS indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
AIDS orphans (maternal orphans <18 years)
2015 ASSA2008 187 391 90 079 284 602 416 265 111 858 140 340 15 365 112 672 58 905  1 400 267 a
ANC clients tested for HIV (%)
2012 DHIS 98.6 98.2 89.1 106.8 101.7 103.8 96.1 97.3 96.4  98.2 b
2013 PMTCT survey 91.5 94.6 97.3 95.4 95.1 94.3 95.3 97.3 97.0  95.5 c
Antenatal client initiated on ART rate
2013 79.0 80.8 63.1 85.4 78.6 74.2 80.3 79.2 68.5  76.3 b
2013 PMTCT survey 86.1 93.0 93.2 91.0 83.4 83.4 89.0 88.3 95.9  90.3 c
2014 91.7 88.7 87.4 95.2 92.9 92.9 89.8 90.2 82.8  91.2 b

270 S A H R 20 1 6
 Health and Related Indicators

EC FS GP KZN LP MP NC NW WC SA Ref
Antiretroviral coverage (%)
2012 THEMBISA children - - - - - - - - -  44.7 d
2012 THEMBISA female 15+ - - - - - - - - -  62.7 d
2012 THEMBISA male 15+ - - - - - - - - -  51.5 d
2012 THEMBISA total - - - - - - - - -  57.0 d
2012 children 0-14 - - - - - - - - -  43.0 e
2013 children 0-14 - - - - - - - - -  47.0 e
2014 children 0-14 - - - - - - - - -  49.0 e
Antiretroviral treatment exposure (%)
2012 age 0-14 - - - - - - - - -  45.1 f
2012 all ages female - - - - - - - - -  34.7 f
2012 all ages male - - - - - - - - -  25.7 f
Early infant diagnosis coverage
2013 NHLS in DHB 80.8 86.2 96.6 93.9 82.0 90.5 82.8 74.8 80.6  88.3 g

PM
HIV testing coverage (%)
2012 NiDS - - - - - - - - -  65.2 h
2014 DHIS 36.0 26.2 23.3 39.0 40.8 30.0 29.5 35.2 31.9  32.1 b
2014 MSM - - - - - - - - -  73.0 i

16 6
2014 Non-MSM - - - - - - - - -  65.1 i
HIV-positive new and relapse TB patients on antiretroviral therapy (ART) during TB treatment (%)

20 IL
2012 TB register 66.9 78.8 65.5 50.4 53.2 60.4 63.5 63.2 69.8  60.6 j
2013 DHIS 35.7 20.4 3.5 59.0 48.6 60.9 0.0 40.0 -  29.9 k
2013 TB register 87.5 Y T 78.4 75.4 66.1 59.7 61.8 73.9 69.1 77.8  72.0 j
2014 DHIS 43.8 43.5 2.7 61.5 45.7 54.6 34.2 47.9 -  32.8 k
A N
2014 TB register 89.1 76.2 77.5 74.8 75.3 90.4 83.5 75.4 77.4  78.9 j
Infant 1st PCR test around 6 weeks uptake rate (%)
M U

2012 DHIS 84.2 101.2 97.3 114.6 91.5 102.2 94.0 103.0 55.0  98.7 l
2013 DHIS 91.7 103.0 97.8 113.1 94.9 106.1 87.1 109.4 94.7  102.5 l
4 ED

2014 DHIS 95.2 91.3 98.6 107.9 93.9 106.0 90.8 100.1 96.5  100.6 l
Infant 1st PCR test positive around 6 weeks rate (%)
2012 DHIS 3.0 2.3 2.4 2.2 2.4 3.0 2.7 2.8 1.7  2.5 b
2013 DHIS 2.0 2.8 2.0 1.6 2.6 2.1 2.5 2.3 1.9  2.0 b
O

2014 DHIS 1.7 1.3 1.3 1.3 2.0 1.7 2.1 1.8 1.4  1.5 b
Male circumcision (% of men who are circumcised)
G

2012 HSRC age 15+ 74.0 36.0 48.2 23.2 72.6 49.9 20.3 36.7 41.0  46.4 m
2012 NCS 2012 - - - - - - - - -  48.1 n
R

Mother-to-child transmission rate of HIV <2 months of age

2013 NHLS in DHB 2.4 2.1 2.0 2.0 3.0 2.3 2.8 2.5 2.2  2.2 o
BA

2013 PMTCT survey 2.4 2.8 2.2 2.9 2.1 1.5 2.2 5.4 1.9  2.6 p
Number of patients receiving ART
O

2015 Adults (Mar) 301 782 158 909 700 357 897 270 219 851 269 866 39 921 179 729 172 856  2 940 541 q
EM

2015 Children (Mar) 18 280 9 968 30 219 54 192 12 655 15 118 3 133 11 883 7 913  163 361 q
2015 Total (Mar) 320 062 168 877 730 576 951 462 232 506 284 984 43 054 191 612 180 769  3 103 902 q
TB cases with known HIV status (%)
2012 TB register 86.3 87.1 89.8 83.9 90.4 85.3 78.8 83.1 94.5  86.9 j
2013 TB register 88.4 89.1 92.8 88.8 93.1 90.1 77.3 89.5 95.6  90.3 j
2014 TB register 92.3 89.6 93.7 92.5 94.1 92.5 84.6 91.7 95.9  92.8 j
Percentage of deaths due to AIDS
2013 ASSA2008 27.0 31.8 35.5 38.1 25.6 36.6 20.9 36.2 16.7  31.9 a
2013 GBD 2013 - - - - - - - - -  51.6 r
2015 ASSA2008 28.5 32.0 35.4 39.0 27.2 37.4 21.9 36.4 17.6  32.8 a
2015 mid-year - - - - - - - - -  30.5 s

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a ASSA2008.82
b DHIS.45
c PMTCT Survey 2012-13.74 Among self-reported HIV-positive mothers 54.8% received maternal ART during or before pregnancy and 35.5% received
maternal and infant ARV prophylaxis.
d THEMBISA 1.0.86
e Global Plan 2015 Progress.73
f HIV Household Survey 2012.83
g DHB 2013/14.87 2013/14 financial year. Numerator: NHLS PCR tests under 2 months of age. Denominator: Live births from Stats SA x antenatal HIV
prevalence from antenatal surveys to estimate HIV-exposed infants.

S A H R 20 1 6 27 1
h Maughan-Brown et al. 2015.88 Proportion of adults having ever received an HIV test.
i HEAIDS 2014.89 Defined in survey as ‘Have had HIV test’. MSM = men who have sex with men.
j DoH TB.
k DHIS.45 Data appear to be incomplete and under-reporting treatment coverage. WC use a different routine information system and data had not been
successfully imported into the national DHIS datamart at that time of extraction.
l DHIS.45 Due to problems with recording the denominator of live births to HIV positive women and also uncertainty about whether the numerator may also
include tests in older infants, this indicator substantially over-estimates coverage of early infant diagnosis for HIV.
m HIV Household Survey 2012.83 Self-reported circumcision.
n NCS 2012.90 Survey sampled men aged 16–55. Among the 5 471 890 men who said they were not circumcised: Almost a million said they definitely
intended to get circumcised in the next 12 months. Of those that say they will definitely get circumcised, 80.5% (803 690) intend to have a medical
circumcision.
o DHB 2013/14.87 2013/14 financial year.
p PMTCT Survey 2012-13.74
q DHIS.45 As at March. Based on DHIS data element ‘Adult remain on ART total’ or ‘Child remain on ART total’ derived from aggregated TIER.Net data.
r Murray et al. 2014.60 Calculated from estimated deaths due to HIV of 251 912 divided by 458 933 registered deaths (adjusted for estimated completeness
of registration of 94%).
s Stats SA Mid-year Estimates.20 2015 mid-year estimates.

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

272 S A H R 20 1 6
 Health and Related Indicators

Reproductive health
Contraception, sexual behaviour, sexually transmitted infections and termination of pregnancy

Context Apart from the usual maternal indicators, the WHO 100 Core Health Indicators have also included two key
measures of reproductive health: “demand for family planning satisfied with modern methods” and “contraceptive
prevalence rate”.
New data sources No new data have been found, either nationally or internationally.
Key issues and trends The National Adolescent Sexual and Reproductive Health and Rights Framework 2014–2019 was published in
February 2015.

The National Adolescent Sexual and Reproductive Health and ➢➢ gender-based violence among adolescents;
Rights Framework 2014–2019 has been issued by the Department ➢➢ adolescent age at sexual debut;
of Social Development. The Framework proposed a number of
➢➢ uptake of condom usage and levels of consistent condom
indicators for monitoring and evaluation, including:
usage during sex; and

➢➢ incidence of STIs, HIV and AIDS and other sexual and
reproductive health (SRH) illnesses such as cervical and breast
cancer;
PM
➢➢ level of medical male circumcision in adolescents.
However, the Framework does not define these indicators, nor
does it explain where the data would be sourced. As the tables

16 6
➢➢ incidence of under-18 years childbirths;
below show, much of the data in this regard is dated, or is not
➢➢ maternal mortality ratio among adolescents; disaggregated in the way desired by the Framework.

20 IL
➢➢ termination of pregnancy among adolescents;
Y T
A N
Table 15: Contraception and sexual behaviour indicators by province
M U

EC FS GP KZN LP MP NC NW WC SA Ref
4 ED

Age of first sex under 15 years (% having first had sex at age 14 or younger)
2012 age 15-24 16.8 10.3 9.5 7.6 11.8 7.7 10.1 9.8 14.2  10.7 a
2014 MSM under 16 - - - - - - - - -  24.4 b
2014 Non-MSM under 16 - - - - - - - - -  15.9 b
O

Condom use at last sex (%)

2012 HSRC age 15+ 38 41 36 40 39 39 27 41 24  36 a
G

2014 MSM - - - - - - - - -  63 c

2014 Non-MSM - - - - - - - - -  59 c
R

Couple year protection rate

BA

2014 DHIS 39.4 43.7 38.7 57.8 49.2 39.8 44.9 42.7 60.0  46.8 d
N

HIV knowledge: correct knowledge about prevention and rejection of major misconceptions
O

2012 age 15+ 25.6 34.7 31.7 24.4 19.3 21.9 28.0 20.8 29.5  26.8 a
Male condom distribution coverage (condoms per male 15 years and older)
EM

2014 DHIS 33.6 34.1 25.8 58.9 38.2 34.3 20.3 28.1 55.3  38.4 d
Male condoms distributed (thousands)
2014 DHIS 68 783 32 872 131 322 196 002 66 161 48 371 8 271 37 170 123 436  712 387 d
Teenage pregnancy (%)
2012 NiDS female 15-19 14.5 7.4 12.0 14.1 10.5 15.2 16.2 10.1 6.7  12.4 e
2014 GHS age 15-19 9.0 8.5 6.5 7.0 9.6 9.1 10.3 10.1 8.1  8.0 f

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a HIV Household Survey 2012.83
b HEAIDS 2014.89 MSM = student men who have sex with men – those who report first having had sex at age younger than 13 or 16 years.
c HEAIDS 2014.89 Defined in survey as ‘Condom use by participants during last sex act’. MSM = men who have sex with men.
d DHIS.45 Financial year.
e NiDS Wave 3 v1.2.91 Based on answering ‘Yes’ to the survey question ‘Ever given birth?’
f Stats SA GHS 2014.21 Survey asked females whether they were pregnant during the 12 months before the survey (different to the usual definition of ever
having been pregnant while aged 15–19).

S A H R 20 1 6 273
Table 16: STI indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Percentage men with painful urination, genital symptoms
2014 MSM - - - - - - - - -  26.5 a
2014 Non-MSM - - - - - - - - -  33.3 a
STI treated new episode incidence (per 1 000)
2014 DHIS 45.0 24.8 18.5 61.7 24.0 23.8 20.1 16.8 19.5  31.0 b

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a HEAIDS 2014.89 Defined in survey as ‘Have you ever had burning or pain when you urinated?’ MSM = student men who have sex with men.
b DHIS.45 Financial year.

Table 17: Termination of pregnancy indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
ToP rate (%)

PM
2014 DHIS 8.7 10.8 7.8 3.6 5.5 2.3 6.4 9.8 16.8  7.4 a
ToPs (Terminations of Pregnancy)
2014 DHIS 14 096 6 144 18 465 9 590 8 387 2 405 1 756 8 294 19 989  89 126 b

16 6
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):

20 IL
a DHIS.45 ToPs as % of all expected pregnancies in catchment population. Data extracted June 2012. Data for financial year from April of the year to March
of the following year (not calendar year).
b DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

274 S A H R 20 1 6
 Health and Related Indicators

Maternal health

Context Although subsumed in Sustainable Development Goal (SDG) 3, maternal health remains a key priority for global
action and measurement. Target 3.1 is to reduce the global maternal mortality ratio to less than 70 per 100 000
live births by 2030.
New data sources Nationally, new data have been reported in the:
• Stats SA Census 2011: Estimation of Mortality in South Africa
• Rapid Mortality Surveillance Report 2014

Internationally, reports of interest include:

• Trends in Maternal Mortality: 1990 to 2015
• The Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030
Key issues and trends Estimates of maternal mortality ratio have varied widely, calling into question the utility of this indicator, especially
when used to track progress over time and to assess the impact of interventions. Investment is needed in vital
registration systems in order to improve the quality of data on which these indicators depend. The institutional

PM
maternal mortality ratio may be a better indicator for monitoring trends and health systems improvements, although
it does not quantify outcomes for those delivering outside of the healthcare system.

16 6
As indicated before, the continuing analysis of the Census 2011 data satisfied with modern methods) and the contraceptive prevalence
has provided an additional estimate of the maternal mortality ratio rate (defined as the percentage of women aged 15−49 years,

20 IL
for 2010.39 However, the figure provided (580 per 100 000 live
births) is very different from those calculated from vital registration
data and reported internationally, as shown in Table 18. Dorrington
Y T
and Bradshaw have drawn attention to the high levels of uncertainty
A N
in estimates of South Africa’s maternal mortality ratio.92 They have
pointed out that successive estimates from the same sources (such as
M U
married or in union, who are currently using, or whose sexual
partner is using, at least one method of contraception, regardless
of the method used). Another indicator of relevance to maternal
health is the anaemia prevalence in women of reproductive age (the
percentage of women aged 15−49 years with a haemoglobin level
less than 120 g/L for non-pregnant women and lactating women,

WHO and IHME) do not lie within the 95% uncertainty bounds of and less than 110 g/L for pregnant women, adjusted for altitude
previous estimates. Such variation calls into question the validity of and smoking). Based on data from only one regional hospital in
4 ED

these measures as indicators of progress over time. The 1990–2015
trends in maternal mortality recently published by WHO illustrates
this again.93 Although methodological changes to “optimise use of
country-level data” have brought the results for South Africa closer
O
KwaZulu-Natal, the prevalence of anaemia among 2 000 antenatal
presenters over the period 2012 to 2014 was shown to be 42.7%
overall, but 71.3% in HIV-positive women.96 In 68.9% of cases,
the anaemia was mild, normocytic and normochromic. This is

to national estimates in recent years, there are still substantial higher than the KZN provincial value for anaemia in all women of
differences in the trends. reproductive age reported by SANHANES-1 (Table 24).
G

An updated Global Strategy for Women’s, Children’s and Adole- Another new indicator added to Table 18 is that on postnatal visits.
R

scents’ Health 2016–2030 was issued by the United Nations The WHO 100 Core indicator definition for “postpartum care
in 2015.94 The updated Strategy has a focus on equity, which coverage” is the “percentage of mothers and babies who received
BA

demands sex-disaggregated data and gender-sensitive indicators. postpartum care within two days of childbirth (regardless of place
In this regard, the Strategy calls for specific action around health of delivery)”. The locally accessible data are on the percentage of
O

information gathering and analysis: for example, that “by 2020, all mothers making a postnatal visit within six days of delivery.
EM

countries have established a system for registration of births, deaths

and causes of death and have well-functioning health information
systems that combine data from facilities, administrative sources and
surveys”, and that “by 2016, all stakeholders have agreed on ten
measurable umbrella-level or global-level indicators on women’s,
children’s and adolescents’ health, disaggregated for gender and
other equity considerations, to facilitate high-level political monitoring
of progress towards the objectives of the Global Strategy”. It is
intended that these political-level indicators will “complement the
much longer technical indicator list at the target level for the Global
Strategy and the Sustainable Development Goals”.
A ‘best-buy’ analysis by the Priority Cost-effective Lessons for
System Strengthening South Africa (PRICELESS SA) group based on
KwaZulu-Natal (KZN) data showed that the most significant gains in
terms of reducing maternal deaths could be made by focusing on
contraceptive coverage.95 The WHO 100 Core Health Indicators
include two measures of access to family planning: demand for
family planning satisfied with modern methods (defined as the
percentage of women of reproductive age (15−49 years) who
are sexually active and who have their need for family planning
The Caesarean section rate, in both the public and private sectors,
has long been a bone of contention. The usual WHO target is no
higher than 15%, but this target has been challenged.97 Critically,
they note that the appropriate Caesarean delivery rate remains
unknown, but that the question is rather whether appropriate
performance of Caesareans is available as part of a system of
optimal maternal and neonatal care.
A qualitative study of South Africa’s maternal care system by
Amnesty International was published in late 2014.98 The study set
out to “help identify some of the problems that are contributing to
the high number of women and girls who are still dying needlessly
each year during pregnancy or shortly after giving birth, and to offer
some recommendations for action”. Based on individual testimonies,
it drew attention to the barriers to access to early and ongoing
antenatal care as being “violations of the right to privacy and
confidentiality; the need for more health information and education;
and violations of the right to health as a consequence of persistent
transport and cost barriers to accessing health facilities, particularly
for marginalized communities”.

S A H R 20 1 6 27 5
Table 18: Maternal health indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
ANC coverage (%)
2013 DHIS 82.3 87.8 104.5 89.5 83.0 81.0 88.3 86.5 81.7 88.8 a
2014 DHIS 79.3 89.6 109.7 87.9 89.0 85.2 87.9 86.7 82.7 90.4 a
Caesarean section rate (%)
2013 DHIS 26.3 25.5 25.6 29.9 16.5 17.6 18.9 19.2 28.6 24.4 a
2013 NCCEMD 26.2 25.1 25.5 30.0 16.2 17.4 18.6 18.3 28.1 24.2 b
2013 Private sector - - - - - - - - - 67.5 c
2014 Private sector - - - - - - - - - 70.8 c
2014 DHIS 26.9 25.2 25.5 29.5 17.2 17.3 19.4 21.4 29.1 24.7 a
Delivery rate in facility (%)
2013 DHIS 75.2 81.6 93.7 77.2 86.8 75.7 84.4 72.2 84.7 82.0 a
2014 DHIS 77.2 88.2 96.8 82.4 91.0 80.5 88.1 74.8 87.9 85.9 a
Maternal mortality ratio (MMR)

PM
2010 Census - - - - - - - - - 580 d
2010 RMS 2014 - - - - - - - - - 267 e
2010 WHO (2015 estimates) - - - - - - - - - 154 f

16 6
2011 RMS 2014 - - - - - - - - - 200 e
2012 RMS 2014 - - - - - - - - - 166 e

20 IL
2013 RMS 2014 - - - - - - - - - 155 e
2013 IHME (2014 estimates) - - - - - - - - - 174 g
2015 WHO (2015 estimates) - Y T -
Maternal mortality ratio in facility / institutional (iMMR)
- - - - - - - 138 f
A N
2010 DHIS 147.9 237.2 93.8 196.9 142.1 161.1 90.7 204.6 - 138.5 h
2010 NCCEMD 197.0 263.5 159.2 208.7 166.7 218.6 267.4 256.1 88.0 186.2 i
M U

2011 DHIS 114.9 199.1 123.3 192.2 184.6 135.0 147.7 189.7 28.6 144.9 h
2011 NCCEMD 179.4 246.8 136.4 197.6 196.4 199.7 193.6 173.0 62.6 169.2 j
4 ED

2012 DHIS 109.5 132.7 116.5 165.5 177.9 175.8 144.6 166.6 8.7 132.9 h
2012 NCCEMD 153.7 149.3 163.7 170.2 192.9 177.4 166.5 164.8 81.8 160.2 j
2013 DHIS 156.2 143.4 104.5 148.4 152.0 149.1 118.9 184.9 68.6 133.3 h
O

2013 NCCEMD 172.7 185.1 115.0 146.5 201.2 150.3 158.3 168.5 83.9 147.7 j
2014 DHIS 148.3 217.8 112.6 124.9 165.2 115.4 254.1 167.1 54.4 132.5 h
G

Mother postnatal visit within 6 days rate (%)

2010 17.1 47.4 14.4 40.6 45.3 4.8 25.6 52.3 - 26.3 a
R

2011 48.5 82.0 72.0 57.3 65.2 51.9 42.7 76.4 - 56.4 a
2012 55.5 82.3 85.1 69.4 73.0 61.6 51.7 78.9 - 65.2 a
BA

2013 54.6 83.9 86.5 72.2 72.3 53.9 51.2 74.0 82.8 73.0 a
2014 58.0 80.8 85.5 66.4 72.4 59.7 56.5 74.7 100.5 74.3 k
O

Number of maternal deaths

EM

2010 DHIS 172 112 185 365 172 113 19 111  - 1 249 a
2010 NCCEMD 232 120 293 385 198 150 52 134 82 1 646 l
2010 WHO (2015 estimates) - - - - - - - - - 1 700 f
2011 DHIS 137 94 250 366 236 101 30 107 26 1 347 a
2011 NCCEMD 210 124 270 360 249 148 40 99 60 1 560 j
2012 DHIS 128 64 242 314 226 135 32 97 64 1 302 a
2012 NCCEMD 183 72 339 326 245 136 33 96 75 1 508 j
2013 DHIS 183 64 217 280 193 114 26 106 66 1 249 a
2013 IHME (2014 estimates) - - - - - - - - - 1 925 g
2013 NCCEMD 200 85 240 278 256 115 34 97 79 1 384 j
2014 DHIS 174 100 236 252 211 90 57 97 53 1 270 a
2015 WHO (2015 estimates) - - - - - - - - - 1 500 f
PM (proportion of deaths among women of reproductive age that are due to maternal causes)
2010 WHO (2015 estimates) - - - - - - - - - 1.5 f
2015 WHO (2015 estimates) - - - - - - - - - 1.7 f

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b Saving Mothers 2011–13b.11
c Medical Schemes 2014–15.22
d Census 2011 Mortality.39 The estimated MMR is very different from the 269 estimated using vital registration data for SA by Dorrington et al. 2014.

276 S A H R 20 1 6
 Health and Related Indicators

e RMS 2014.40 The MMR is calculated (according to the method proposed by HDACC) from adjusted vital statistics by proportional redistribution of the
ill-defined natural causes (ICD codes R00–R99) among the specified natural causes. Thereafter, the number is adjusted to allow for the fact that about 7%
of deaths are not registered. These estimates have been adjusted for an increase in under-registration of deaths which appear to have become significant
since 2011.
f Maternal Mortality 1990-2015.93
g Kassebaum et al. 2014.99
h DHIS.45 Institutional (facility) MMR based only on maternal deaths in facilities. Data for financial year from April of the year to March of the following year
(not calendar year). Data from WC for 2010 were not included in the national DHIS datamart at the time of extraction.
i Saving Mothers 2012.100
j Saving Mothers 2011–2013.101 Institutional MMR using live births from DHIS as denominator.
k DHIS.45 Rates over 100% are possible due to data quality problems or simply because there is a time lag between the collection of the numerator (post
natal visits) and the denominator (deliveries in facility).
l Saving Mothers 2008-10.102

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 27 7
Child health
Context Child health, which was a key focus of the MDG era, will continue to be an important target for intervention as
part of the Sustainable Development Goals (SDGs)
New data sources Nationally, new data have been reported in the:
• South African Child Gauge 2015
• Stats SA Census 2011: Estimation of Mortality in South Africa
• Rapid Mortality Surveillance Report 2014
Internationally, reports and data sources of interest include:
• Lancet series on breastfeeding
• Lancet series on stillbirths
• UNICEF For every child, a fair chance
• The Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030

PM
• Global and National Burden of Diseases and Injuries among children and adolescents (GBD 2013)
Key issues and trends Globally, increased attention is being paid to the prevention of stillbirths. There is also global attention being
given to the question of immunisation coverage, not only because of outbreaks of diseases such as measles in
affluent communities, but also because of public demands for access to new vaccines (such as that for meningitis

16 6
B). Locally, there are concerns that complacency caused by consistently high coverage figures at an aggregated
level may be obscuring low levels of vaccine uptake in some areas (not only in underserved communities but also

20 IL
in those served by the private sector).

Y T
Globally, there have been calls for increased attention to be paid
to the issue of stillbirths.103 The WHO 100 Core Indicator definition
The WHO 100 Core Health Indicators includes a measure of
excusive breastfeeding (percentage of infants 0–5 months of age
A N
is the “number of stillbirths per 1 000 births (live and stillbirths)”, (<6 months) who are fed exclusively with breast milk). It has been
with the explanatory note that “for purposes of international estimated that scaling up breastfeeding to near universal levels could
M U

comparison, stillbirths are defined as third trimester foetal deaths prevent 823 000 deaths in children under 5 annually at a global
(≥1000 g or ≥28 weeks)”. Stillbirths were not mentioned in the level, as well as 20 000 deaths from breast cancer.108 Although
4 ED

Millennium Development Goals, nor were they counted in the measured in younger infants, aged 4–8 weeks, the PMTCT survey
Global Burden of Disease studies. A Lancet Series on the issue found an increase in breastfeeding from 2010, with 57.5% overall
called for the development of indicators to measure the effect of being exclusively breastfed in 2013.74
O

interventions, programmatic progress and quality of care.104 In Estimates from the Census 2011 have been added to the infant and
addition to measures of stillbirth itself, progress can also be tracked under-5 mortality figures in Table 21. The national estimates for
G

via indicators of contraceptive coverage and access to antenatal 2010 based on the Census are not that different from the modelled
and peri-partum care.105 Globally, it is feared that less than 5% Stats SA mid-year estimates, but are 10% (U5MR) and 25% (IMR)
R

of neonatal deaths and even fewer stillbirths are captured in vital higher than estimates based on the Rapid Mortality Surveillance
registration records.106
BA

system for 2011.

Equity, which is the driving force behind the UNICEF: For every No new immunisation coverage data are available, so only the
O

child, a fair chance” agenda,107 is also the main underpinning 2014 figures are shown in Table 23. In 2015, Africa as a continent
EM

principle behind the annual South African Child Gauge.28 The 2015 celebrated one year without a wild-type polio case.109
edition reports on the development of a Youth Multidimensional
Poverty Index (MPI), which specifically targets those aged 15–24
years. Based on the Census 2011, it was shown that 33% of young
South Africans were multi-dimensionally poor at that time. Over half
of the South African population is under the age of 25 years, so the
overall burden of disease often falls heavily on this age group.

278 S A H R 20 1 6
 Health and Related Indicators

Table 19: Child health indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Child under 5 years diarrhoea with dehydration incidence (per 1 000)
2013 DHIS 16.1 24.4 8.1 15.0 14.2 13.0 18.5 14.3 15.6  14.1 a
2014 DHIS 11.6 19.1 6.8 11.7 13.1 11.7 10.1 8.9 14.8  11.3 a
Child under 5 years pneumonia incidence (per 1 000)
2013 DHIS 42.3 84.4 37.3 92.2 34.2 18.5 67.6 25.7 66.5  53.2 a
2014 DHIS 32.7 81.4 31.7 86.1 27.7 13.5 42.5 18.7 89.4  49.3 a
Child under 5 years severe acute malnutrition incidence (per 1 000)
2013 DHIS 5.4 9.1 2.4 5.6 4.2 2.6 4.2 8.1 2.0  4.5 a
2014 DHIS 5.1 8.7 1.9 6.3 4.9 2.9 4.5 6.7 2.4  4.5 a
Children living far from their usual health facility (%)
2013 GHS 36.6 21.8 9.4 32.9 23.5 23.1 18.5 29.4 8.0  23.4 b
2014 GHS 36.3 20.1 7.9 27.3 23.7 22.4 20.2 25.5 8.4 21.5 b
Exclusive breastfeeding rate (%)

PM
2010 HIV-exposed 4-8 weeks - - - - - - - - -  20.4 c
2010 HIV-unexposed 4-8 weeks - - - - - - - - -  31.3 c
2011 HIV-exposed 4-8 weeks - - - - - - - - -  35.5 c
2011 HIV-unexposed 4-8 weeks - - - - - - - - -  43.6 c

16 6
2013 HIV-exposed 4-8 weeks - - - - - - - - -  54.1 c

20 IL
2013 HIV-unexposed 4-8 weeks - - - - - - - - -  59.2 c
2013 all 4-8 weeks old - - - - - - - - -  57.5 c
Number of orphans
2014 GHS double
2014 GHS maternal
121 604
97 102
Y T
54 496
28 458
77 435
88 314
197 273
157 631
55 253
56 521
69 928
46 364
14 665
12 792
49 702
41 041
13 348
30 459
653 704
 558 681
d
d
A N
2014 GHS paternal 313 938 102 633 254 479 491 085 205 561 182 531 39 182 138 842 92 036 1 820 287 d
2015 ASSA2008 maternal/double 249 084 112 728 350 770 495 337 152 965 167 040 24 124 136 669 101 947 1 779 248 e
M U

Orphanhood (%)
2014 GHS double 4.6 6.0 2.2 4.8 2.5 4.6 3.6 3.9 0.7  3.5 d
4 ED

2014 GHS maternal 3.7 3.1 2.5 3.9 2.6 3.0 3.1 3.2 1.6  3.0 d
2014 GHS paternal 11.9 11.3 7.2 12.1 9.4 12.0 9.6 11.0 4.9  9.9 d

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
O

a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b SA Child Gauge 2014.110 Based on GHS; Stats SA. Children are defined as people aged 0–17 years.
G

c PMTCT Survey 2012-13.74

d Stats SA GHS 2014.21 Among children under 18 years of age.
R

e ASSA2008.82
BA

Table 20: Child health indicators by population group

African Coloured Indian White All Ref

O

Children living far from their usual health facility (%)

EM

2014 GHS 24.2 10.2 1.2 3.6  21.5 a

Number of orphans
2014 GHS double 635 427 13 620 1 281 3 377  653 704 a
2014 GHS maternal 517 056 28 838 4 433 8 354  558 681 a
2014 GHS paternal 1 708 412 82 948 7 798 21 129  1 820 287 a
Orphanhood (%)
2014 GHS double 4.1 0.9 0.4 0.3  3.5 a
2014 GHS maternal 3.3 1.9 1.3 0.9  3.0 a
2014 GHS paternal 11.0 5.3 2.3 2.2  9.9 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2014.21 Among children under 18 years of age.

S A H R 20 1 6 279
Table 21: Child mortality and related indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Child mortality (deaths between 1–4 years per 1 000 live births)
2013 GBD 2013 - - - - - - - - - 8.2 a
Infant mortality rate (deaths under 1 year per 1 000 live births)
2010 Census 40.3 53.2 23.8 46.8 27.6 39.0 37.0 46.8 20.4 35.0 b
2011 RMS 2014 - - - - - - - - - 28.0 c
2012 RMS 2014 - - - - - - - - - 27.0 c
2013 RMS 2014 - - - - - - - - - 29.0 c
2013 mid-year - - - - - - - - - 36.4 d
2014 RMS 2014 - - - - - - - - - 28.0 c
2014 mid-year - - - - - - - - - 35.3 d
2015 mid-year - - - - - - - - - 34.4 d
2015 ASSA2008 42.8 37.8 22.9 40.3 25.8 34.3 22.9 28.0 16.5 31.3 e
2015 Inter-agency group (2015) - - - - - - - - - 34.0 f

PM
Live birth under 2500g in facility rate (%)
2013 DHIS 13.4 13.5 15.1 12.5 10.5 11.6 18.0 14.1 15.1 13.4 g
2014 DHIS 13.5 13.1 12.8 11.7 10.4 11.4 18.5 14.0 14.7 12.6 g
Neonatal death rate (NNDR) (deaths <28 days old per 1 000 live births)

16 6
2011 RMS 2014 - - - - - - - - - 13.0 c
2012 RMS 2014 - - - - - - - - - 11.0 c

20 IL
2013 DHIS 16.6 15.2 12.2 11.8 13.6 10.0 15.1 11.6 5.7 12.2 g
2013 GBD 2013 - - - - - - - - - 14.6 h
2013 PPIP all levels
2013 RMS 2014
-
-
Y T -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
10.6
11.0
i
c
A N
2014 RMS 2014 - - - - - - - - - 11.0 c
2014 DHIS 18.2 12.4 12.9 13.2 13.0 9.3 16.9 13.9 6.2 12.8 j
M U

2015 Inter-agency group (2015) - - - - - - - - - 11.0 f

Number of under-5 deaths
4 ED

2013 Inter-agency group (2014) - - - - - - - - - 47 000 k

2013 vital registration - - - - - - - - - 35 094 l
2015 Inter-agency group (2015) - - - - - - - - - 42 000 f
Perinatal care index (perinatal MR / LBWR)
O

2013 PPIP all levels - - - - - - - - - 2.30 i

Perinatal mortality rate (stillbirths plus deaths <8 days old per 1 000 total births)
G

2013 PPIP all levels - - - - - - - - - 33.4 i

R

2013 registered - - - - - - - - - 25.0 m

2013 registered (updated) - - - - - - - - - 21.8 n
BA

2014 DHIS 26.9 33.1 29.4 27.0 31.5 24.5 37.1 26.2 20.9 27.7 g
Post-neonatal mortality rate (deaths 28–365 days age per 1 000 live births)
O

2013 GBD 2013 - - - - - - - - - 14.7 a

Stillbirth rate (per 1 000 total births)
EM

2013 PPIP all levels - - - - - - - - - 23.1 i

2013 registered - - - - - - - - - 17.0 m
2013 registered (updated) - - - - - - - - - 14.4 n
2014 DHIS 19.6 25.4 19.6 21.1 21.4 21.1 25.5 22.8 17.2 20.7 g
Under 5 mortality rate (deaths under 5 years per 1 000 live births)
2010 Census - - - - - - - - - 44.0 b
2011 GBD 2013 - - - - - - - - - 42.6 o
2011 RMS 2014 - - - - - - - - - 40.0 c
2012 GBD 2013 - - - - - - - - - 40.0 o
2012 RMS 2014 - - - - - - - - - 41.0 c
2013 GBD 2013 - - - - - - - - - 37.0 o
2013 GBD 2013 female - - - - - - - - - 32.9 o
2013 GBD 2013 male - - - - - - - - - 40.9 o
2013 RMS 2014 - - - - - - - - - 41.0 c
2013 mid-year - - - - - - - - - 48.8 d
2014 mid-year - - - - - - - - - 46.5 d
2014 RMS 2014 - - - - - - - - - 39.0 c
2015 mid-year - - - - - - - - - 45.1 d
2015 ASSA2008 59.6 53.5 33.7 57.8 36.6 49.6 32.2 40.9 23.1 44.8 e
2015 Inter-agency group (2015) - - - - - - - - - 41.0 f

28 0 S A H R 20 1 6
 Health and Related Indicators

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Wang et al. 2014.111
b Census 2011 Mortality.39
c RMS 2014.40
d Stats SA Mid-year estimates 2015. 2015 mid-year estimates.20
e ASSA2008.82
f Child Mortality 2015 IGME.112 Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME) in 2015.
g DHIS.45 Financial year.
h Wang et al. 2014.111 Total of early neonatal (0–6 days: 11.4) and late neonatal (7–28 days: 3.2).
i NaPeMMCo 2010–13.113 Data for 2012–2013.
j DHIS.45 Inpatient neonatal death rate using live births in facility for denominator. 2014/15 financial year.
k Child Mortality 2014 IGME.114 Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (IGME) in 2014.
l Stats SA Causes of death 2013.59 Data have been updated with late registrations processed in 2014. Not adjusted for under-reporting – completeness of
death registration for children uncertain.
m Perinatal deaths 2011–13.115 Not adjusted for under-registration of deaths. Number of births given is substantially incomplete for 2013 (approximately
140 000 late registrations in 2014).
n Perinatal deaths 2011–13.115 Not adjusted for under-registration of deaths. Updated denominator of total births given in publication using Stats SA live births
published in September 2015.
o Global Burden of Disease 2013.42 Both genders.

PM
Table 22: Child mortality indicators by population group

African Coloured Indian White All Ref

16 6
Infant mortality rate (deaths under 1 year per 1 000 live births)
2010 Census 38.5 20.3 10.1 8.3  35.0 a

20 IL
Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Census 2011 Mortality.39 Y T
A N
Table 23: Immunisation indicators by province
M U

EC FS GP KZN LP MP NC NW WC SA Ref
BCG coverage (%)
2014 DHIS 88.5 100.8 119.0 81.9 95.2 84.9 95.2 79.6 97.0  94.5 a
4 ED

2014 UNICEF/WHO - - - - - - - - -  77.0 b

DTP3 coverage (%)
2014 DHIS 84.7 97.5 109.8 94.6 95.1 93.6 91.3 89.6 96.7  96.2 a
O

2014 UNICEF/WHO - - - - - - - - -  70.0 b

Immunisation coverage of children <1 year (%)
G

2014 DHIS 80.9 90.1 107.7 89.9 82.2 80.1 85.4 82.1 90.9  89.8 a
Measles 1st dose coverage (%)
R

2014 DHIS 88.3 93.5 110.2 91.8 92.3 84.2 86.5 86.0 94.1  94.1 a
2014 UNICEF/WHO - - - - - - - - -  70.0 b
BA

OPV 1 coverage (%)

2014 DHIS 83.1 101.3 110.4 93.8 97.6 84.4 104.5 88.3 108.2  96.9 a
O

PCV7 3rd dose coverage (%)

EM

2014 DHIS 85.2 91.7 107.8 91.7 91.3 83.0 87.6 84.2 93.6  92.8 a
2014 UNICEF/WHO - - - - - - - - -  65.0 b
RV 2nd dose coverage (%)
2014 DHIS 83.3 98.6 109.7 93.6 94.2 90.4 91.5 88.2 95.2  95.2 a
2014 UNICEF/WHO - - - - - - - - -  64.0 b

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b Immunization 2015.116 Estimates derived by review of available data (including routine service delivery data and surveys), informed and constrained by a
set of heuristics.

S A H R 20 1 6 28 1
Nutrition
Context Nutrition represents an opportunity for intersectoral action, but also shows how a ‘health indicator’ may represent
the net effects of many non-health issues, such as poverty (SDG1), climate action (SDG13) and life on land
(SDG14) and below the water (SDG13). SDG2 sets the specific goal to “end hunger, achieve food security and
improved nutrition and promote sustainable agriculture”.
New data sources Nationally, new data have been reported in the:
• NDoH Strategy for the Prevention and Control of Obesity in South Africa 2015–2020
• Who is getting fat in South Africa: Obesity trends and risk factors in the South African adult population
(analysis of National Income Dynamics Study data)
• Obesity trends and risk factors paper (analysis of National Income Dynamics Study data)
• SALDRU working paper on Multidimensional food insecurity measurement 2015
Internationally, reports of interest include:
• The State of Food Insecurity in the World 2015 (FAO)

PM
• Global Hunger Index 2015 (IFPRI)
• Global Food Security Index 2015 (The Economist Intelligence Unit)
• 2015 Global Nutrition Report (IFPRI)

16 6
• Report of the Commission on Ending Childhood Obesity

20 IL
• Global Burden of Disease Study 2013 – comparative risk assessment
Key issues and trends Although malnutrition, including obesity, is well recognised as a public health problem in South Africa, effective
intervention has been difficult. One of the more recent proposals has been for the introduction of a tax on sugar-
Y T
sweetened beverages.
A N
Measuring achievement of food security, as included in SDG2, is The Global Nutrition Report 2015 provides baseline data on a range
M U

a complex exercise. Data from South Africa have been used to of nutritional indicators, as well as identifying the ‘levers’ that are at
derive a Multidimensional Food Insecurity Index (MFII), based on the hand if countries wish to address malnutrition in all its forms.128 The
4 ED

methodology of the Multidimensional Poverty Index (MPI).117 Based
on this measure, which takes into account dietary diversity and
subjective food consumption adequacy, close to half of the South
African population can be considered to be “multidimensionally food
O
Report also draws attention to the World Health Assembly Global
Targets 2025 to improve maternal, infant and young child nutrition,
which are:

➢➢ a 40% reduction in the number of children under age 5 who

insecure”. Not surprisingly, the highest levels of food insecurity are
are stunted;
in Limpopo and KwaZulu-Natal, and the lowest in the Western Cape
G

and Gauteng. Globally, reports on food insecurity have also been ➢➢ a 50% reduction of anaemia in women of reproductive age;
R

issued by the United Nations Food and Agriculture Organization118 ➢➢ a 30% reduction in low birth weight;
and the Economist Intelligence Unit.119,120 The former rates South
BA

➢➢ no increase in childhood overweight;

N

Africa as ‘close’ to meeting World Food Summit goals set in 1996.

The latter shows some progress, with the gap between the most and ➢➢ an increase in the rate of exclusive breastfeeding in the first six
O

least food-secure nations narrowing. South Africa is ranked 42nd, months up to at least 50%; and
EM

with a Global Food Security Index of 64.5 (the highest being 89.0
and the lowest 25.1).
The National Budget 2016 floated the idea of introducing a ‘sin’
tax on sugar-sweetened beverages.121,122 Globally, this has been
identified as a suitable target for intervention.123 This fiscal measure
is also mentioned in the Strategy for the Prevention and Control of
Obesity in South Africa 2015–2020, published in 2015.124 The
targets set in the strategy are no increase in the prevalence of obesity
in 2016, a 3% decrease in all age groups by 2017, and a 10%
decrease in all age groups by 2020. The scale of the challenge is
underlined by the data from the National Income Dynamics Study
(NiDS) Waves 1–3, which showed increasing body mass index and
obesity in South Africa, particularly among women.125,126 Data
from the Global Burden of Disease Study 2013 have been used to
show that behavioural, environmental, occupational and metabolic
risks can explain half of global mortality and more than one-third
of global DALYs.127 In particular, this analysis showed that the
attributable burden of high body mass index (BMI) has increased in
the past 23 years, globally.
➢➢ to reduce and maintain childhood wasting to less than 5%.
The Global Hunger Index (based on the proportion of undernourished
in the population, the prevalence of wasting in children under 5
years, the prevalence of stunting in children under 5 years, and
the under-5 mortality rate) for South Africa in 2015 was 12.4 (a
moderate value, and down by 8.6 points since 2005).129
In 2016, the World Health Organization issued a report from the
Commission on Ending Childhood Obesity.130 The Commission’s
recommendations focus on promoting the intake of healthy foods
and reducing the intake of unhealthy foods and sugar-sweetened
beverages by children and adolescents. The Commission endorsed
the monitoring indicators included in the Global Monitoring
Framework for Non-communicable Diseases and the Global
Monitoring Framework for Maternal, Infant and Young Child
Nutrition (as shown above). In addition, the Commission called on
governments to “ensure data collection on BMI-for-age of children
– including for ages not currently monitored – and set national
targets for childhood obesity”. Secondary data analysis from the

282 S A H R 20 1 6
 Health and Related Indicators

National Food Consumption Survey – Fortification Baseline I study,

published in 2016, showed that stunted children are more likely
to be obese.131 Of 36–119 month-old children in Gauteng and
Mpumalanga, 12% were overweight and 17% were stunted. In the
obese group, 68.4% were stunted.

The WHO 100 Core Health Indicators includes a measure of the

age-standardised mean population intake of salt (sodium chloride)
per day in grams in persons aged 18+ years. The available
evidence on salt intake in South Africa, and its implications for non-
communicable disease prevalence, and in particular hypertension,
has recently been reviewed.132 Although figures of 6–11g intake
per day have been reported (exceeding the recommended intake
of less than 5g per day), the research studies are all for small areas
and fairly dated.133 A recent review of dietary surveys conducted

PM
in South Africa has called for the creation of a national nutrition
monitoring system, in order to identify specific dietary deficiencies
in different population groups.134 Such deficiencies will most likely
affect communities in poorer urban and rural areas, where access to

16 6
affordable, healthy foods is a challenge.

20 IL
Table 24: Nutrition indicators by province

EC Y T FS GP KZN LP MP NC NW WC SA Ref
Anaemia prevalence in children (%)
A N
2012 under 5 years - - - - - - - - -  10.7 a
Anaemia prevalence in women of reproductive age (%)
M U

2012 16-35 years 19.9 17.6 18.6 35.9  - 29.5  - 16.9 16.1  23.1 b
Iron deficiency anaemia prevalence (%)
4 ED

2012 under 5 years - - - - - - - - -  1.9 a

Iron deficiency prevalence (%)
2012 under 5 years - - - - - - - - -  8.1 a
Obesity (%)
O

2011 NYRBS 12.4 7.1 6.1 6.5 4.0 3.4 4.3 3.8 11.3  6.9 c
2012 NiDS female <15 14.6 14.3 14.8 11.6 9.9 12.7 7.4 16.2 21.6  13.9 d
G

2012 NiDS male <15 14.8 7.3 13.9 16.7 9.8 15.1 4.8 8.2 16.1  13.6 d
2012 NiDS <15 years 14.7 11.0 14.4 14.2 9.9 14.0 6.2 12.4 18.8  13.7 d
R

2012 NiDS female 15+ - - - - - - - - -  36.0 e

2012 NiDS male 15+ - - - - - - - - -  12.2 e
BA

2012 NiDS total 15+ - - - - - - - - -  25.1 e

O

2012 boys 2-14 years 3.7 4.1 5.3 6.1 3.3 6.1 3.9 2.7 4.1  4.7 a
2012 female 15+ 41.8 43.0 39.9 44.0 32.6 35.8 38.6 31.7 37.9  39.2 a
EM

2012 girls 2-14 years 6.7 4.7 10.0 8.5 4.3 5.5 3.5 4.3 7.2  7.1 a
2012 male 15+ 7.2 5.8 12.9 7.9 11.5 13.0 7.2 7.3 16.1  10.6 a
2013 boys <20 years - - - - - - - - -  7.0 f
2013 female 20+ - - - - - - - - -  42.0 f
2013 girls <20 years - - - - - - - - -  9.6 f
2013 male 20+ - - - - - - - - -  13.5 f
Overweight (%)
2011 NYRBS 31.1 20.9 22.6 26.8 14.0 17.8 13.0 15.5 31.5  23.1 g
2012 NiDS female <15 19.9 22.4 20.5 22.9 18.6 23.5 14.0 15.4 14.2  19.9 d
2012 NiDS male <15 21.0 18.7 17.0 20.3 16.2 13.2 11.0 14.4 14.3  17.3 d
2012 NiDS <15 years 20.5 20.6 18.8 21.6 17.5 17.7 12.6 14.9 14.3  18.6 d
2012 NiDS female 15+ - - - - - - - - -  27.6 e
2012 NiDS male 15+ - - - - - - - - -  25.2 e
2012 NiDS total 15+ - - - - - - - - -  26.5 e
2012 boys 2-14 years 12.4 10.8 11.0 15.1 4.8 10.6 2.9 6.4 18.2  11.5 a
2012 female 15+ 21.7 20.7 28.1 25.2 24.0 26.2 23.4 22.3 24.5  24.8 a
2012 girls 2-14 years 12.4 17.7 20.3 20.3 9.1 14.1 8.3 15.2 19.1  16.5 a
2012 male 15+ 17.1 19.5 21.0 23.7 16.3 17.4 17.8 9.0 26.9  20.1 a
2013 boys <20 years - - - - - - - - -  11.8 h
2013 female 20+ - - - - - - - - -  27.3 h

S A H R 20 1 6 28 3
 EC FS GP KZN LP MP NC NW WC SA Ref
2013 girls <20 years - - - - - - - - -  16.7 h
2013 male 20+ - - - - - - - - -  25.3 h
Stunting (%)
2011 NYRBS 19.6 14.4 7.1 12.7 10.9 12.6 19.4 12.1 14.8  12.9 i
2012 NiDS <15 years 21.8 19.6 19.8 21.6 26.4 23.4 22.0 21.3 14.3  21.2 d
2012 NiDS female <15 21.2 16.5 17.7 20.5 27.4 18.6 17.9 23.7 14.1  20.1 d
2012 NiDS male <15 22.3 23.0 22.0 22.8 25.3 27.1 26.5 18.9 14.5  22.3 d
2012 female <15 years 15.6 22.1 10.0 14.4 9.4 13.0 15.0 17.8 13.9  13.7 a
2012 male <15 years 21.6 19.4 11.9 13.5 13.7 23.1 22.8 23.7 17.5  16.7 a
Underweight (%)
2011 NYRBS 5.8 9.1 6.0 6.2 7.1 7.6 17.2 12.6 5.0  7.0 i
2012 NiDS female <15 7.0 9.6 6.5 5.6 8.4 7.9 11.0 15.3 4.6  7.4 d
2012 NiDS male <15 8.2 6.0 8.8 7.4 12.0 10.5 18.7 16.9 8.0  9.5 d
2012 NiDS <15 years 7.6 7.9 7.7 6.5 10.1 9.5 14.6 16.1 6.3  8.5 d

PM
2012 NiDS female 15+ 1.4 3.6 1.4 1.5 2.1 2.0 4.3 2.6 3.3  2.0 e
2012 NiDS male 15+ 4.1 8.8 3.8 3.2 6.4 4.0 10.2 7.2 6.8  5.0 e
2012 NiDS total 15+ 2.6 6.1 2.6 2.2 3.9 2.9 7.1 4.8 4.8  3.4 e
2012 female 15+ 5.2 3.5 1.7 5.3 4.0 5.2 8.4 7.8 3.5  4.2 a

16 6
2012 female <15 years 5.6 6.9 1.2 1.5 2.4 3.7 10.8 7.9 4.6  3.6 a
2012 male 15+ 13.5 13.9 9.0 13.8 20.7 8.7 15.1 23.6 8.1  12.8 a

20 IL
2012 male <15 years 1.9 2.2 8.7 3.4 9.1 10.4 23.8 15.2 7.2  7.4 a
Vitamin A coverage children 12-59 months (%)
2012 DHIS 40.1 Y T 59.3 45.6 41.4 35.8 34.8 34.7 32.2 37.8  40.5 j
2013 DHIS 44.7 54.8 49.9 47.8 33.8 36.0 38.7 39.3 44.4  44.3 j
A N
2014 DHIS 53.0 58.7 56.6 54.5 44.4 50.0 45.3 52.2 47.4  52.2 j
Vitamin A deficiency (%)
M U

2012 under 5 years - - - - - - - - -  43.5 k

Waist-hip ratio (WHR) above cut-off (%)
4 ED

2012 female 15+ 46.1 43.1 43.3 50.0 44.7 49.6 46.7 50.9 51.5  47.1 l
2012 male 15+ 3.9 6.3 6.7 9.0 5.2 5.3 2.7 10.1 8.2  6.8 l
Wasting (%)
2011 NYRBS 1.6 4.6 3.6 2.2 4.9 5.3 10.8 6.0 1.3  3.5 i
O

2012 NiDS female <15 3.7 4.1 6.6 4.3 4.2 9.1 6.9 5.9 4.9  5.3 d
2012 NiDS male <15 4.2 2.3 7.5 5.6 2.3 7.3 11.5 5.0 5.3  5.5 d
G

2012 NiDS <15 years 4.0 3.2 7.1 4.9 3.3 8.1 9.1 5.5 5.1  5.4 d
2012 female <15 years 3.2 1.4 0.4  - 2.8 1.8 5.1 5.2 1.3  1.7 a
R

2012 male <15 years 1.6 1.7 3.6 2.4 6.5 2.8 18.5 8.5 2.0  3.8 a
BA

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a SANHANES-1.47
O

b SANHANES-1. Hb <12 g/dL

c NYRBS 2011.135 Obese according to the age-dependent BMI cut-offs suggested by Cole (30 kg/m2 by age 18)
EM

d NiDS Wave 3 v1.2.91

e NCD Trends 2015.136
f Ng et al. 2014. Age-standardised estimate.
g NYRBS 2011.135 Overweight according to the age-dependent BMI cut-offs suggested by Cole (25 kg/m2 by age 18)
h Ng et al. 2014.137 Age-standardised estimate. Calculated as ‘overweight and obese’ minus ‘obese’.
i NYRBS 2011.135
j DHIS.45 Financial year.
k SANHANES-1.47 Vitamin A <0.7 micromol/L
l SANHANES-1.47 Of participants 15 years and older.

28 4 S A H R 20 1 6
 Health and Related Indicators

Table 25: Nutrition indicators by population group

African Coloured Indian White Other All Ref

Age-standardised mean population intake of salt (sodium chloride) per day in grams
2005 7.8 - - 9.5 -  - a
Obesity (%)
2011 NYRBS 6.7 7.1 7.3 9.0 7.6  6.9 b
2012 NiDS <15 years 13.6 10.3 11.7 21.1 -  13.7 c
2012 NiDS female 15+ 35.4 34.1 34.8 42.6 -  36.0 d
2012 NiDS male 15+ 9.5 14.0 14.2 34.1 -  12.2 d
2012 boys 2-14 years 4.8 3.8 - - -  4.7 e
2012 female 15+ 39.9 34.9 32.4 - -  39.2 e
2012 girls 2-14 years 7.3 5.3 - - -  7.1 e
2012 male 15+ 9.4 15.1 7.6 - -  10.6 e
Overweight (%)
2011 NYRBS 23.0 21.3 20.6 30.4 13.7  23.1 f

PM
2012 NiDS <15 years 19.5 12.2 5.9 17.3 -  18.6 c
2012 NiDS female 15+ 27.7 22.7 28.8 31.2 -  27.6 d
2012 NiDS male 15+ 23.4 21.2 36.6 42.3 -  25.2 d
2012 boys 2-14 years 11.9 8.0 - - -  11.5 e

16 6
2012 female 15+ 24.9 24.4 22.8 - -  24.8 e

20 IL
2012 girls 2-14 years 16.2 14.6 - - -  16.5 e
2012 male 15+ 19.1 22.1 32.2 - -  20.1 e
Stunting (%)
2011 NYRBS
2012 NiDS <15 years
Y T
13.4
22.6
13.9
17.8
8.8
13.5
3.3
4.8
19.7
-
 12.9
 21.2
g
c
A N
2012 female <15 years 13.6 16.1 - - -  13.7 e
2012 male <15 years 16.7 18.6 - - -  16.7 e
M U

Underweight (%)
2011 NYRBS 7.0 9.7 11.0 2.0 5.6  7.0 g
4 ED

2012 NiDS <15 years 9.1 8.4 0.0 1.4 -  8.5 c

2012 NiDS female 15+ 2.0 1.9 3.9 1.8 -  2.0 d
2012 NiDS male 15+ 4.9 9.7 6.5 0.5 -  5.0 d
O

2012 female 15+ 3.6 4.9 16.4 - -  4.2 e

2012 female <15 years 0.5 9.8 - - -  3.6 e
G

2012 male 15+ 12.9 12.4 32.6 - -  12.8 e

2012 male <15 years 1.3 2.2 - - -  7.4 e
R

Waist-hip ratio (WHR) above cut-off (%)

2012 female 15+ 45.7 52.9 64.8 - -  47.1 h
BA

2012 male 15+ 5.1 8.4 24.9 - -  6.8 h

Wasting (%)
O

2011 NYRBS 3.3 5.5 8.8 1.5 2.1  3.5 g

2012 NiDS <15 years 5.0 7.1 8.1 7.2 -  5.4 c
EM

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Wentzel-Viljoen et al. 2013.133 Citing Charlton et al. study, Cape Town circa 2005. Data only reported for African and White groups. Not age-standardised.
b NYRBS 2011.135 Obese according to the age-dependent BMI cut-offs suggested by Cole (30kg/m2 by age 18)
c NiDS Wave 3 v1.2.91
d NCD Trends 2015.136
e SANHANES-1.47
f NYRBS 2011.135 Overweight according to the age-dependent BMI cut-offs suggested by Cole (25 kg/m2 by age 18)
g NYRBS 2011.135
h SANHANES-1.47 Of participants 15 years and older.

S A H R 20 1 6 285
Non-communicable diseases
Context Tracking non-communicable disease (NCD) prevalence and associated mortality poses significant challenges for
the health information system. The Sustainable Development Goals (SDGs) have paid more attention to NCDs
than did the Millennium Development Goals (MDGs), but the range of conditions to be tracked is also far wider.
New data sources Nationally, new data have been reported in the:
• National Cancer Registry summary statistics on histologically diagnosed cancer up to 2010
• Stats SA Causes of Death 2014 report (unit records not available at time of writing)
• South African NCD Alliance Civil Society Status Report 2010–2015
Internationally, reports of interest include:
• IDF Diabetes Atlas 2015
• PRB Non-communicable diseases in Africa Policy Brief
• Global Burden of Disease study 2013 global estimates of cardiovascular and ischaemic heart disease

PM
Key issues and trends Measures of non-communicable disease incidence, prevalence and associated mortality are difficult to extract
from routine service data. Over time, more data will be available from the National Income Dynamics Study
(NiDS) and the South African National Health and Nutrition Examination Surveys (SANHANES). There will
always be a differences between self-reported cases and clinically-confirmed cases, but longitudinal studies

16 6
can also provide insights into treatment gaps and the adequacy of treatment, at least for conditions such as
hypertension. Assessing the adequacy of care for other conditions is far more challenging.

20 IL
The WHO 100 Core Health Indicators include a number of measures exploration of the correlation between hypertension and various
of NCD incidence, prevalence and associated mortality, including: risk factors. Across the three waves of NiDS, for instance, mean
Y T
➢➢ age-standardised prevalence of raised blood pressure among
systolic and diastolic blood pressures increased as BMI increased.
Self-reported treatment coverage in those self-reporting hypertension
A N
persons aged 18+ years;
did not vary between the three waves of NiDS (73.4%, 77.5%,
➢➢ age-standardised prevalence of raised blood glucose/
M U

74.7%). Somewhat higher proportions of women (75.0%, 80.1%,

diabetes among persons aged 18+ years or on medication for 76.8%) than men (69.0%, 71.2%, 70.2%) reported being on
raised blood glucose; treatment for hypertension. However, only a minority of those
4 ED

➢➢ mortality between ages 30 and 70 years from cardiovascular with measured elevated blood pressure (35.9%, 34.1%, 38.4%)
diseases, cancer, diabetes or chronic respiratory diseases; and were on treatment. In addition, of those on treatment, at least half
(50.0%, 54.0%, 53.8%) were uncontrolled (i.e. had an elevated
O

➢➢ cancer incidence rate, by type of cancer (per 100 000

blood pressure). Although prevalence was lower, similar trends in
population).
self-reported diabetes, stroke, asthma, cancer and heart problems
G

Each of these indicators poses significant challenges for routine data were reported in the 2008, 2010 and 2012 waves of NiDS. The
collection. However, cross-sectional surveys and longitudinal studies
R

prevalence of diabetes and asthma was higher for females than

promise to deliver more useful data. For example, data on self- males, and also increased with age. However, simple measures of
BA

reported hypertension and actual hypertension can be gleaned from the adequacy of treatment are not as easily performed. Cancer,
the three waves of the National Income Dynamics Study (NiDS) and in particular, represents a daunting list of very different conditions,
O

from the South African National Health and Nutrition Examination for which treatment is not continuous. Yet another challenge facing
Surveys (SANHANES). Self-reported data on hypertension can also
EM

be extracted from the annual General Household Surveys (GHS). The
prevalence of self-reported hypertension in females aged 15 years
and older varied from 14% in GHS 2012, to 21% in both NiDS
2012 and SANHANES 2012. The corresponding figures for men
were 7% (GHS 2012), 11% (NiDS 2012) and 12% (SANHANES
2012).136 However, when actually measured by fieldworkers,
differences in the prevalence of hypertension by sex are negligible.
Prevalence of elevated blood pressure in females was 26.0% in
NiDS 2012 and 26.9% in SANHANES 2012. The corresponding
figures for men were 27.0% and 26.4%. Hypertension prevalence
by district is shown in the appendix (Map 2). Over the three waves
of NiDS, between 2008 and 2012, prevalence of elevated blood
pressure increased slightly in white females and African males, and
decreased slightly in coloured males. Prevalence remained almost
unchanged in African females, coloured females and white males.
The prevalence of elevated blood pressure in those self-reporting
no hypertension was higher in males, and increased steadily
with age for both sexes. NiDS and SANHANES also allow for
the SDG targets for NCDs is the extent to which they address
issues of equity. It has been suggested, for instance, that target 3.4
be reworded by adding the text in italics: “by 2030, reduce by
one-third premature mortality from NCDs through prevention and
treatment and promote mental health and well-being, with particular
emphasis on improving the status of the worst off”.138 This would
require disaggregation of survey data by some measure of socio-
economic status. In South Africa, consideration would also need
to be given to the particular needs of those on long-term treatment
for HIV, as some of the antiretroviral medicines used have negative
implications for cardiometabolic disease.139
The value of spot measurements of blood pressure should not,
however, be accepted without caution. A study in 101 employees
of a large North West firm (50% male) showed that clinic blood
pressure measurements revealed 18% as hypertensive, but 24-hour
measurements revealed 63% to be hypertensive.140
The second wave of the Study on global AGEing and adult health
(SAGE) was due to be completed in China, Ghana, India, Mexico,

28 6 S A H R 20 1 6
 Health and Related Indicators

and South Africa by the end of 2015, with the Russian Federation
to follow. Data are expected to be available in the public domain
starting in the first half of 2016.e
Data from the Global Burden of Disease Study 2013 have been
used to trace global and regional trends in cardiovascular mortality
between 1990 and 2013,141 as well as to estimate the contribution
of cardiovascular disease to premature mortality by 2025.142 The
data suggest that there are higher rates of cardiovascular disease
in eastern and central Africa compared with West and Southern
Africa, but there is considerable uncertainty around the estimates.
Premature mortality due to cardiovascular disease has fallen in
South Africa, but not sufficiently to meet the 25% reduction that
was targeted. For Southern Africa as a region, a modest 4 to 8%
reduction is expected between 2013 and 2025 if current risk factors
necessary insights that will allow for programme design, adaptation
and management.
Much of the battle against NCDs will rely on changing behaviours,
which in turn will rely on being able to provide high-quality
information to the public. It has been shown, for example, that
combining the provision of information with human papilloma
vaccination at school can help to improve knowledge about cervical
cancer symptoms, screening and the role of vaccination among
mothers of adolescent girls.147 However, the scale of the effort
dedicated to public knowledge of HIV will need to be replicated
in respect of the wider range of NCDs, including mental health. In
Africa, with its youthful population, adolescents and young adults
need to be prioritised in this regard.148
In 2015 the Rural Mental Health Campaign Report drew attention

are not addressed. Hypertension is regarded as the most important
risk factor for such premature mortality in this region. Specifically
with reference to ischaemic heart disease, age-standardised death
rates in sub-Saharan Africa have seen one of the highest relative
PM
to the parlous state of mental health services in rural areas of South
Africa.149 The report called for provinces to take deliberate steps to
implement the National Mental Health Policy Framework, including

16 6
increases between 1990 and 2013.143 setting targets, indicators, budgets and timelines. As can be seen
in Table 26, data on the prevalence and treatment of mental health
Globally, the International Diabetes Federation has published a

20 IL
conditions are generally lacking. The underlying source of the data
seventh edition of its Atlas, which estimates that 193 million people
on suicide in South Africa, which was obtained from the Global
with diabetes are undiagnosed, that 1 in 15 adults has impaired
Y T Health Observatory, is unclear.
glucose tolerance, and that 1 in 7 births is affected by gestational
diabetes.144 The total number of people living with diabetes was Although more data on the incidence of cancer cases diagnosed
A N
estimated to be between 7.2% and 11.4% of the global population, histologically are now available from the National Health Laboratory
M U

or between 339 and 536 million people. The highest number of Service, the most recent data presented in Table 28 are from 2010.
undiagnosed patients with diabetes was expected to be in Africa,
where between 9.5 million and 29.3 million people were estimated
4 ED

to be living with diabetes. An estimated 7.6% (age-standardised) of

South Africans aged 20–79 years were estimated to have diabetes
in 2015. Of particular concern are the considerable barriers to
O

access to insulin, a product where generic or biosimilar penetration

has been delayed and poor.145 Three multinational manufacturers
G

control 96% of the global insulin market by volume and 99% by

value. Despite marginal benefits, the more expensive analogue
R

insulins are increasingly used, even in middle-income countries.

BA

A South African Non-Communicable Disease Alliance has been

created, as part of the global NCD Alliance. A capacity-building
O

programme has been funded by Medtronic Philanthropy to assist

EM

civil society organisations in Brazil, the Caribbean region and

South Africa. One of the goals of the programme is to conduct
national level research and analysis. Medtronic Philanthropy is a
US-based corporate responsibility structure aiming to expand access
to chronic disease care for the underserved.f A Civil Society Status
Report 2010–2015 was issued in September 2015, which sets out
to map South Africa’s response to the NCD epidemic.146 Although
the criticism of the lack of budgetary allocations for NCDs within
the Primary Health Care programme budget is probably misplaced,
as ring-fenced, disease-specific budgeting is not applied in this
programme, it is worth reflecting on the call for improved monitoring
and evaluation. In the press release accompanying the Report, the
NCD Alliance noted a “continuing and alarming trend to make
policy and plans without any budgetary allocation” and that there is
“poor or non-existent monitoring and evaluation”. As argued above,
routine health information system data are unable to provide the

e http://www.who.int/healthinfo/sage/cohorts/en/index3.html
f http://philanthropy.medtronic.com/who-we-are/about-us/index.htm

S A H R 20 1 6 287
Table 26: Chronic disease indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Cervical cancer screening coverage (%)
2014 DHIS 56.3 40.9 43.6 70.3 47.9 63.3 30.0 65.8 56.8  54.5 a
Diabetes prevalence (%)
2012 age 15+ 8.5 10.1 7.9 10.0 4.6 5.6 21.7 12.5 11.2  9.5 b
2013 age 20-79 - - - - - - - - -  8.3 c
2013 age 20-79 (age-standardised) - - - - - - - - -  9.3 c
2014 age 20-79 - - - - - - - - -  8.4 d
2014 age 20-79 (age-standardised) - - - - - - - - -  9.4 d
2015 age 20-79 - - - - - - - - -  7.0 e
2015 age 20-79 (age-standardised) - - - - - - - - -  7.6 e
Diabetes prevalence (per 1 000)
2013 all beneficiaries - - - - - - - - -  26.9 f
Hyperlipidaemia prevalence (per 1 000)

PM
2013 all beneficiaries - - - - - - - - -  35 f
Hypertension prevalence (%)
2012 NiDS female 15+ - - - - - - - - -  33.5 g
2012 NiDS female 15-24 - - - - - - - - -  7.9 g

16 6
2012 NiDS female 25-34 - - - - - - - - -  18.9 g

20 IL
2012 NiDS female 35-44 - - - - - - - - -  33.2 g
2012 NiDS female 45-54 - - - - - - - - -  52.4 g
2012 NiDS female 55-64 - - - - - - - - -  66.6 g
2012 NiDS female 65+
2012 NiDS male 15+
-
-
Y T -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 78.7
 29.8
g
g
A N
2012 NiDS male 15-24 - - - - - - - - -  11.8 g
2012 NiDS male 25-34 - - - - - - - - -  21.1 g
M U

2012 NiDS male 35-44 - - - - - - - - -  32.6 g

2012 NiDS male 45-54 - - - - - - - - -  46.5 g
4 ED

2012 NiDS male 55-64 - - - - - - - - -  59.4 g

2012 NiDS male 65+ - - - - - - - - -  70.6 g
2012 NiDS total 15+ 36.3 33.0 31.3 31.1 22.8 23.9 38.6 35.6 38.6  31.8 g
Hypertension prevalence (per 1 000)
O

2013 all beneficiaries - - - - - - - - -  87 f

Hypertension treatment coverage (%)
G

2012 both 15+ - - - - - - - - -  38.4 g

R

2012 female 15+ - - - - - - - - -  48.1 g

2012 male 15+ - - - - - - - - -  25.5 g
BA

Mortality between 30-70 years from cardiovascular, cancer, diabetes or chronic respiratory disease
2012 - - - - - - - - -  26.8 h
O

Prevalence of abnormal lipid profiles (%)

2012 female serum chol >5 mmol/L 30.8 29.0 27.1 22.9 15.9 22.9 32.4 38.2 39.3  28.1 b
EM

2012 male serum chol >5 mmol/L 20.8 20.3 14.7 18.7 10.9 14.6 15.4 17.5 34.8  18.9 b
Prevalence of mental disorders
2012 current (depression) total  15.2 - - - - - - - - - i
2012 lifetime (depression) total  31.4 - - - - - - - - - i
Prevalence of raised blood pressure (%)
2012 NiDS female 15+ - - - - - - - - -  26.1 j
2012 NiDS female 15-24 - - - - - - - - -  7.6 j
2012 NiDS female 25-34 - - - - - - - - -  18.1 j
2012 NiDS female 35-44 - - - - - - - - -  26.5 j
2012 NiDS female 45-54 - - - - - - - - -  40.7 j
2012 NiDS female 55-64 - - - - - - - - -  46.1 j
2012 NiDS female 65+ - - - - - - - - -  55.3 j
2012 NiDS male 15+ - - - - - - - - -  26.5 j
2012 NiDS male 15-24 - - - - - - - - -  11.8 j
2012 NiDS male 25-34 - - - - - - - - -  20.6 j
2012 NiDS male 35-44 - - - - - - - - -  31.5 j
2012 NiDS male 45-54 - - - - - - - - -  39.0 j
2012 NiDS male 55-64 - - - - - - - - -  42.9 j
2012 NiDS male 65+ - - - - - - - - -  58.0 j
2012 NiDS total 15+ - - - - - - - - -  26.3 j

28 8 S A H R 20 1 6
 Health and Related Indicators

EC FS GP KZN LP MP NC NW WC SA Ref
2012 raised SYS and DIA 10.4 17.3 11.4 8.4 6.6 9.1 10.8 13.0 9.4  10.2 k
2012 raised SYS or DIA or both 27.1 30.5 27.3 26.4 20.7 20.9 23.5 29.9 30.7  26.6 l
Suicide rate (per 100 000 population)
2012 age-standardised - - - - - - - - -  3.0 m
2012 age-standardised female - - - - - - - - -  1.1 m
2012 age-standardised male - - - - - - - - -  5.5 m

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a DHIS.45 Data for financial year from April of the year to March of the following year (not calendar year).
b SANHANES-1.47
c Diabetes Atlas 2013.150 Modelled estimates based on best published studies. Estimated number of cases of diabetes = 2 646 050 of which 1 217 180
estimated to be undiagnosed.
d Diabetes Atlas 2014.151 Modelled estimates based on best published studies. Estimated number of cases of diabetes = 2 713 380 of which 1 248 160
estimated to be undiagnosed.
e Diabetes Atlas 2015.144 Estimated number of cases of diabetes = 2 286 000 of which 1 396 800 estimated to be undiagnosed.
f Medical Schemes 2014–15.22 Diagnosed and treated.

PM
g NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of hypertension was defined as those with BP equal or above
140/90 mmHg and/or taking anti-hypertensive medication.
h Global NCD 2014.152
i Andersson et al. 2013.153 Cross-sectional population-based survey of persons aged 18–40 living in the EC.
j NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of raised BP was defined as those with BP equal or above

16 6
140/90 mmHg regardless of medication usage.
k SANHANES-1.47 Restrictive definition of both parameters raised. Of participants 15 years and older.

20 IL
l SANHANES-1.47 Calculated from (raised SYS) + (raised DIA) – (both SYS and DIA raised). Age 15+.
m Global Health Observatory.154 Downloaded 14-02-2016 http://apps.who.int/gho/data/view.main.2485

Y T
Table 27: Chronic disease indicators by population group
A N
African Coloured Indian White All Ref
Diabetes prevalence (%)
M U

2012 age 15+ 8.2 13.4 30.7 8.1  9.5 a

Hypertension prevalence (%)
4 ED

2012 NiDS female 15+ 31.7 40.3 41.2 40.0  33.5 b

2012 NiDS male 15+ 28.0 37.3 42.6 36.2  29.8 b
Prevalence of abnormal lipid profiles (%)
2012 female serum chol >5 mmol/L 24.9 40.6 45.3  -  28.1 c
O

2012 male serum chol >5 mmol/L 15.3 27.2 41.2  -  18.9 c
Prevalence of raised blood pressure (%)
G

2012 NiDS female 15+ 24.8 33.6 38.5 27.3  26.1 d

2012 NiDS male 15+ 25.6 32.6 31.8 26.5  26.5 d
R

2012 raised SYS and DIA 9.9 11.8 7.3 12.2  10.2 e
BA

2012 raised SYS or DIA or both 25.6 33.2 25.9 29.3  26.6 f
N
O

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a SANHANES-1.47
EM

b NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of hypertension was defined as those with BP equal or above
140/90 mmHg and/or taking anti-hypertensive medication.
c SANHANES-1.47 Too few observations in White population group.
d NCD Trends 2015.136 National Income Dynamics Study (NiDS). The measured prevalence of raised BP was defined as those with BP equal or above
140/90 mmHg regardless of medication usage.
e SANHANES-1.47 Restrictive definition of both parameters raised. Of participants 15 years and older.
f SANHANES-1.47 Calculated from (raised SYS) + (raised DIA) – (both SYS and DIA raised). Age 15+.

S A H R 20 1 6 289
Table 28: Cancer incidence for leading types of cancer (per 100 000 population) for South Africa, 2010

Female Male Ref

Breast 25.9 Prostate 29.9 a
Cervix 22.3 Primary unknown 8.8 a
Colorectal 4.8 Lung 8.5 a
Uterus 4.8 Colorectal 7.6 a
Primary unknown 6.2 Kaposi sarcoma 5.9 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Cancer incidence 2010.155 Age-standardised incidence (World Standard Population). Rates are also given by gender and population group in the source
tables.

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

290 S A H R 20 1 6
 Health and Related Indicators

Risk behaviour and determinants of health

Context The Sustainable Development Goals (SDGs) have drawn attention not only to the usual social determinants of
health (such as sedentary lifestyles, smoking and substance abuse), but also to the environmental factors that
demand intersectoral approaches.
New data sources Nationally, new data have been reported in the:
• South African Community Epidemiology Network on Drug Use (SACENDU) updates
• NDoH Strategy for the Prevention and Control of Obesity in South Africa 2015–2020
Internationally, reports of interest include:
• Global Burden of Disease Study 2013 – new interactive visualisations of risk factors (such as alcohol use)
by country.
Key issues and trends Longitudinal data from a panel study – the National Income Dynamics Study (NiDS) – provide concerning
evidence of growing overweight and obesity in South Africa. Across every social divide, South Africans report
high levels of inactivity. Addressing non-communicable diseases will require concerted efforts to address these

PM
risk behaviours, in addition to smoking and unsafe alcohol use.

Global guidelines consistently call for a minimum of 60 minutes per

day of moderate-to-vigorous physical activity by school-age children.

16 6
The International Study of Childhood Obesity, Lifestyle and the
Environment (ISCOLE), which included children from South Africa,

20 IL
confirmed the association of exercise with avoidance of obesity.156
Data from the three waves of NiDS and from SANHANES 2012 have
Y T
shown that the prevalence of overweight and obesity is consistently
higher in South African women than men at all ages. Mean body
A N
mass index (BMI) has increased between 1998 and 2012, for all
ages, sexes and population groups. In all three waves of NiDS, men
M U

and women, of all ages and all population groups, whether living
in urban or rural settings, and regardless of educational level, have
4 ED

self-reported high levels of physical inactivity (being active less than

3 times a week), ranging from 78% to 97%.136

Longitudinal data on smoking prevalence and alcohol usage have

O

also been reported in NiDS. Higher levels of self-reported smoking

continue to be recorded for the coloured community across all three
G

waves of NiDS. Smoking was also more prevalent among farm

dwellers and those with only a primary level of education. Although
R

NiDS showed that almost three-quarters of South Africans were non-

BA

users of alcohol, risky drinking (5 or more standard drinksg per day)

was more prevalent among Coloureds and moderate drinking (less
O

than 5 drinks per day) among Whites.136

EM

The most recent update from the South African Community

Epidemiology Network on Drug Use (SACENDU) provides data from
substance abuse treatment centres in all nine provinces. However,
as in previous editions, data from Mpumalanga and Limpopo are
combined as the ‘Northern Region’ and those from the Free State,
North West and Northern Cape as the ‘Central Region’, which
makes depiction by province difficult.

g The amount of standard alcohol (small glass of wine; a 330 ml can of

regular beer; a tot of spirits; or a mixed drink).

S A H R 20 1 6 291
Table 29: Behaviour and awareness indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Alcohol dependence (%)
2014 MSM - - - - - - - - -  43.4 a
2014 Non-MSM - - - - - - - - -  32.5 a
Currently drink alcohol (%)
2011 NYRBS 25.7 46.2 43.7 25.8 21.1 31.9 49.2 38.5 44.4  32.3 b
Ever drank alcohol (%)
2011 NYRBS 42.6 60.5 66.7 42.8 30.2 46.1 67.1 58.9 66.2  49.2 c
Ever smoked cigarettes (%)
2011 GYTS Grade 8-11 - - - - - - - - -  31.3 d
2011 NYRBS 21.4 35.0 41.8 22.6 18.5 20.8 38.7 27.6 42.9  27.6 e
2012 NiDS total 15+ - - - - - - - - -  22.5 f
2012 age 15+ 22.5 32.2 16.0 20.8 14.4 17.6 33.2 14.9 38.5  20.8 g
2012 female age 15+ 9.3 14.6 7.3 7.0 2.9 3.9 26.4 6.5 31.7  10.1 g

PM
2012 male age 15+ 36.8 50.4 24.6 38.1 29.4 33.6 40.2 25.2 46.0  32.8 g
Ever used drugs (%)
2011 NYRBS 10.3 11.7 7.9 8.3 12.5 10.1 7.9 9.1 9.3  9.7 h
2014 MSM – injected drugs - - - - - - - - -  2.1 i

16 6
2014 Non-MSM – injected drugs - - - - - - - - -  1.2 i
Frequent smokers (%)

20 IL
2011 NYRBS 3.4 8.8 7.9 3.6 3.5 3.1 8.7 3.7 7.6  4.9 j
2012 female 18+ 5.6 8.4 3.0 3.6 2.0 3.4 23.1 4.9 25.6  6.5 k
2012 male 18+
2012 total 18+
27.1
15.9
Y T 39.3
23.6
20.6
11.8
31.5
15.6
23.0
11.0
27.3
14.6
34.7
28.8
21.2
12.1
38.0
31.4
 26.6
 15.9
k
k
A N
Number of admissions for alcohol and other drug abuse
2012 Jul-Dec 316 - 3 552 831 - - - - 3 178  9 190 l
M U

2013 Jan-Jun 587 - 4 026 934 - - - - 3 717  10 677 m

2013 Jul-Dec 527 318 3 128 610 - - - 96 3 478  9 116 n
4 ED

2015 Jan-Jun 363 - 4 285 1 122 - - - - 3 524  10 936 o

Percentage participating in insufficient physical activity
2011 NYRBS 43.8 37.6 38.1 49.7 42.4 35.4 35.9 38.0 49.9  42.8 j
Prevalence of smoking (%)
O

2011 GYTS - - - - - - - - -  16.9 p

G

2011 GYTS factsheet - - - - - - - - -  12.7 q

2011 NYRBS 13.7 24.9 25.0 15.6 12.5 13.2 23.2 16.3 25.1  17.6 r
R

2012 IHME total - - - - - - - - -  15.3 s

2012 NiDS 15-24 - - - - - - - - -  10.9 f
BA

2012 NiDS 25-34 - - - - - - - - -  23.8 f

2012 NiDS 35-44 - - - - - - - - -  24.1 f
O

2012 NiDS 45-54 - - - - - - - - -  25.5 f

2012 NiDS 55-64 - - - - - - - - -  19.2 f
EM

2012 NiDS 65+ - - - - - - - - -  14.3 f

2012 NiDS female 15+ - - - - - - - - -  7.8 f
2012 NiDS male 15+ - - - - - - - - -  33.6 f
2012 NiDS total 15+ - - - - - - - - -  19.6 f
2012 female 18+ 6.7 8.5 4.4 4.1 2.1 3.6 24.5 5.2 26.8  7.3 t
2012 male 18+ 31.4 46.9 21.8 35.7 26.9 28.7 38.3 22.3 39.6  29.2 t
2012 total 18+ 18.4 27.4 13.0 17.8 12.8 15.3 31.2 12.7 32.9  17.6 t
2013 age-standardised 18+ - - - - - - - - -  16.0 u
Primary drug of abuse as % of all drugs of abuse
2014 alcohol 33.0 - 18.0 42.0 - - - - 20.0  - v
2014 cannabis 20.0 - 45.0 36.0 - - - - 24.0  - v
2014 cocaine 6.0 - 3.0 2.0 - - - - 1.0  - v
2014 heroin 2.0 - 12.0 10.0 - - - - 14.0  - v
2014 mandrax 3.0 - 2.0 4.0 - - - - 5.0  - v
2014 methamphetamine 18.0 - 4.0 1.0 - - - - 34.0  - v
2015 alcohol 29.0 - 20.0 38.0 - - - - 21.0  - w
2015 cannabis 27.0 - 38.0 39.0 - - - - 22.0  - w
2015 cocaine 6.0 - 3.0 4.0 - - - - 1.0  - w
2015 heroin 4.0 - 13.0 5.0 - - - - 14.0  - w
2015 mandrax 12.0 - 2.0 6.0 - - - - 4.0  - w
2015 methamphetamine 15.0 - 4.0 1.0 - - - - 35.0  - w

2 92 S A H R 20 1 6
 Health and Related Indicators

EC FS GP KZN LP MP NC NW WC SA Ref
Smoking age of initiation <10 years (%)
2011 NYRBS 4.6 7.9 8.2 6.5 5.0 6.2 8.5 6.1 10.2  6.6 j
Total alcohol per capita (age 15+ years) consumption (litres per year)
2010 drinkers only - - - - - - - - -  27.1 x
Watch TV more than 3 hours per day (%)
2011 NYRBS 24.2 33.8 41.0 27.1 24.6 29.6 35.8 30.4 37.5  30.3 j

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a HEAIDS 2014.89 Moderate to high use measured on a multi-item measure of alcohol and drug use. MSM is men who have sex with men students.
b NYRBS 2011.135 Defined in survey as ‘Used alcohol in the past month’.
c NYRBS 2011.135 Defined in survey as ‘Ever used alcohol’.
d GYTS 2011.157
e NYRBS 2011.135 Defined as ‘Ever smokers’ in survey.
f NCD Trends 2015.136
g SANHANES-1. 47 Indicated as ‘have ever smoked tobacco’ in SANHANES survey.
h NYRBS 2011.135 Defined in survey as ‘Ever taken drug like heroin, mandrax, sugars, tik’.

PM
i HEAIDS 2014.89 Defined in survey as ‘Have you or your sex partner used needles to inject drugs?’ MSM is men who have sex with men students.
j NYRBS 2011.135 Learners in grades 8–11.
k Reddy et al. 2015.158 SANHANES-1. Adults 18 years and older. Data reported as ‘Current daily smoking’
l SACENDU. 159 Update June 2013. Data for Jul – Dec 2012. The total figure includes patients from MP and LP (Northern Region) and from FS, NW and NC

16 6
combined (Central Region).
m SACENDU. 159 Update Dec 2013. Data for Jan – Jun 2013. The total figure includes patients from MP and LP (Northern Region) and from FS, NW and NC
combined (Central Region).

20 IL
n SACENDU. 159 SACENDU Phase 35 report. The total figure includes patients from MP and LP (Northern Region).
o SACENDU. SACENDU Nov 2015 Update.160 The total figure includes 1076 patients from MP and LP (Northern Region).
p Reddy et al. 2013.161 Smoked cigarettes on 1 or more days in the past 30 days.
Y T
q GYTS 2011.157 Results quite different to those published by Reddy et al. from same survey.
r NYRBS 2011.135 Defined in survey as ‘Current smokers’.
A N
s Smoking 1980–2012.162 Age-standardised prevalence.
t Reddy et al. 2015.158 SANHANES-1. Adults 18 years and older.
M U

u Global Tobacco 2015.163

v SACENDU.159 SACENDU 2014 Update. Note grouped results for MP and LP (Northern Region) and from FS, NW and NC combined (Central Region) not
presented here.
4 ED

w SACENDU. SACENDU Nov 2015 Update.160 Note grouped results for MP and LP (Northern Region) and from FS, NW and NC combined (Central Region)
not presented here.
x Global Alcohol 2014.164
O
G
R
BA

N
O
EM

S A H R 20 1 6 2 93
Table 30: Behaviour and awareness indicators by population group

African Coloured Indian White Other All Ref

Currently drink alcohol (%)
2011 NYRBS 29.6 51.7 36.7 50.7 33.7  32.3 a
Ever drank alcohol (%)
2011 NYRBS 45.7 73.3 68.9 77.6 45.4  49.2 a
Ever smoked cigarettes (%)
2011 NYRBS 23.9 54.8 40.5 49.2 30.0  27.6 a
2012 age 15+ 17.4 44.9 25.2 24.5 -  20.8 b
2012 female age 15+ 4.8 39.7 9.4 23.7 -  10.1 b
2012 male age 15+ 31.4 50.8 41.4 25.5 -  32.8 b
Ever used drugs (%)
2011 NYRBS 9.7 10.7 12.8 6.1 7.8  9.7 a
Frequent smokers (%)
2011 NYRBS 3.9 12.6 5.5 12.7 4.7  4.9 a

PM
2012 female 18+ 2.6 32.1 4.8 12.8 -  6.5 c
2012 male 18+ 25.5 45.1 35.6 17.3 -  26.6 c
2012 total 18+ 13.3 38.0 20.1 14.9 -  15.9 c
Percentage participating in insufficient physical activity

16 6
2011 NYRBS 42.9 47.2 38.7 29.2 45.5  42.8 a
Prevalence of smoking (%)

20 IL
2011 GYTS 15.4 31.4 26.5 12.4 -  16.9 d
2011 NYRBS 15.9 31.9 25.3 24.2 14.9  17.6 a
2012 female 18+
2012 male 18+
Y T
3.3
28.5
34.4
47.0
7.5
36.8
12.9
18.0
-
-
 7.3
 29.2
c
c
A N
2012 total 18+ 15.1 40.1 22.1 15.3 -  17.6 c
Smoking age of initiation <10 years (%)
M U

2011 NYRBS 5.8 11.3 10.4 11.1 10.4  6.6 a

Watch TV more than 3 hours per day (%)
4 ED

2011 NYRBS 29.7 39.4 47.8 28.5 32.3  30.3 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a NYRBS 2011.135 Learners in grades 8–11.
O

b SANHANES-1.47 Indicated as ‘have ever smoked tobacco’ in SANHANES survey.

c Reddy et al. 2015.158 SANHANES-1. Adults 18 years and older.
G

d Reddy et al. 2013.161 Smoked cigarettes on 1 or more days in the past 30 days.
R
BA

N
O
EM

2 94 S A H R 20 1 6
 Health and Related Indicators

Injuries
Context Injuries are perhaps the most neglected component of the quadruple burden of disease in South Africa.
New data sources Nationally, new data have been reported in the:
• Stats SA Victims of Crime Survey (VOCS) 2014/15
• South African Child Gauge 2015
Internationally, data of interest have been reported in the:
• WHO Global Status Report on Road Safety 2015
• Global Burden of Disease 2013 Study results on injuries among children and adolescents
• Global Burden of Disease 2013 report on injury (incidence, mortality, DALYs)
Key issues and trends No new data on road safety have been issued by the Road Traffic Management Corporation (RTMC) since 2011.
Alternative sources, such as the cause of death statistics issued by Stats SA, are incomplete because of a lack of
adequate coding of injuries.

PM
Although there is some evidence, at least for the Western Cape, that reported data on homicide rates are
accurate, it would be useful to have the means to triangulate and confirm such data from alternative sources in
all provinces.

16 6
The Global Burden of Disease Study 2013 reported that, while The Statistics South Africa Victims of Crime Survey 2014/15 also
injuries are still “an important cause of morbidity and mortality in makes for sober reading.168 Although the VOCS is not intended

20 IL
the developed and developing world”, the data do show that the
“world is becoming a safer place to live”. As always, such data
hide significant variations.165 In younger adults (15 years to 49
Y T
years), for instance, high DALYs due to injury are mostly attributable
A N
to road injuries and interpersonal violence in Latin America and sub-
Saharan Africa, but to drowning and self-harm in Eastern Europe
M U
to replace police statistics, it is described as “a rich source of
information which will assist in the planning of crime prevention as
well as providing a more holistic picture of crime in South Africa”. The
VOCS 2014/15 is being used to “pilot the possibility of integrating
the crime statistics obtained from administrative data with those of a
sample survey in order to maximise our understanding of the extent

and Central Asia. Although the WHO 100 Core Indicator measure of crime and the under-reporting of crime”. The VOCS 2014/15
of suicide rate per 100 000 population is classified as an outcome shows that most households were of the opinion that the levels for
4 ED

measure for injury and violence, it has been retained in the mental
health (NCD) section of this chapter. Data on the relative mortality
burden from injuries per district and by age groups were included in
the District Health Barometer 2014/15.67
O
both violent and non-violent crimes had increased in their areas of
residence between 2011 and 2014. However, it also pointed out
that some property-related crimes (such as housebreaking/burglary,

theft of personal property and theft of livestock) were less likely to

be reported to the police as compared to contact-related crimes,
Road traffic injuries are among the top 10 global causes of death
G

for adolescents and children.36 The Sustainable Development Goals partly because of a lack of confidence in the abilities or commitment
(SDGs) include a target of a 50% reduction in road traffic deaths of the police. In terms of homicide, the highest rates are reported
R

and injuries by 2020. In 2015, the World Health Organization in the Western Cape. Data from state mortuaries and the Provincial
released the Global Status Report on Road Safety, which noted that Injury Mortality Surveillance System were used to calculate crude
BA

most of the 1.2 million annual deaths from road traffic accidents homicide rates and compare these with the figures reported by
the South African Police Service.169 The calculated figure for the
O

occur in low- and middle-income countries, “where rapid economic

growth has been accompanied by increased motorization and road Western Cape (43/100 000 population) in 2009 was very similar
EM

traffic injuries”.166 It also noted that only 95 countries have any to that reported by SAPS (42.4/100 000).
data on the proportion of road traffic deaths attributable to alcohol,
contrasting the low rates (less than 1%) in Costa Rica and Oman
with the high rate (58%) in South Africa. It pointed out that 39% of
road traffic deaths in Africa are among pedestrians. With a road
accident fatality rate substantially higher than the global average of
17.4 deaths per 100 000 population and estimated GDP lost due to
road traffic crashes of 7.8%, analysis of country statistics ought to be
a priority. However, the Annual Report 2014/15 of the Road Traffic
Management Corporation (RTMC) admits that five out of six planned
road safety reports have not been issued.167 The reason given is
that the outstanding reports were “still subject to quality assurance
processes”. The promised remedial action is long on words, but
will need to be backed by action: “A long-term strategy is being
undertaken to ensure alignment, integration and co-ordination in
the management of road traffic information which, going forward,
will result in a refined operating model in the management of
information”.

S A H R 20 1 6 295
Table 31: Injury indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Always wear a seat belt when driven by someone else (%)
2011 NYRBS 14.6 25.2 29.1 16.6 24.6 22.4 25.4 24.9 19.2  21.5 a
Drove after drinking alcohol (%)
2011 NYRBS 10.9 19.4 19.2 10.6 8.1 10.8 12.0 13.6 11.7  12.8 a
Road accident fatalities per 100 000 population
2009 female - - - - - - - - -  16.8 b
2009 male - - - - - - - - -  57.2 b
2009 total - - - - - - - - -  36.1 b
2010 26.5 41.4 19.5 26.2 28.1 44.0 40.1 36.2 25.3  27.9 c
2011 - - - - - - - - -  27.6 d

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a NYRBS 2011.135 Learners in grades 8–11.

PM
b Matzopoulos et al. 2015.170
c Road Accidents 2010.171
d Arrive Alive.172 Number of fatalities: 13 954. No provincial values available in source found. No updated stats on RTMC website.

16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

2 96 S A H R 20 1 6
 Health and Related Indicators

Health services indicators

Health facilities
Context Strengthening the public health sector is a key early task in the National Health Insurance implementation
plan. The Office for Health Standards Compliance will also need to accredit private sector health facilities,
which could potentially put more data on health facility quality into the public domain.
New data sources Nationally, new data have been reported in the:
• TAC and Section27 NSP Review 13
• The Ideal Clinic Programme 2015/16
• SAHRC Access to Emergency Medical Services in EC
Internationally, reports of interest include:
• WHO Global standards to improve quality of health services for adolescents
Key issues and trends Although the data in this section have not been updated, they are striking for what they do not adequately

PM
convey, in particular measures of the performance of particular parts of the health system, such as maternity
and obstetrics units, emergency services and the provision of essential medicines (other than ARVs, TB
medicines and a limited list of tracer items).

16 6
Civil society pressure on public and private sector health facilities provision of the needed resources, and the means to monitor and
can be a powerful driver of change. An example is provided by the react to measures of quality of care. Without that support, initiatives

20 IL
Treatment Action Campaign (TAC) march on 27 September 2015 like the Ideal Clinic programme will remain paper exercises,
to the Western Cape Provincial Department of Health, specifically applied only in ‘pilot’ sites at best. What is needed is not merely
Y T
to raise concerns about the quality of care provided to pregnant
women at maternity and obstetrics units.173 As the NSP Review put it:
‘strengthening’, but the long-term development of ‘resilience’.178 By
August 2015, compliance with the Ideal Clinics standards had been
A N
“Long queues, medicines shortages, rude staff, undignified facilities, assessed in 962 of 1 139 facilities (85% of the total selected for
M U

many users of the public healthcare system simply just accept it as assessment in this period, but excluding the Western Cape).179 The
the way things are”. The NSP Review also drew attention to the national performance figures may appear to be reassuring for some
South African Human Rights Commission’s report into emergency components (Figure 9), but it is the remedial action that is important,
4 ED

medical services in the Eastern Cape,174 a service described as “a and how sustainable any change will prove to be. Achieving
complete shambles”. Noting that positive policy statements do not the required standard is elusive, with one facility obtaining gold
always translate into improved services, the NSP Review concluded status and three facilities obtained silver status. The remaining 958
O

that “even as the Minister makes the ‘test and treat’ announcement facilities that conducted status determinations did not obtain any
and as the world applauds, there will be many clinics in this country Ideal Clinic category status.
G

without key medicines. There will be out-of-order ambulances

The WHO 100 Core Health Indicators propose that measures of
gathering dust in quiet parking lots”.
R

service utilisation, health service access, hospital bed density and

There is no shortage of standards, such as the Global Standards the availability of essential medicines and commodities be included
BA

for Quality Health-Care Services for Adolescents, issued by WHO in national information systems. Where available, data have been
and UNAIDS,175,176 nor is there a dearth of local experience.177 included in Table 32 and Table 33.
O

However, taking models to scale requires deliberate effort, sustained

EM

Table 32: Health services indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Percentage of users of private health services highly satisfied with the service received
2012 GHS 96.0 93.5 94.7 81.0 94.1 93.0 87.0 91.8 94.1  92.2 a
2012 inpatient care - - - - - - - - -  69.5 b
2012 outpatient care - - - - - - - - -  57.1 b
2013 GHS 97.0 92.5 94.2 93.1 94.3 95.1 91.3 93.5 93.4  94.0 c
2014 GHS 95.1 91.2 91.6 89.8 95.1 95.9 92.0 91.4 92.4  91.5 d
Percentage of users of public health services highly satisfied with the service received
2012 GHS 64.6 61.4 52.3 51.6 67.5 59.2 61.7 50.7 57.8  57.3 a
2012 inpatient care - - - - - - - - -  32.7 b
2012 outpatient care - - - - - - - - -  24.5 b
2013 GHS 67.3 62.1 54.4 56.8 73.3 65.0 58.8 54.2 60.3  60.5 c
2014 GHS 62.1 59.0 51.8 56.7 68.0 64.1 64.8 50.1 52.8  57.1 d

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2012.46
b SANHANES-1.47 All participants aged 15 years and older very satisfied with care.
c Stats SA GHS 2013.23
d Stats SA GHS 2014.21

S A H R 20 1 6 2 97
Figure 9: Health facility performance on the Ideal Clinic components nationally, April to August 2015

Administrator

Communication

District Health System Support

Health Information Management

Human Resources for Health

Infrastructure

Integrated Clinical Services Management

Partners and Stakeholders

Pharmaceuticals and Laboratory Services

PM
Support Services

0 10 20 30 40 50 60 70 80 90 100
Percent

16 6
Yes No Partial

20 IL
Source: The Ideal Clinic Programme 2015/16179

Table 33: Health facilities indicators by province

EC
Y T FS GP KZN LP MP NC NW WC SA Ref
A N
Average length of stay (ALOS)
2012 DHIS 6.9 4.9 4.8 6.5 5.7 4.5 3.2 5.8 5.9  5.6 a
M U

2013 DHIS 7.4 6.6 6.3 7.3 5.9 5.0 4.1 6.8 6.4  6.5 a
2014 DHIS 7.3 5.8 6.5 7.1 5.5 4.9 4.7 7.2 6.4  6.5 a
Inpatient bed utilisation rate - total (BUR)
4 ED

2012 DHIS 69 74 76 68 72 72 61 73 83  72 a

2013 DHIS 68 73 79 70 68 70 64 75 84  73 a
2014 DHIS 68 71 77 67 71 71 66 69 85  72 a
O

Inpatient crude death rate

2012 DHIS 7.4 6.2 5.7 5.8 5.9 6.2 5.3 6.5 3.7  5.8 a
G

2013 DHIS 6.7 6.4 5.4 5.3 5.7 5.8 5.5 6.4 3.1  5.4 a
2014 DHIS 6.3 6.1 5.4 5.1 5.6 5.6 5.0 6.6 3.1  5.2 a
R

Number of beds
2014 District Hospitals 6 120 1 598 2 538 8 637 4 153 2 796 583 1 494 2 784  30 703 b
BA

2014 National Central Hospitals 527 636 6 053 846 - - - - 2 359  10 421 b
2014 Provincial Tertiary 1 615 609 2 172 995 1 003 725 657 471 272  8 518 b
O

2014 Regional Hospitals 2 122 1 195 4 425 7 091 1 533 840 141 1 953 1 384  20 682 b
EM

2014 Specialised Psychiatric 1 316 760 1 468 2 456 994 - 106 1 214 1 692  10 007 b
2014 Specialised TB 1 500 - - 2 023 62 384 36 - 1 026  5 031 b
2014 Public sector 13 200 4 798 16 656 22 048 7 745 4 745 1 523 5 132 12 421  85 362 b
Number of health facilities
2014 CHC/CDC 41 10 38 20 25 53 33 45 66  331 b
2014 District Hospitals 65 25 12 40 31 23 11 14 34  255 b
2014 National Central Hospitals 1 1 4 1 - - - - 2  9 b
2014 Private Hospitals 17 13 83 12 10 13 2 14 39  203 b
2014 Provincial Tertiary Hospitals 3 1 3 2 2 2 1 1 1  16 b
2014 Public clinics 731 212 333 592 456 242 131 273 212  3 182 b
2014 Regional Hospitals 5 4 10 13 5 3 1 5 5  51 b
2014 Specialised Hospitals 17 3 10 21 4 5 3 2 11  76 b
Tracer items stock-out rate (fixed clinic/CHC/CDC)
2012 DHIS 15.5 13.5 22.6 4.9 33.3 17.7 10.4 30.3 -  16.4 b
2013 DHIS 18.9 31.9 14.8 6.5 34.6 18.3 17.3 26.3 2.4  18.2 b
2013 Any ART/TB drug out 19.9 53.9 20.4 13.6 40.8 25.9 17.7 4.4 4.9  21.5 c
2014 DHIS 24.8 30.5 16.4 9.0 45.4 27.2 16.3 42.2 4.5  23.6 b
2014 Any ART/TB drug out 28.0 28.0 25.0 19.0 29.0 40.0 21.0 39.0 4.0  25.0 c

2 98 S A H R 20 1 6
 Health and Related Indicators

EC FS GP KZN LP MP NC NW WC SA Ref
Usable beds per 1 000 population
2014 District Hospitals 1.0 0.7 0.3 0.9 0.8 0.8 0.6 0.5 0.6  0.7 d
2014 National Central Hospitals 0.1 0.3 0.7 0.1 - - - - 0.5  0.2 d
2014 Provincial Tertiary 0.3 0.3 0.2 0.1 0.2 0.2 0.7 0.2 0.1  0.2 d
2014 Regional Hospitals 0.4 0.5 0.5 0.8 0.3 0.2 0.2 0.6 0.3  0.5 d
2014 Specialised Psychiatric 0.2 0.3 0.2 0.3 0.2 - 0.1 0.4 0.4  0.2 d
2014 Specialised TB 0.3 - - 0.2 0.0 0.1 0.0 - 0.2  0.1 d
2014 Public sector 2.2 2.1 1.8 2.4 1.5 1.3 1.6 1.6 2.1  1.9 d
Utilisation rate PHC
2012 DHIS 2.7 2.5 2.0 2.9 2.7 2.5 2.9 2.3 2.6  2.5 b
2013 DHIS 2.6 2.5 1.8 3.0 2.6 2.2 2.9 2.2 2.4  2.4 b
2014 DHIS 2.7 2.5 1.8 2.9 2.6 2.3 2.8 2.3 2.3  2.4 b
Utilisation rate PHC <5 years
2012 DHIS 4.4 3.8 4.2 4.7 6.0 4.8 4.9 4.4 4.3  4.6 b

PM
2013 DHIS 4.0 4.3 4.0 4.4 5.2 4.2 4.6 4.1 4.0  4.3 b
2014 DHIS 4.1 4.2 4.1 4.4 5.0 4.3 4.5 4.1 4.0  4.3 b

Reference notes (indicator definitions from page 332 and bibliography of

reference sources from page 342):

16 6
a DHIS.45 All facility types. Data for financial year from April of the year to
March of the following year (not calendar year).

20 IL
b DHIS.45 Data on stock-outs were not available for the WC in the national
DHIS datamart in 2012/13.
c Stock outs survey 2014.180
Y T
d DHIS.45 Calculated from DHIS usable beds for district hospitals, per
1 000 uninsured population (calculated from Stats SA GHS medical
A N
schemes coverage and mid-year population estimates).
M U
4 ED
O
G
R
BA

N
O
EM

S A H R 20 1 6 299
Health personnel
Context Sufficient skilled human resources are an absolute requirement for an effective health system. In South Africa, in
addition to an absolute shortage of human resources for health, there is also a persistent maldistribution of such
resources.
New data sources Nationally, new data have been reported in the:
• Health Professions Council of South Africa
• South African Nursing Council
• South African Pharmacy Council
Key issues and trends One of the key policy interventions in the post-apartheid era has been the introduction of community service for
newly qualified health professionals, starting with medical practitioners and eventually including all professions.
No data could be obtained from the NDoH since 2013 to show the number of community service personnel and
their distribution. It is also unclear whether, as is alleged, increased numbers of health science graduates are
placing this system under strain.

PM
Although, in comparison with other African countries, South
Africa has met the WHO targets for human resources for primary
health care, the country still faces significant challenges in this
regard.181 It appears that changes to public sector remuneration

16 6
(such as the Occupation-specific Dispensation) have succeeded

20 IL
in stemming emigration and decreasing shortages in the public
sector.182 However, at times of fiscal austerity, the imposition of
hiring moratoria can have serious implications for service delivery.
Y T
Such events are expected to be more common in future, as public
A N
expenditure limits are imposed.183 In particular, the Rural Health
Advocacy Project (RHAP) has called for “guidance for Treasuries on
M U

how to exercise their discretion in protecting health rights where the

Treasury directly intervenes in the business of health administration”.
4 ED

RHAP has also drawn attention to the growing ratio of administrative

to clinical staff across the public sector.184 RHAP’s analysis also
pointed to short-term changes in the numbers of filled posts, which
might not be reflected in annual figures as provided in this chapter
O

of the Health Review.

G

All health professions, perhaps apart from nursing, have faced

significant challenges in transforming to more accurately reflect the
R

demographics of the country. A recent review of selection criteria

at the country’s eight medical schools concluded that existing
BA

attempts at redress should be continued and further refined.185

O

Currently, African students constitute the largest group of medical

students (38.7%), followed by white (33.0%), coloured (13.4%)
EM

and Indian (13.6%) students. The majority of medical students

(62.2%) are female. By contrast, based on the figures provided by
the South African Pharmacy Council, 57.0% of pharmacy students
are African, 22.0% are white, 15.5% are Indian and 4.9% are
coloured. A similar proportion (66.5%) are female. The number of
selected professionals registered by population group is shown in
Figure 10.

300 S A H R 20 1 6
 Health and Related Indicators

Figure 10: Number of health professionals registered with their respective professional councils by population group, 2007–2015

Group
400 African
Number of clinical C oloured
HP C S A as s ociates Indian
regis tered 200
White

0
4 000
Number of dental
practitioners
regis tered 2 000

PM
400
Number of dental
therapis ts regis tered
200

16 6
0

20 IL
3 000
Number of 2 000
environmental
health practitioners
Y T
A N
regis tered 1 000
M U

Number of medical 30 000

4 ED

practitioners
(including 20 000
s pecialis ts )
regis tered 10 000
O

0
6 000
G

Number of 4 000
R

phys iotherapis ts
regis tered 2 000
BA

0
O

6 000
EM

Number of
ps ychologis ts 4 000
regis tered
2 000
0
6 000

Number of 4 000
radiographers
regis tered
2 000

10 000
Number of
S AP C pharmacis ts
regis tered 5 000

0
2007 2008 2009 2010 2011 2012 2013 2014 2015

Source: HPCSA and SAPC.186,187 This figure does not show those with missing information for population group.

S A H R 20 1 6 301
Table 34: Number of health personnel practising by sector, and registered with applicable professional council, by province

EC FS GP KZN LP MP NC NW WC SA Ref
Number of clinical associates
2014 Public sector 71 5 39 28 9 26 4 39 0  221 a
2015 Public sector 58 20 39 40 7 54 4 48 0  270 a
Number of clinical associates registered
2014 Registered with HPCSA 65 19 112 50 19 38 13 47 6  369 b
2015 Registered with HPCSA 75 20 146 64 25 72 16 59 7  484 b
Number of dental practitioners
2014 Public sector 122 74 247 128 156 108 33 61 126  1 056 a
2015 Public sector 134 74 244 154 180 114 43 58 135  1 137 a
Number of dental practitioners registered
2014 Registered with HPCSA 317 195 2 274 829 228 282 94 191 1 317  5 856 b
2015 Registered with HPCSA 323 195 2 349 839 247 294 97 196 1 371  6 035 b
Number of dental specialists

PM
2014 Public sector - 1 116 1 4 - 1 - 32  155 a
2015 Public sector - 1 118 - 3 1 1 - 30  154 a
Number of dental therapists
2014 Public sector 9 2 41 117 87 23 9 16 2  306 a

16 6
2015 Public sector 10 1 38 116 101 16 9 16 2  309 a
Number of dental therapists registered

20 IL
2014 Registered with HPCSA 13 22 179 237 62 44 9 41 3  611 b
2015 Registered with HPCSA 15 20 186 249 67 48 10 38 4  638 b
Number of enrolled nurses
2014 Public sector 3 124
Y T 839 6 262 10 784 4 189 1 769 220 909 2 474  30 571 a
A N
2015 Public sector 3 293 882 6 485 10 603 4 240 1 739 232 927 2 468  30 870 a
Number of enrolled nurses registered
M U

2014 Registered with SANC 5 184 2 244 16 543 24 172 5 735 3 038 431 3 171 6 373  66 891 c
2015 Registered with SANC 5 733 2 382 17 469 24 962 6 158 3 262 453 3 265 6 616  70 300 c
4 ED

Number of environmental health practitioners

2014 Public sector 50 85 153 174 151 153 32 43 4  850 a
2015 Public sector 39 73 92 93 91 89 23 37 0  799 a
Number of environmental health practitioners registered
O

2014 Registered with HPCSA 373 228 848 702 287 219 105 154 471  3 391 b
G

2015 Registered with HPCSA 388 261 887 726 305 225 111 164 464  3 535 b
Number of medical practitioners
R

2014 Public sector 1 489 716 3 184 3 537 1 185 875 419 627 1 541  13 593 a
2015 Public sector 1 616 539 3 280 3 418 1 279 836 433 674 1 563  13 656 a
BA

Number of medical practitioners (including specialists) registered

2014 General MPs 2 080 1 237 8 708 4 819 1 192 1 196 448 1 016 5 110  26 585 b
O

2014 Specialist MPs 721 657 5 484 2 346 212 279 132 300 3 784  14 547 b
2014 General MPs + Specialists 2 801 1 894 14 192 7 165 1 404 1 475 580 1 316 8 894  41 132 b
EM

2015 General MPs 2 131 1 233 8 898 4 947 1 256 1 224 463 1 050 5 308  27 315 b
2015 Specialist MPs 750 645 5 666 2 448 228 292 135 306 3 916  15 008 b
2015 General MPs + Specialists 2 881 1 878 14 564 7 395 1 484 1 516 598 1 356 9 224  42 323 b
Number of medical researchers
2014 Public sector - 8 20 9 3 - 1 - 34  103 a
2015 Public sector - 6 21 6 3 - 1 - 40  100 a
Number of medical specialists
2014 Public sector 170 328 1 868 791 92 70 29 117 1 423  4 893 a
2015 Public sector 161 300 1 964 736 80 81 26 115 1 512  4 986 a
Number of nursing assistants
2014 Public sector 5 399 2 098 6 664 6 251 5 125 1 752 916 2 853 4 089  35 147 a
2015 Public sector 5 577 2 114 6 454 6 353 5 049 1 602 887 2 750 4 091  34 877 a
Number of nursing assistants registered
2014 Registered with SANC 7 325 3 319 18 634 12 789 9 600 4 048 1 163 4 974 8 567  70 419 c
2015 Registered with SANC 7 535 3 331 19 178 13 208 9 852 3 892 1 083 4 862 8 522  71 463 c
Number of occupational therapists
2014 Public sector 120 76 306 210 197 95 56 49 141  1 250 a
2015 Public sector 139 67 306 229 205 95 68 59 144  1 313 a

3 02 S A H R 20 1 6
 Health and Related Indicators

EC FS GP KZN LP MP NC NW WC SA Ref
Number of occupational therapists registered
2014 Registered with HPCSA 198 292 1 509 507 179 213 90 134 1 143  4 305 b
2015 Registered with HPCSA 220 310 1 618 537 197 223 92 133 1 208  4 575 b
Number of pharmacists
2014 Public sector 408 297 1 052 722 436 268 135 233 880  4 516 a
2015 Public sector 547 343 1 102 788 511 276 151 238 915  4 970 a
Number of pharmacists registered
2014 Registered with SAPC 939 429 4 463 1 717 436 530 171 601 2 028  13 364 d
2014 Registered with SAPC - female - - - - - - - - -  7 795 d
2014 Registered with SAPC - male - - - - - - - - -  5 576 d
2015 Registered with SAPC 1 570 431 4 655 1 888 516 568 181 639 2 166  13 479 d
2015 Registered with SAPC - female - - - - - - - - -  8 134 d
2015 Registered with SAPC - male - - - - - - - - -  5 345 d
Number of physiotherapists

PM
2014 Public sector 145 68 200 299 160 88 59 73 147  1 239 a
2015 Public sector 160 67 205 326 188 75 63 75 155  1 315 a
Number of physiotherapists registered
2014 Registered with HPCSA 339 358 2 355 939 258 269 111 194 1 743  6 673 b

16 6
2015 Registered with HPCSA 355 375 2 436 987 276 275 114 197 1 824  6 942 b
Number of professional nurses

20 IL
2014 Public sector 10 008 2 435 12 171 16 126 9 093 5 049 1 332 4 494 5 130  66 711 a
2015 Public sector 10 273 2 353 12 672 16 431 9 356 5 194 1 365 4 337 5 268  68 105 a
Number of professional nurses registered Y T
2014 Registered with SANC 15 190 8 004 34 847 29 174 10 987 6 964 2 237 9 236 16 488  133 127 c
A N
2015 Registered with SANC 15 392 8 075 35 770 30 475 11 464 7 106 2 250 9 621 16 701  136 854 c
Number of psychologists
M U

2014 Public sector 62 36 232 115 101 35 17 48 86  1 213 a

2015 Public sector 72 33 231 109 119 36 19 52 88  1 238 a
Number of psychologists registered
4 ED

2014 Registered with HPCSA 460 273 3 794 870 149 174 56 247 1 714  7 883 b
2015 Registered with HPCSA 482 275 3 944 905 158 186 61 266 1 838  8 255 b
Number of pupil auxiliary nurses registered
O

2014 Registered with SANC 1 061 200 3 837 1 727 344 113 113 362 792  8 549 c
2015 Registered with SANC 1 132 199 3 817 1 864 375 428 149 572 776  9 312 c
G

Number of pupil nurses registered

2014 Registered with SANC 1 582 453 7 466 6 849 545 404 - 103 1 365  18 767 c
R

2015 Registered with SANC 2 074 461 6 765 6 501 434 527 0 614 1 470  18 846 c
Number of radiographers
BA

2014 Public sector 344 186 676 568 167 116 100 120 456  2 735 a
2015 Public sector 352 163 694 595 175 95 106 115 468  2 765 a
O

Number of radiographers registered

EM

2014 Registered with HPCSA 614 511 2 512 1 328 243 303 163 267 1 433  7 430 b
2015 Registered with HPCSA 635 528 2 610 1 384 267 321 167 287 1 524  7 787 b
Number of student nurses
2014 Public sector 258 - 4 233 1 815 443 765 - 234 -  7 748 a
2015 Public sector 73 - 3 734 1 694 461 865 - 70 -  6 897 a
Number of student nurses registered
2014 Registered with SANC 3 821 1 394 4 870 3 264 1 951 991 238 1 925 2 849  21 303 c
2015 Registered with SANC 3 611 1 294 4 498 3 387 1 922 958 243 2 003 2 633  20 549 c
Total number of health professional posts
2014 Public sector (filled) 21 779 7 254 37 464 41 675 21 598 11 192 3 363 9 916 16 565  172 307 a
2015 Public sector (filled) 22 504 7 036 37 679 41 691 22 048 11 168 3 431 9 571 16 879  173 761 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a PERSAL.188 Note that this total includes only the posts that are filled at time of data extraction. The South African total includes the sum of the provinces
plus posts within the National Department of Health. Data for Environmental Health Practitioners only include those employed by provincial government.
Note that for provinces such as GP and WC a substantial number of EHPs may be employed by local government.
b HPCSA.187 Total for South Africa includes those with REGION indicated as Foreign or Unknown. The number on the register includes those professionals
who are retired, overseas, working part-time, working in other sectors or not working at all (a substantial proportion of the total for some professions).
c SANC.189 The number on the register includes those professionals who are retired, overseas, working part-time, working in other sectors or not working at
all.
d SAPC.186 The total for South Africa includes large numbers of pharmacists for whom province was unknown and thus the provincial breakdown should be
interpreted with caution. The number on the register also includes those professionals who are retired, overseas, working part-time, working in other sectors
or not working at all.

S A H R 20 1 6 3 03
Table 35: Public sector health personnel per 100 000 uninsured population by province

EC FS GP KZN LP MP NC NW WC SA Ref
Dental practitioners per 100 000 population
2014 Public sector 2.01 3.20 2.71 1.38 3.04 3.03 3.54 1.97 2.77  2.40 a
2015 Public sector 2.16 3.20 2.57 1.62 3.44 3.13 4.52 1.84 2.95  2.53 a
Dental specialists per 100 000 population
2014 Public sector - 0.04 1.27 0.01 0.08 - 0.11 - 0.70  0.35 a
2015 Public sector - 0.04 1.25 - 0.06 0.03 0.11 - 0.66  0.34 a
Dental therapists per 100 000 population
2014 Public sector 0.15 0.09 0.45 1.26 1.70 0.64 0.97 0.52 0.04  0.69 a
2015 Public sector 0.16 0.04 0.40 1.22 1.93 0.44 0.95 0.51 0.04  0.69 a
Enrolled nurses per 100 000 population
2014 Public sector 51.4 36.3 68.6 116.3 81.8 49.6 23.6 29.3 54.4  69.4 a
2015 Public sector 53.2 38.1 68.4 111.4 81.0 47.7 24.4 29.4 54.0  68.6 a
Environmental health practitioners per 100 000 population

PM
2014 Public sector 0.82 3.68 1.68 1.88 2.95 4.29 3.44 1.39 0.09  1.93 a
2015 Public sector 0.63 3.16 0.97 0.98 1.74 2.44 2.42 1.17 -  1.78 a
Medical practitioners per 100 000 population
2014 Public sector 24.5 31.0 34.9 38.1 23.1 24.5 45.0 20.2 33.9  30.8 a

16 6
2015 Public sector 26.1 23.3 34.6 35.9 24.4 22.9 45.5 21.3 34.2  30.3 a
Medical researchers per 100 000 population

20 IL
2014 Public sector - 0.35 0.22 0.10 0.06 - 0.11 - 0.75  0.23 a
2015 Public sector - 0.26 0.22 0.06 0.06 - 0.11 - 0.88  0.22 a
Medical specialists per 100 000 population
2014 Public sector 2.8
Y T 14.2 20.5 8.5 1.8 2.0 3.1 3.8 31.3  11.1 a
A N
2015 Public sector 2.6 13.0 20.7 7.7 1.5 2.2 2.7 3.6 33.1  11.1 a
Nursing assistants per 100 000 population
M U

2014 Public sector 88.9 90.8 73.0 67.4 100.0 49.1 98.4 91.9 90.0  79.8 a
2015 Public sector 90.1 91.4 68.1 66.7 96.5 43.9 93.3 87.1 89.5  77.5 a
4 ED

Occupational therapists per 100 000 population

2014 Public sector 2.0 3.3 3.4 2.3 3.8 2.7 6.0 1.6 3.1  2.8 a
2015 Public sector 2.2 2.9 3.2 2.4 3.9 2.6 7.2 1.9 3.2  2.9 a
Pharmacists per 100 000 population
O

2014 Public sector 6.7 12.9 11.5 7.8 8.5 7.5 14.5 7.5 19.4  10.2 a
G

2015 Public sector 8.8 14.8 11.6 8.3 9.8 7.6 15.9 7.5 20.0  11.0 a
Physiotherapists per 100 000 population
R

2014 Public sector 2.39 2.94 2.19 3.22 3.12 2.47 6.34 2.35 3.23  2.81 a
2015 Public sector 2.59 2.90 2.16 3.42 3.59 2.06 6.63 2.38 3.39  2.92 a
BA

Professional nurses per 100 000 population

2014 Public sector 164.8 105.4 133.3 173.9 177.5 141.4 143.1 144.8 112.9  151.4 a
O

2015 Public sector 166.0 101.7 133.7 172.6 178.7 142.5 143.6 137.3 115.3  151.3 a
Psychologists per 100 000 population
EM

2014 Public sector 1.02 1.56 2.54 1.24 1.97 0.98 1.83 1.55 1.89  2.75 a
2015 Public sector 1.16 1.43 2.44 1.15 2.27 0.99 2.00 1.65 1.93  2.75 a
Radiographers per 100 000 population
2014 Public sector 5.7 8.1 7.4 6.1 3.3 3.2 10.7 3.9 10.0  6.2 a
2015 Public sector 5.7 7.0 7.3 6.2 3.3 2.6 11.1 3.6 10.2  6.1 a
Student nurses per 100 000 population
2014 Public sector 4.2 - 46.4 19.6 8.6 21.4 - 7.5 -  17.6 a
2015 Public sector 1.2 - 39.4 17.8 8.8 23.7 - 2.2 -  15.3 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a PERSAL.188 Note that this value was calculated using only the posts that are filled at time of data extraction. Population estimates for the applicable year
and medical scheme coverage from Stats SA GHS were used to estimate the public sector dependent population denominator.

304 S A H R 20 1 6
 Health and Related Indicators

Table 36: Number of health personnel by population group

African Coloured Indian White Other All Ref

Number of clinical associates
2014 Public sector 211 5 2 3 -  221 a
2015 Public sector 258 5 2 5 -  270 a
Number of clinical associates registered
2014 Registered with HPCSA 337 9 6 15 2  369 b
2015 Registered with HPCSA 438 13 9 22 2  484 b
Number of dental practitioners
2014 Public sector 496 100 227 230 -  1 056 a
2015 Public sector 567 113 217 236 4  1 137 a
Number of dental practitioners registered
2014 Registered with HPCSA 845 245 1 030 2 145 1 591  5 856 b
2015 Registered with HPCSA 923 266 1 077 2 221 1 548  6 035 b
Number of dental specialists

PM
2014 Public sector 49 11 31 64 -  155 a
2015 Public sector 48 9 34 63 -  154 a
Number of dental therapists
2014 Public sector 260 4 33 4 -  306 a

16 6
2015 Public sector 269 6 33 1 -  309 a
Number of dental therapists registered

20 IL
2014 Registered with HPCSA 359 3 124 31 94  611 b
2015 Registered with HPCSA 394 4 126 29 85  638 b
Number of enrolled nurses
2014 Public sector
Y T
27 590 2 247 321 398 -  30 571 a
A N
2015 Public sector 28 106 2 069 299 360 36  30 870 a
Number of environmental health practitioners
M U

2014 Public sector 786 18 18 24 -  850 a

2015 Public sector 741 16 17 22 3  799 a
4 ED

Number of environmental health practitioners registered

2014 Registered with HPCSA 2 048 206 75 366 696  3 391 b
2015 Registered with HPCSA 2 227 214 77 366 651  3 535 b
Number of medical practitioners
O

2014 Public sector 7 000 761 2 084 3 695 -  13 593 a

G

2015 Public sector 7 164 805 1 969 3 663 55  13 656 a

Number of medical practitioners (including specialists) registered
R

2014 General MPs 7 856 944 3 781 10 428 3 576  26 585 b
2014 Specialist MPs 2 023 247 2 017 7 428 2 832  14 547 b
BA

2014 General MPs + Specialists 9 879 1 191 5 798 17 856 6 408  41 132 b
2015 General MPs 8 449 1 039 3 817 10 592 3 418  27 315 b
O

2015 Specialist MPs 2 092 285 2 132 7 753 2 746  15 008 b
2015 General MPs + Specialists 10 541 1 324 5 949 18 345 6 164  42 323 b
EM

Number of medical researchers

2014 Public sector 49 20 9 24 -  103 a
2015 Public sector 47 22 7 24 -  100 a
Number of medical specialists
2014 Public sector 1 437 253 936 2 252 -  4 893 a
2015 Public sector 1 505 267 958 2 243 13  4 986 a
Number of nursing assistants
2014 Public sector 30 636 3 583 200 703 -  35 147 a
2015 Public sector 30 701 3 306 189 621 60  34 877 a
Number of occupational therapists
2014 Public sector 518 129 115 485 -  1 250 a
2015 Public sector 562 152 115 482 2  1 313 a
Number of occupational therapists registered
2014 Registered with HPCSA 608 268 300 2 714 415  4 305 b
2015 Registered with HPCSA 674 304 326 2 870 401  4 575 b
Number of pharmacists
2014 Public sector 2 433 567 622 867 -  4 516 a
2015 Public sector 2 787 598 691 879 15  4 970 a

S A H R 20 1 6 305
 African Coloured Indian White Other All Ref
Number of pharmacists registered
2014 Registered with SAPC 2 260 463 2 595 7 978 74  13 364 c
2015 Registered with SAPC 2 595 487 2 736 7 608 53  13 479 c
Number of physiotherapists
2014 Public sector 552 194 161 326 -  1 239 a
2015 Public sector 596 204 183 329 3  1 315 a
Number of physiotherapists registered
2014 Registered with HPCSA 956 542 597 3 582 996  6 673 b
2015 Registered with HPCSA 1 059 598 638 3 717 930  6 942 b
Number of professional nurses
2014 Public sector 56 889 5 897 1 491 2 319 -  66 711 a
2015 Public sector 58 311 5 890 1 528 2 216 160  68 105 a
Number of psychologists
2014 Public sector 695 82 63 369 -  1 213 a

PM
2015 Public sector 723 86 69 353 7  1 238 a
Number of psychologists registered
2014 Registered with HPCSA 886 308 480 4 655 1 554  7 883 b
2015 Registered with HPCSA 1 004 349 515 4 930 1 457  8 255 b

16 6
Number of radiographers
2014 Public sector 1 514 498 298 421 -  2 735 a

20 IL
2015 Public sector 1 554 497 305 402 7  2 765 a
Number of radiographers registered
2014 Registered with HPCSA 1 993
Y T 701 705 2 375 1 656  7 430 b
2015 Registered with HPCSA 2 243 764 756 2 477 1 547  7 787 b
A N
Number of student nurses
2014 Public sector 7 137 166 242 159 -  7 748 a
M U

2015 Public sector 6 394 155 205 140 3  6 897 a

Total number of health professional posts
4 ED

2014 Public sector (filled) 138 252 14 535 6 853 12 343 -  172 307 a
2015 Public sector (filled) 140 333 14 200 6 821 12 039 368  173 761 a

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
O

a PERSAL.188 Total for South Africa includes those with unknown population group.
b HPCSA.187 Total for South Africa includes those with unknown population group. The number on the register includes those professionals who are retired,
overseas, working part-time, working in other sectors or not working at all.
G

c SAPC.186 The total for South Africa includes pharmacists for whom population group was unknown. The number on the register also includes those
professionals who are retired, overseas, working part-time, working in other sectors or not working at all.
R
BA

N
O
EM

3 06 S A H R 20 1 6
 Health and Related Indicators

Health financing
Context Health financing remains the most contested element of the plans to implement National Health Insurance (NHI).
A Treasury input document on this subject is expected shortly.
New data sources Nationally, new data have been reported in the:
• National Treasury Budget Review 2016
Documents of interest:
• White Paper on National Health Insurance (Dec 2015)
Internationally, reports of interest include:
• WHO Health financing country diagnostic
• WHO Raising revenues for health in support of UHC policy brief
Key issues and trends Although updated budget figures for the public sector are presented here, no new private sector expenditure, as
reported by the Council for Medical Schemes, has been reported since the last issue of the Health Review. Of
particular note is the allocation of funds to implement a national electronic medicine stock management system.

PM
The extent to which this system will be able to deliver real-time, disaggregated (by district and facility) data
remains to be seen.

The WHO 100 Core Health Indicators propose a daunting list of Even before NHI is implemented, progress towards the goal of

16 6
measures, some of which are not easily completed at present, from universal health coverage will depend on a sufficient public sector

20 IL
existing data sources: health budget.190 Doherty and McIntyre have argued cogently that “to
➢➢ total current expenditure on health (% of gross domestic preserve the impetus towards universal health coverage, the Minister
product); Y T of Health and others need to engage with debates within Cabinet
and Treasury on appropriate macroeconomic and fiscal policy
➢➢ current expenditure on health by general government and
A N
choices. The Department of Health will strengthen these arguments,
compulsory schemes (% of current expenditure on health); and win the trust of colleagues from Cabinet and Treasury, if it is
M U

➢➢ out-of-pocket payment for health (% of current expenditure on able to demonstrate achievements in service delivery and combat
health); corruption.”191 A ‘country diagnostic’ review of health financing has
4 ED

been issued by the World Health Organization, in order to explain

➢➢ externally sourced funding (% of current expenditure on
the factors that should be considered when engaging in reforms
health);
aimed at ensuring universal health coverage.192
➢➢ total capital expenditure on health (% current + capital
O

expenditure on health); The medium-term estimates of public sector health expenditure

for fiscal years 2015/16 to 2018/19 are shown in Table 37.
G

➢➢ headcount ratio of catastrophic health expenditure; and

Importantly, the comprehensive HIV and AIDS conditional grant,
➢➢ headcount ratio of impoverishing health expenditure. which is one of the largest of such grants, will be extended to include
R

tuberculosis interventions, thus emphasising the integration of the

However, as was shown in the non-communicable disease section,
response to the syndemic. Of note, this grant in slated to benefit from
BA

where a priority programme is in place, there is always demand for

an additional R1.6 billion in 2018/19. The provincial equitable
clear budget allocations, if not for ring-fenced budgets.
O

share formula was updated with 2011 Census data in 2013/14.

The National Treasury Budget Review 2016 showed that consolidated In order to ‘cushion’ this effect, the Census updates were phased in
EM

government expenditure was expected to grow by 7.1% over the over three years. Although the ‘cushion’ was intended only to apply
medium term, to reach R1.69 trillion in fiscal year 2018/19.122 until 2015/16, it was extended for an additional year. The largest
The Treasury pointed out that average growth in spending on share of this R2.1 billion ‘cushion’ in 2016/17 was allocated to
education, health and social protection had outpaced inflation by KwaZulu-Natal, followed by the Eastern Cape and Limpopo.
1.4%. The health budget will be R168.4 billion in 2016/17, of
which R31.9 billion will be for primary healthcare services, R88.2
billion for hospitals, and R15.9 billion for HIV and AIDS treatment
and prevention. Some of the key additional allocations are:

➢➢ R984 million to expand coverage of HIV and AIDS treatment

and prevention initiatives, including supply of antiretrovirals;

➢➢ R740 million for the treatment of tuberculosis, including

enhanced screening and earlier detection and diagnosis;

➢➢ R300 million to develop a national electronic medicine stock

management system.

S A H R 20 1 6 3 07
Table 37: Medium term estimates for public sector health expenditure, 2015/16–2018/19h

2015/16 2016/17 2017/18 2018/19 Percentage Average

Revised Medium-term estimates of total MTEF annual MTEF
estimate allocation by growth
R million function
Health expenditure 159 377 168 393 183 629 198 556 100.0% 7.6%
of which:
Central hospital services 28 986 32 430 34 955 37 469 19.0% 8.9%
Provincial hospital services 30 032 29 442 32 020 34 055 17.3% 4.3%
District health services 70 206 74 967 81 820 88 375 44.5% 8.0%
of which:
Comprehensive HIV and AIDS and tuberculosis grant 13 671 15 115 17 620 20 032 9.6% 13.6%
Emergency medical services 6 261 6 653 7 460 7 897 4.0% 8.0%
Facilities management and maintenance 8 268 8 329 8 829 9 293 4.8% 4.0%
Health science and training 4 533 4 858 5 206 5 499 2.8% 6.7%

PM
National Health Laboratory Service 5 466 5 672 6 193 6 542 3.3% 6.2%
National Department of Health 2 421 3 094 3 694 4 429 2.0% 22.3%
Total 159 377 168 393 183 629 198 556 100.0% 7.6%
of which:

16 6
Compensation of employees 100 095 107 990 116 379 123 996 63.3% 7.4%
Goods and services 44 545 46 463 51 725 58 045 28.4% 9.2%

20 IL
Transfers and subsidies 5 640 4 687 4 950 5 252 2.7% -2.3%
Buildings and other fixed structures 6 019 5 994 7 230 7 838 3.8% 9.2%
Machinery and equipment 2 942 3 140 3 225 3 418 1.8% 5.1%
Y T
Source: National Treasury as cited in 2016 Budget Review.122
A N
M U

The Municipal Demarcation Board has effected major boundary

changes, reducing the total number of municipalities from 278 to
4 ED

257. These changes will come into effect on the date of the 2016
local government elections. The Treasury describes this as “the most
wide-ranging re-demarcation since the current system of wall-to-wall
O

municipalities was introduced in 2000”.122 These changes will have

significant implications for the allocations to municipalities in terms
G

of the Division of Revenue Act.

As much as emphasis is placed here on public sector health

R

financing, the contribution of out-of-pocket expenditure must never

BA

be ignored. Data from two cohorts of TB patients seen at 10 clinics

N

in four provinces has underlined the substantial direct and indirect

O

costs associated with accessing ‘free’ TB diagnosis and care.193

This section only covers financing under the ambit of ‘Health’, and
EM

does not include expenditure on social determinants of health, which

makes a substantial difference to health outcomes, albeit indirectly.

h National Department of Health line item excludes grants and transfers

reflected as expenditure in appropriate sub-functional areas.

308 S A H R 20 1 6
 Health and Related Indicators

Table 38: Health financing indicators by province

EC FS GP KZN LP MP NC NW WC SA Ref
Claims ratio (%)
2013 - - - - - - - - -  86.5 a
2014 - - - - - - - - -  88.2 a
Headcount ratio of catastrophic health expenditure (%)
2006 49.3 37.6 35.7 59.0 32.6 48.2 57.7 36.1 30.6  42.0 b
Headcount ratio of impoverishing health expenditure (%)
2006 78.3 98.8 53.4 96.5 109.9 51.1 29.4 60.4 19.3  72.0 b
Health as percentage of total expenditure
2013 Outcome - - - - - - - - -  15.5 c
2014 medium-term estimate - - - - - - - - -  15.1 c
2015 medium-term estimate - - - - - - - - -  15.0 c
Total current expenditure on health as percentage of gross domestic product
2013 Private sector - - - - - - - - -  4.6 c

PM
2013 Public sector - - - - - - - - -  4.4 c
2013 Total - - - - - - - - -  9.0 c
2014 Private sector - - - - - - - - -  4.4 c
2014 Public sector - - - - - - - - -  4.3 c

16 6
2014 Total - - - - - - - - -  8.7 c

20 IL
2015 Private sector - - - - - - - - -  4.3 c
2015 Public sector - - - - - - - - -  4.2 c
2015 Total - - - - - - - - -  8.5 c
Medical scheme beneficiaries
2013 703 895
Y T
404 691 2 952 924 1 293 764 433 220 588 386 189 264 524 408 1 299 153  8 778 308 d
A N
2014 697 125 402 672 2 982 814 1 301 813 437 906 589 900 192 409 524 879 1 310 998  8 814 458 e
Medical scheme coverage (%)
M U

2013 GHS 10.5 17.1 29.3 13.3 9.0 15.6 20.2 15.6 25.7  18.4 f
2013 med schemes 10.9 14.9 24.1 13.2 8.4 14.8 17.4 15.4 22.6  16.6 g
4 ED

2014 GHS 10.5 17.9 28.2 12.8 8.6 14.9 19.8 14.8 26.3  18.1 h
2014 med schemes 10.2 14.4 23.0 12.1 7.8 14.0 16.4 14.4 21.5  16.3 i
Pensioner ratio (%)
O

2013 Female - - - - - - - - -  7.9 j

2013 Male - - - - - - - - -  6.2 j
G

2013 Total - - - - - - - - -  7.1 j

2014 Female - - - - - - - - -  8.2 a
R

2014 Male - - - - - - - - -  6.4 a

2014 Total - - - - - - - - -  7.3 a
BA

Per capita expenditure (non-hospital PHC)

2013 real 2014/15 prices 826 880 886 897 706 704 1 056 910 887  850 k
O

2014 real 2014/15 prices 835 916 939 977 756 740 1 058 920 952  897 k
Per capita health expenditure
EM

2013 Private (med schemes) - - - - - - - - -  12 893 l

2013 Public (provincial) 2 881 3 408 3 047 3 257 2 617 2 315 3 667 2 764 3 560  3 023 m
2014 Private (med schemes) - - - - - - - - -  14 186 l
2014 Public (provincial) 2 878 3 612 3 337 3 339 2 827 2 475 3 942 2 690 3 852  3 183 m
Ratio of private to public sector per capita health expenditure
2013 - - - - - - - - -  4.3 n
2014 - - - - - - - - -  4.5 n

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Medical Schemes 2014–15.22
b Ataguba et al. 2014.194 Based on analysis of the Stats SA Income and Expenditure Survey.
c Fiscal Review 2015.195 Financial year.
d Medical Schemes 2014–15.22 SA total includes 4 640 outside of the Republic and 383 963 unclassified. Provincial numbers are calculated primarily on
the basis of the location of principal members.
e Medical Schemes 2014–15.22 SA total includes 4 224 outside of the Republic and 369 718 unclassified. Provincial numbers are calculated primarily on
the basis of the location of principal members.
f Stats SA GHS 2013.23
g Medical Schemes 2013–14.196 Calculated from Medical Schemes beneficiaries per population from Stats SA mid-year estimates for 2013.
h Stats SA GHS 2014.21
i Medical Schemes 2014–15.22 Calculated from Medical Schemes beneficiaries per population from Stats SA mid-year estimates for 2014.
j Medical Schemes 2013–14.196
k DHB 2014/15.67 Data for financial year from April of the year to March of the following year (not calendar year).
l Medical Schemes 2014–15.22 Average benefits paid per beneficiary per annum.

S A H R 20 1 6 3 09
m National Treasury. Calculated from provincial expenditure (National Treasury) per uninsured population. For financial year in nominal prices.
n Calculated from Medical Schemes Council and National Treasury data.

Table 39: Medical scheme coverage by population group

African Coloured Indian White All Ref

Medical scheme coverage (%)
2013 GHS 10.8 21.6 46.1 77.0  18.4 a
2014 GHS 10.6 20.3 48.7 76.9  18.1 b

Reference notes (indicator definitions from page 332 and bibliography of reference sources from page 342):
a Stats SA GHS 2013.23
b Stats SA GHS 2014.21

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

310 S A H R 20 1 6

Conclusion
As South Africa embarks on the challenging task of achieving the
targets set by the Sustainable Development Goals (SDGs), access
to accurate indicators of progress will be needed to ensure focused
action. This is as true for the health sector as for any other. In
addition, the SDGs will demand greater attention to intersectoral
issues, many of which are important determinants of health. As this
chapter has shown, the range of data sources continues to expand,
allowing greater opportunities for triangulation of data and attention
to issues of data quality, reliability and timeliness. However, there
are still significant lacunae, especially in regard to the delivery of
health services in the private sector. All too often, data are sourced
exclusively from the public sector, or from structures such as the
National Health Laboratory Service. The implementation of National
Health Insurance will both present new opportunities to bridge this
gap and demand data that reflect the health status of all South
Africans.
16 6
20 IL
Y T
A N
Acknowledgements
M U
As in previous years, this chapter is very much the product of
collective efforts at all levels of the health system over many years. In
4 ED
particular we acknowledge the national and provincial Departments
of Health for the use of data from the District Health Information
System and various other databases and publications. Other people
O
and institutions have also contributed significantly. Thanks are due to
Muchiri Wandai, Noluthando Ndlovu and Algernon Africa for data
G
capture, extraction, analysis and assistance with referencing. We
also appreciate the perceptive review comments and strategic inputs
R
of the team of reviewers (Peter Barron, Robin Dyers, Ega Janse van
Rensburg-Bonthuyzen).
BA
N
O
EM
S A H R 20 1 6
Health and Related Indicators
Appendices
Maps
The indicator maps show the provincial, district and sub-district
boundaries according to the demarcation which came into effect
with the local government elections in May 2011. The boundaries
of wards and districts are determined by the Municipal Demarcation
Board (MDB). As at September 2010, the MDB demarcated
4 277 wards in 231 local municipalities within eight metropolitan
councils and 45 districts. Wards are voting areas, as used by the
Independent Electoral Commission and have been identified as the
level of service delivery for PHC Ward-based Outreach Teams by
the PHC Re-engineering Strategy. The MDB has announced several
major boundary changes that will come into effect on the date of
PM
the 2016 local government elections, reducing the total number of
municipalities in the country from 278 to 257 (Map 1).
The remaining maps show the spatial variation in a selection of
indicators relating to non-communicable diseases and their risk
factors or determinants. Since many NCDs increase in prevalence
in the elderly, the Ageing Index indicates where disease prevalence
may be concentrated (Map 4). Maps 5 to 12 are based on the
analysis of premature mortality or Years of Life Lost (YLLs) presented
in the District Health Barometer 2014/15. These percentages do
not give any indication of the absolute level of mortality due to this
cause as would be provided by age-standardised mortality rates,
but only the relative proportion of all premature mortality (years of
life lost). Therefore the percentage of YLLs due to all causes would
total 100%. Map 5 gives the relative proportion of YLLs for the
broad cause group non-communicable diseases. The next set of
maps provides the same information by the main NCD single causes
of premature mortality.
3 11
Map 1: Changes in demarcation of municipalities to come into effect in 2016

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

Source: Municipal Demarcation Board. Personal communication 8 March 2016.

3 12 S A H R 20 1 6
 Health and Related Indicators

Map 2: Hypertension prevalence (%) in adults age 15 years and older by district, 2012

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

Source: Analysis of National Income Dynamics Study as reported in the District Health Barometer 2014/15.67

S A H R 20 1 6 313
Map 3: Air pollution level in cities (annual mean concentration of particulate matter less than 10 microns in diameter in μg/m3), 2012

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

Source: WHO Air Pollution database.

314 S A H R 20 1 6
 Health and Related Indicators

Map 4: Ageing index by sub-district, 2015

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

Source: Calculated from DHIS population estimates for 2015 as the ratio of the number of people 65+ to the number under 15 years.

S A H R 20 1 6 315
Map 5: Percentage of years of life lost (YLLs) due to non-communicable diseases by district, 2013

PM
16 6
20 IL
Y T
A N
M U
4 ED
O
G
R
BA

N
O
EM

Source: Stats SA Causes of death 2013 as analysed and reported in the District Health Barometer 2014/15.67

Note: These percentages do not give any indication of the level of mortality due to this cause as would be provided by age-standardised mortality rates, but
only the relative proportion of all premature mortality (years of life lost).

316 S A H R 20 1 6
 Health and Related Indicators

Map 6: Percentage of YLLs due to asthma by district, 2013

PM
16 6
20 IL
Y T
A N
M U
4 ED

Map 7: Percentage of YLLs due to cancers by district, 2013

O
G
R
BA

N
O
EM

S A H R 20 1 6 3 17
Map 8: Percentage of YLLs due to cerebrovascular disease by district, 2013

PM
16 6
20 IL
Y T
A N
M U
4 ED

Map 9: Percentage of YLLs due to chronic obstructive pulmonary disease (COPD) by district, 2013
O
G
R
BA

N
O
EM

318 S A H R 20 1 6
 Health and Related Indicators

Map 10: Percentage of YLLs due to diabetes mellitus by district, 2013

PM
16 6
20 IL
Y T
A N
M U
4 ED

Map 11: Percentage of YLLs due to hypertensive heart disease by district, 2013
O
G
R
BA

N
O
EM

S A H R 20 1 6 319
Map 12: Percentage of YLLs due to ischaemic heart disease by district, 2013

PM
16 6
20 IL
Y T
A N
M U
4 ED
O

Selected data sources and results for WHO Core

G

indicators
R

The WHO Global Reference List of 100 Core Health Indicators7 HIV/AIDS; Global TB = Global Tuberculosis Reports / Database;
provides a useful starting point for national indicator choices that GYTS = Global Youth Tobacco Survey; HDR = Human Development
BA

will be useful to monitor the SDGs as well as progress in realising Report; HEAIDS = Higher Education HIV/AIDS Programme;
universal health coverage. Figure 11 gives a sense of the range Hospitals Direct = Wilbury & Claymore database of private
O

of sources available for these indicators at national level for South hospitals; HSRC = Human Sciences Research Council; IES = Stats SA
EM

Africa. It is not intended to be exhaustive, but the density of blocks
gives an indication of the wealth (or dearth) of data sources, and
the time periods for which they are available. Some sources may
be disaggregated geographically and by some dimensions such as
age group, gender or population group, and selected results are
included in Table 40.
Figure 11 indicates the number of main data series available from
country sources (star symbol) and global agency estimates (circle).
It is not intended to identify every source but to show the variety
of sources and the number of years for which data are readily
available.
Abbreviations for data sources include:
AHS = Annual Health Statistics; ASSA = Actuarial Society of South
Africa; BoD = National Burden of Disease Study; Countdown =
Countdown to 2015: Maternal, Newborn and Child Survival; CS
= Community Survey; DHIS = District Health Information System;
GBD = Global Burden of Disease study; GHS = Stats SA General
Household Survey; Global Report = various UNAIDS reports on
Income and Expenditure Survey; IHME = Institute for Health Metrics
and Evaluation; MDG = Millennium Development Goals reports /
database; med schemes = Council for Medical Schemes; mid-year
= Stats SA mid-year estimates; NCCEMD = National Committee
on Confidential Enquiries into Maternal Deaths; NCR = National
Cancer Registry; NICD = National Institute for Communicable
Diseases; NiDS = National Income Dynamics Study; NYRBS =
National Youth Risk Behaviour Survey; PMTCT survey = Prevention
of mother-to-child transmission survey; Postmortem = mortuary
and post-mortem records; PPIP = Perinatal Problem Identification
Program; RMS = Rapid Mortality Surveillance; RTMC = Road Traffic
Management Corporation; SABSSM = South African HIV/AIDS
Behavioural Risks, Sero-Status and Mass Media Impact Survey;
SAGE = Study on global AGEing and adult health; SANHANES =
South African National Health and Nutrition Examination Survey;
THEMBISA = integrated demographic and epidemiological model
of the South African population; Treasury = South African National
Treasury; UNICEF/WHO = United Nations Children’s Emergency
Fund/WHO; WHO = World Health Organization.

320 S A H R 20 1 6
 Health and Related Indicators

Figure 11: Snapshot of data available for South Africa in relation to the WHO 100 Core Health Indicators

Domain Sub-domain Indicator 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 data_series
Null
Input

Total current expenditure on health

Health Financing AHS
as percentage of gross domestic p..
systems
Antenatal Survey
Children living far from their usual
Infrastructure ASSA
health facility (%)
BoD
Usable beds per 1 000 population Census
Countdown
Workforce Dental practitioners CS
DHIS
Medical practitioners Diabetes Atlas
DoH surveillance
Medical specialists Econex
GBD
Pharmacists GHS
Global Report
Professional nurses Global TB
GYTS
Output

Tracer items stock-out rate (fixed

Health Access and HDR
clinic/CHC/CDC)

PM
systems availability
HEAIDS
Utilisation rate PHC Hospitals Direct
HSRC
Quality and Inpatient crude death rate IES
safety
IHME
Maternal mortality ratio in facility /

16 6
institutional (iMMR) Inter-agency group
MDG
Outcome

Air pollution level in cities

Risk factors Environment med schemes
(particulate matter [PM])

20 IL
mid-year
Percentage of households using
electricity for cooking (%) Nanoo et al.
NCCEMD
Percentage of households with
access to piped water NCR

Population using safely managed

sanitation services (%)
Y T NICD
NiDS
A N
NYRBS
Infectious Condom use at the last high-risk
disease sex (%) PMTCT survey
Postmortem
M U

NCDs and Anaemia prevalence in children (%) PPIP

nutrition
private sector
Anaemia prevalence in women of
reproductive age (%) public sector
4 ED

RMS
Diabetes prevalence (%) RTMC
SABSSM
Exclusive breastfeeding rate (%) SAGE
SANHANES
O

Obesity (%) Spectrum

Stats SA P0309.4
Overweight (%) Stock outs survey
G

TB register
Percentage participating in
insufficient physical activity THEMBISA
R

Treasury
Prevalence of raised blood
pressure (%) UNICEF/WHO
vital registration
BA

Prevalence of smoking (%) WHO

data_s eries (group)

Stunting (%)
O

Null
C ountry data s eries
Total alcohol per capita (age 15+
years) consumption (litres per year) G lobal data s eries
EM

Wasting (%)

Repro, Live birth under 2500g in facility

maternal, child.. rate (%)

Access to malaria treatment within

Service Infectious
24 hours (%)
coverage disease
Antenatal client initiated on ART
rate

Antiretroviral coverage (%)

Antiretroviral treatment exposure

(%)

Case detection rate (all forms)

HIV-positive new and relapse TB

patients on antiretroviral therapy (..

Mother postnatal visit within 6 days

rate (%)

Number of patients receiving ART

TB cases with known HIV status

(%)

Repro, ANC coverage (%)

maternal, child,
adolescent
BCG coverage (%)

Births attended by skilled health

personnel (%)
Cervical cancer screening coverage
(%)

S A H R 20 1 6 32 1
 Births attended by skilled health
Domain Sub-domain Indicator (%)
personnel 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 data_series
Service Repro, Null
Outcome

Cervical cancer screening coverage

coverage maternal, child, AHS
(%)
adolescent
Antenatal Survey
DTP3 coverage (%) ASSA
BoD
Immunisation coverage of children
<1 year (%) Census
Countdown
Measles 1st dose coverage (%) CS
DHIS
OPV 1 coverage (%) Diabetes Atlas
DoH surveillance
PCV7 3rd dose coverage (%) Econex
GBD
RV 2nd dose coverage (%) GHS
Global Report
Vitamin A coverage children 12-59
months (%) Global TB
GYTS
Impact

Adolescent fertility rate (per 1000

Health Fertility HDR
girls aged 15–19 years)
status
HEAIDS
Total fertility rate Hospitals Direct

PM
HSRC
Adult mortality (45q15 - probability
General IES
of dying between 15-60 years of a..
IHME
Life expectancy at birth Inter-agency group
MDG
Child under 5 years diarrhoea with
Infectious med schemes
dehydration incidence (per 1 000)

16 6
disease
mid-year
Child under 5 years pneumonia
incidence (per 1 000) Nanoo et al.
NCCEMD

20 IL
HIV incidence (%) NCR
NICD
HIV prevalence (%) (age 15-49) NiDS

HIV prevalence (%) (antenatal)

Y T NYRBS
PMTCT survey
Postmortem
A N
HIV prevalence (%) (total
population) PPIP
private sector
Incidence of TB (all types) (per 100
M U

000) public sector

RMS
Malaria mortality rate (per 100 000
population) RTMC
SABSSM
4 ED

Percentage of deaths due to AIDS SAGE

SANHANES
Reported cases of cholera Spectrum
Stats SA P0309.4
Reported cases of malaria (per 100
O

000) Stock outs survey

TB register
Reported cases of measles THEMBISA
G

Treasury
Reported cases of TB (all types)
(per 100 000) UNICEF/WHO
vital registration
R

STI treated new episode incidence

(per 1 000) WHO

Tuberculosis mortality rate per 100 data_s eries (group)

BA

000
N

Null

Tuberculosis mortality rate per 100 C ountry data s eries

000 (excluding HIV) G lobal data s eries
O

Tuberculosis prevalence rate per

100 000 population
EM

Road accident fatalities per 100

Injury and
000 population
violence
Suicide rate (per 100 000
population)

Cancer incidence rate, by type of

NCDs and
cancer (per 100 000 population)
nutrition
Mortality between 30-70 years from
cardiovascular, cancer, diabetes o..

Infant mortality rate (deaths under 1

Repro,
year per 1 000 live births)
maternal, child,
adolescent
Maternal mortality ratio (MMR)

Neonatal mortality rate (NNMR)

(deaths <28 days old per 1 000 liv..

Stillbirth rate (per 1 000 total births)

Under 5 mortality rate (deaths

under 5 years per 1 000 live births)

Headcount ratio of catastrophic

Health Financing
health expenditure (%)
systems
Headcount ratio of impoverishing
health expenditure (%)

Source: Compiled from WHO 100 Core Health Indicators list and multiple data sources reviewed for this chapter.

322 S A H R 20 1 6
 Table 40: Selected national trends for WHO 100 Core Health Indicators

Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total current expenditure on health as percentage of Fiscal Review 2015 private sector 4.6 4.5 4.6 4.6 4.4 4.3

Input Level
gross domestic product public sector 4.1 4.4 4.4 4.4 4.3 4.2
EM

Financing Subdomain
Total 8.7 8.9 9.0 9.0 8.7 8.5

Health systems Domain

Usable beds per 1 000 population AHS 2012 public and private 2.3
DHIS District Hospitals 0.7 0.7 0.7
National Central 0.2

Infrastructure
BA
Hospitals
Provincial Tertiary 0.2
R public sector 2.2 2.2 2.2 2.1 1.9
Regional Hospitals 0.6 0.6 0.5
O G
Dental practitioners PERSAL public sector 1.7 1.8 1.9 1.9 1.9 2.2 2.3 2.4 2.4 2.5
Dental specialists per 100 000 population PERSAL public sector 0.1 0.1 0.1 0.1 0.3 0.3 0.3 0.3 0.4 0.3
N O

Workforce
Dental therapists per 100 000 population PERSAL public sector 0.4 0.4 0.4 0.4 0.4 0.4 0.6 0.6 0.7 0.7
Enrolled nurses PERSAL public sector 50.6 51.8 55.4 56.2 58.8 65.8 69.3 69.9 69.4 68.6
Environmental health practitioners per 100 000 PERSAL public sector 2.1 2.1 2.0 1.8 1.9 1.9 2.1 2.2 1.9 1.8
population
4 ED
Medical practitioners per 100 000 population PERSAL public sector 23.2 24.1 26.0 26.5 27.3 29.0 29.0 31.3 30.8 30.3
Medical researchers per 100 000 population PERSAL public sector 0.3 0.2 0.2 0.3 0.3 0.3 0.2 0.2 0.2 0.2

S A H R 20 1 6
M U
Medical specialists per 100 000 population PERSAL public sector 9.0 9.7 9.8 10.5 10.7 11.2 11.1 11.4 11.1 11.1
Nursing assistants per 100 000 population PERSAL public sector 77.4 80.4 83.1 82.8 84.2 87.7 85.7 83.9 79.8 77.5
A N
Occupational therapists PERSAL public sector 1.6 1.8 1.9 2.0 2.0 2.3 2.4 2.6 2.8 2.9
Pharmacists PERSAL public sector 4.2 4.4 4.5 4.5 7.2 8.6 9.1 9.8 10.2 11.0
Y T
Physiotherapists per 100 000 population PERSAL public sector 1.9 2.1 2.2 2.3 2.4 2.6 2.6 2.8 2.8 2.9
Professional nurses PERSAL public sector 107.2 109.2 116.7 120.4 125.6 135.4 139.5 147.6 151.4 151.3
Psychologists PERSAL public sector 1.0 1.0 1.1 1.1 1.2 1.3 1.4 2.6 2.8 2.8
20 IL
Radiographers PERSAL public sector 5.1 5.1 5.2 5.4 5.6 5.9 6.1 6.1 6.2 6.1
Student nurses PERSAL public sector 21.8 23.4 23.8 26.1 26.4 26.5 25.0 17.6 15.3
16 6
Tracer items stock-out rate (fixed clinic/CHC/CDC) DHIS NDoH 10.5 16.4 18.2 23.6

Output
Stock outs survey Any ART/TB drug out 21.5 25.0
Utilisation rate PHC DHIS DHIS 2.2 2.2 2.3 2.4 2.4 2.5 2.5 2.4 2.4
PM

Health systems
Inpatient crude death rate DHIS NDoH 5.6 5.5 5.1 5.8 5.4 5.2
Maternal mortality ratio in facility / institutional (iMMR) DHIS DHIS 138.5 144.9 132.9 133.3 132.5

Quality Access and

and safety availability
Saving Mothers NCCEMD 151.8 164.8 188.9 186.2 169.2 160.2 147.7
Health and Related Indicators

323
324
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Air pollution level in cities (particulate matter [PM]) Global Health Observatory PM10 56.0
Percentage of households using electricity for cooking Census Census 73.9

Outcome Level
(%) Community Survey CS 66.4

Risk factors Domain

Environment Subdomain
Stats SA GHS GHS 71.1 71.1 73.1 75.2 78.4 79.8
EM
Percentage of households with access to piped water Census Census 91.2
Community Survey CS 88.7
Stats SA GHS GHS 89.3 89.3 89.5 90.8 89.9 90.0
Population using safely managed sanitation services (%) Stats SA GHS GHS 76.9 77.9 79.5
BA
Condom use at the last high-risk sex (%) HIV Household Survey age 15-49 75.2
2008
R

disease
Infectious
Anaemia prevalence in children (%) SANHANES-1
O G
under 5 years 10.7
Anaemia prevalence in women of reproductive age (%) SANHANES-1 16-35 years 23.1
Diabetes prevalence (%) Diabetes Atlas
N O age 20-79 8.3 8.4 7.0
age 20-79 (age- 9.3 9.4 7.6
standardised)

NCDs and nutrition

SANHANES-1 age 15+ 9.5
4 ED
Exclusive breastfeeding rate (%) HIV Children 2008 <6 months 25.7
PMTCT Survey all 4-8 weeks old 57.5

S A H R 20 1 6
HIV-exposed 4-8 weeks 20.4 35.5 54.1
M U
HIV-unexposed 4-8 31.3 43.6 59.2
weeks
A N
Obesity (%) NCD Trends 2015 NiDS female 15+ 35.0 38.9 36.0
Y T
NiDS male 15+ 12.7 16.2 12.2
NiDS total 15+ 25.2 28.5 25.1
Ng et al. 2014 boys <20 years 7.0
20 IL
female 20+ 42.0
girls <20 years 9.6
male 20+ 13.5
16 6
NYRBS NYRBS 5.3 6.9
NYRBS female 7.2 10.0
PM
NYRBS male 3.3 3.6
SANHANES-1 boys 2-14 years 4.7
female 15+ 39.2
girls 2-14 years 7.1
male 15+ 10.6
 Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Percentage participating in insufficient physical activity NYRBS NYRBS 41.5 42.8
NYRBS female 46.2 47.5

Outcome Level
NYRBS male 36.7 37.7

Risk factors Domain

Phaswana-Mafuya et al. age 50+ 60.5
EM
2013

NCDs and nutrition Subdomain

age 50+ female 63.1
age 50+ male 57.2
Prevalence of raised blood pressure (%) NCD Trends 2015 NiDS female 15+ 26.7 26.9 26.1
NiDS male 15+ 24.5 25.0 26.5
BA
NiDS total 15+ 25.7 26.0 26.3
SANHANES-1
R raised SYS and DIA 10.2
raised SYS or DIA or both 26.6
Prevalence of smoking (%)
O
Global Tobacco 2015
Gage-standardised 18+ 16.0
NCD Trends 2015 NiDS female 15+ 9.1 7.3 7.8
N O
NiDS male 15+ 36.5 30.6 33.6
NiDS total 15+ 21.2 18.0 19.6
NYRBS NYRBS 21.0 17.6
NYRBS female 15.8 12.1
4 ED
NYRBS male 26.4 23.2
Reddy et al. 2013 GYTS 16.5 16.9

S A H R 20 1 6
M U
GYTS female 10.5 12.1
GYTS male 22.8 21.7
A N
Reddy et al. 2015 female 18+ 7.3
male 18+ 29.2
Y T
total 18+ 17.6
SANHANES-1 age 15+ 16.2
20 IL
Smoking 1980-2012 IHME female 8.5 9.1
IHME male 23.1 22.0
IHME total 15.5 15.3
16 6
Wu et al. 2015 SAGE Wave1: 50+ 19.4
Stunting (%) NiDS NiDS <15 years 17.4 22.2 21.2
PM
NiDS female <15 16.2 21.1 20.1
NiDS male <15 18.5 23.3 22.3
NYRBS 2011 NYRBS 13.1 12.9
NYRBS female 11.1 11.3
NYRBS male 15.2 14.7
SANHANES-1 female <15 years 13.7
male <15 years 16.7
Health and Related Indicators

32 5
326
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total alcohol per capita (age 15+ years) consumption Global Alcohol 2014 drinkers only 27.1
(litres)

Outcome Level
Wasting (%) NiDS Wave 3 v1.2 under 5 years 5.6 4.6 5.4

Risk factors Domain

NiDS <15 years 5.3 4.1 5.3
EM
NiDS female <15 6.0 5.1 5.5

NCDs and nutrition Subdomain

NYRBS NYRBS 4.4 3.5
NYRBS female 2.3 1.6
NYRBS male 6.7 5.5
BA
SANHANES-1 female <15 years 1.7
male <15 years 3.8
R
Live birth under 2500g in facility rate (%) DHIS DHIS 11.8 11.7 11.8 12.3 12.7 13.2 13.5 13.4 12.6
Saving Babies/NaPeMMCo
O G DHIS CHC 9.0 8.5 9.1 9.3

adolescent
DHIS DH 12.5 12.0 12.9 12.4
N O DHIS NC 26.2 26.6 25.9 30.1
DHIS PT 20.7 18.2 22.1 23.1

Repro, maternal, child,

DHIS RH 15.3 15.5 17.6 17.7
Access to malaria treatment within 24 hours (%) DoH Malaria Statistics NDoH 100.0
4 ED
Antenatal client initiated on ART rate DHIS NDoH 86.7 80.4 81.6 76.3 91.2
PMTCT Survey 2012-13 PMTCT survey 90.3

S A H R 20 1 6
M U
Antiretroviral coverage (%) Global Plan Progress children 0-14 (GP 2015) 11.0 32.0 43.0 47.0 49.0

Service coverage
Infectious disease
THEMBISA 1.0 THEMBISA children 44.7
A N
THEMBISA female 15+ 62.7
THEMBISA male 15+ 51.5
Y T
THEMBISA total 8.6 13.0 18.7 27.0 35.7 46.0 57.0
Antiretroviral treatment exposure (%) HIV Household Survey 2012 age 0-14 45.1
age 15-24 14.3
20 IL
age 15-49 28.9
age 25-49 32.2
16 6
age 50+ 42.7
all ages 31.2
Case detection rate (all forms) Global TB Report Global TB 64.0 65.0 71.0 73.0 73.0 75.0 69.0 68.0 68.0
PM
HIV-positive new and relapse TB patients on DHIS DHIS 29.9 32.8
antiretroviral therapy (ART) during TB treatment (%) DoH TB TB register 28.0 60.6 72.0 78.9
Mother postnatal visit within 6 days rate (%) DHIS NDoH 5.6 26.3 56.4 65.2 73.0 74.3
 Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Number of patients receiving ART AHS 2012 Adults (men) 550 492
Adults (women) 1 060 579

Outcome Level
Children 124 619
DHIS Adults (Mar) 2 161 170 2 519 870 2 940 541
EM

Service coverage Domain

Infectious disease Subdomain
Children (Mar) 148 342 150 298 163 361
Total (Mar) 2 309 512 2 670 168 3 103 902
Johnson 2012 Children (<15) 22 000 35 000 51 000 76 000 113 000 152 000
Men 75 000 120 000 183 000 283 000 396 000 551 000
BA
NGO programmes 15 000 24 000 32 000 47 000 60 000 78 000
R Private sector 57 000 68 000 86 000 117 000 154 000 190 000
Public sector 163 000 290 000 470 000 748 000 1 073 000 1 525 000
O G
Total 235 000 382 000 588 000 912 000 1 287 000 1 793 000
Women 138 000 228 000 354 000 553 000 777 000 1 090 000
Medical Schemes 2014-15 Private (med schemes) 51 974 153 460
Percentage of TB cases with known HIV status DoH TB TB register 43.3 58.9 73.5 82.7 86.9 90.3 92.8
N OE
ANC coverage (%) DHIS DHIS 101.3 100.5 111.7 106.8 100.7 101.2 98.5 88.8 90.4
4
HIV Children 2008 HSRC 97.1
BCG coverage (%) DHIS DHIS 85.7 89.7 94.6 91.9 93.3 98.0 100.1 90.2 94.5
HIV Children 2008 HSRC 85.5

S A H R 20 1 6
M DU
Immunization UNICEF/WHO 78.0 84.0 72.0 77.0
Births attended by skilled health personnel (%) HIV Children 2008 doctor 27.6
A N
doctor or nurse/midwife 94.3
nurse/midwife 66.7
Y T

Repro, maternal, child, adolescent

Cervical cancer screening coverage (%) DHIS DHIS 32.0 36.1 45.6 47.6 52.2 50.2 50.3 54.1 54.5
DTP3 coverage (%) DHIS DHIS 102.3 110.0 99.4 88.2 99.3 91.8 92.9 96.2
20 IL
HIV Children 2008 HSRC 62.6
Immunization UNICEF/WHO 72.0 68.0 65.0 70.0
Immunisation coverage of children <1 year (%) DHIS DHIS 85.2 84.6 87.0 88.8 80.8 83.9 83.6 84.4 89.8
16 6
Measles 1st dose coverage (%) DHIS DHIS 86.9 87.5 93.2 98.6 94.5 100.9 99.7 87.1 94.1
HIV Children 2008 HSRC 64.8
PM
Immunization UNICEF/WHO 66.0 70.0
OPV 1 coverage (%) DHIS DHIS 105.8 107.6 114.0 107.8 101.3 105.1 94.2 94.5 96.9
PCV7 3rd dose coverage (%) DHIS DHIS 0.2 23.3 72.8 83.8 87.5 87.2 92.8
Immunization UNICEF/WHO 72.0 81.0 62.0 65.0
RV 2nd dose coverage (%) DHIS DHIS 0.5 34.7 72.3 98.2 100.3 90.3 95.2
Immunization 2015 UNICEF/WHO 72.0 78.0 72.0 64.0
Vitamin A coverage children 12-59 months (%) DHIS DHIS 25.1 28.1 32.2 33.9 34.6 41.6 40.5 44.3 52.2
Health and Related Indicators

327
328
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Adolescent fertility rate (per 1000 girls aged 15–19 Fertility 2011 Census 70
years)

Impact Level
Millennium Development 54.0

Fertility Subdomain
Goals

Health status Domain

Total fertility rate CS Fertility 2007 CS 2.8
EM
Fertility 2011 Census 2.7
Human Development HDR 2.4
Report 2015
NiDS Demography Wave 1 NiDS 2.8
BA
Stats SA Mid-year mid-year 2.5 2.5 2.5 2.5 2.5 2.4 2.4 2.3 2.6
estimates
Adult mortality (45q15 - probability of dying between ASSA2008
R ASSA2008 49.2 48.6 46.7 44.4 43.1 42.6 42.5 42.6 42.8 42.9
15-60 years of age) ASSA2008 female 42.1 41.2 39.3 37.4 36.3 36.1 36.2 36.7 37.2 37.7

General
O G
ASSA2008 male 56.4 56.1 54.1 51.4 50.0 49.2 48.8 48.6 48.4 48.2
Burden of Disease SA 2010 BoD 42.6
Global Burden of Disease GBD 2013 female 35.0 35.3
GBD 2013 male 44.1 45.2
N OE
NiDS Demography Wave 1 NiDS female 52.0
4
NiDS male 57.0
RMS 2014 RMS 2014 female 40.0 38.0 35.0 32.0 30.0 28.0

S A H R 20 1 6
RMS 2014 male 51.0 48.0 46.0 44.0 42.0 40.0
M DU
RMS 2014 total 46.0 43.0 40.0 38.0 36.0 34.0
Life expectancy at birth ASSA2008 ASSA2008 54.6 55.1 56.4 57.6 58.2 58.4 58.5 58.5 58.5 58.6
A N
ASSA2008 female 57.7 58.3 59.7 60.9 61.5 61.7 61.7 61.6 61.5 61.5
ASSA2008 male 51.6 51.9 53.1 54.3 54.9 55.2 55.4 55.5 55.6 55.7
Y T
Burden of Disease SA 2010 BoD 58.8
RMS 2014 RMS 2014 female 59.7 61.2 63.2 64.0 65.1 65.8
20 IL
RMS 2014 male 54.6 56.0 57.8 58.5 59.4 60.0
RMS 2014 total 57.1 58.5 60.5 61.3 62.2 62.9
Stats SA Mid-year mid-year 55.3 57.5 58.7 59.7 60.0 59.7 60.2 61.3 62.5 62.5
16 6
estimates mid-year female 56.6 58.8 60.3 61.3 61.5 61.1 61.6 62.8 64.5 64.3
mid-year male 53.9 56.2 57.1 58.0 58.3 58.3 58.8 59.7 60.5 60.6
PM
Child under 5 years diarrhoea with dehydration incidence DHIS DHIS 21.1 17.1 13.2 11.2 14.1 11.3
(per 1 000)

disease
Infectious
Child under 5 years pneumonia incidence (per 1 000) DHIS DHIS 87.0 90.1 94.9 97.4 83.6 80.3 66.8 53.2 49.3
 Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
HIV incidence (%) ASSA2008 ASSA2008 total 1.0 0.9 0.8 0.8 0.7 0.7 0.7 0.7 0.7 0.7
population

Impact Level
HIV Household Survey 2012 HSRC age 2+ 1.1

Health status Domain

HSRC age 15-49 1.7
EM

Infectious disease Subdomain

Murray et al. 2014 GBD 2013 total 0.7
population
Rehle et al. 2010 HSRC age 15-49 1.3
THEMBISA 1.0 THEMBISA age 15-49 1.6 1.5
BA
THEMBISA female age 2.0 1.9
15-49
R THEMBISA male age 1.2 1.1
15-49
HIV prevalence (%) (age 15-49) Antenatal Survey
O GSpectrum/EPP 17.2 17.2 17.9 17.3 17.9
ASSA2008 ASSA2008 16.6 16.8 16.9 16.9 17.0 17.0 17.0 17.0 17.0 17.0
N
HIV Household Survey
O HSRC 16.9 18.8
Stats SA Mid-year mid-year 15.2 15.3 15.4 15.5 15.6 15.7 15.8 15.9 16.5 16.6
Estimates
HIV prevalence (%) (antenatal) Antenatal Survey 29.1 29.4 29.3 29.4 30.2 29.5 29.5 29.7
4 ED
HIV prevalence (%) (total population) ASSA2008 ASSA2008 10.3 10.5 10.6 10.7 10.9 11.0 11.1 11.2 11.3 11.3
HIV Household Survey HSRC 10.6 12.2

S A H R 20 1 6
M U
Stats SA Mid-year mid-year 9.1 9.2 9.3 9.5 9.6 9.8 9.9 10.0 11.1 11.2
Estimates
Incidence of TB (all types) (per 100 000) Global TB Report 2015 Global TB (2015) 963 977 977 967 948 922 892 860 834
A N
Malaria mortality rate (per 100 000 population) DoH Malaria Statistics DoH Surveillance 0.2 0.3
Y T
Stats SA Causes of death VR 0.5
2013
Percentage of deaths due to AIDS ASSA2008 ASSA2008 39.9 39.1 36.1 32.9 31.7 31.3 31.5 31.9 32.4 32.8
20 IL
Burden of Disease SA 2010 BoD 35.0
BoD female 36.9
BoD male 33.1
16 6
Murray et al. 2014 GBD 2013 51.6
Stats SA Mid-year mid-year 46.2 42.6 38.9 35.8 34.6 34.6 33.5 31.9 29.2 30.5
Estimates
PM
Reported cases of cholera DoH Notification System NDoH 4 343.0 7 554.0
NICD surveillance NICD lab confirmed 570.0 1.0 1.0 0.0 1.0 2.0 0.0
cases
Reported cases of malaria (per 100 000) DoH Malaria Statistics NDoH 25.7 11.1 14.0 11.4 15.8 19.1 13.1 16.7 25.8 19.9
Reported cases of measles DoH Notification System NDoH 1 243.0 2 188.0 4 867.0 8 683.0
NICD surveillance NICD lab confirmed 40.0 5 860.0 12 499.0 92.0 20.0 8.0 69.0 15.0
cases
Health and Related Indicators

32 9
33 0
Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Reported cases of TB (all types) (per 100 000) DoH TB TB register 722.4 739.6 794.9 820.2 802.2 762.3 689.3 648.9 592.5

Impact Level
Nanoo et al. 2015 Nanoo et al. 774.0
STI treated new episode incidence (per 1 000) DHIS DHIS 48.3 43.1 45.4 42.6 39.4 38.7 35.0 32.5 31.0

Health status Domain

Tuberculosis mortality rate per 100 000 Stats SA Causes of death vital registration 160.1 157.7 153.4 139.9 123.4 104.9 92.6 76.5
EM

Infectious disease Subdomain

Tuberculosis mortality rate per 100 000 (excluding HIV) Global TB Report Global TB 73.0 69.0 65.0 62.0 59.0 55.0 51.0 47.0 44.0
Tuberculosis prevalence rate per 100 000 population Global TB Report Global TB 829.0 831.0 825.0 808.0 789.0 713.0 705.0 706.0 696.0
Road accident fatalities per 100 000 population Road Accidents 32.2 30.8 28.4 27.8 27.9 27.6
Matzopoulos et al. 2015 female 16.8
BA
male 57.2
R Total 36.1

Injury and violence

Suicide rate (per 100 000 population) Global Health Observatory age-standardised 3.0
O G
age-standardised female 1.1
age-standardised male 5.5
Cancer incidence rate, by type of cancer (per 100 000 Cancer incidence 2010 female breast 25.9
population) female cervix 22.3
N OE
female colorectal 4.8
4
female primary unknown 6.2

NCDs and nutrition

female uterus 4.8

S A H R 20 1 6
male colorectal 7.6
M DU
male kaposi sarcoma 5.9
male lung 8.5
A N
male primary unknown 8.8
male prostate 29.9
Y T
Mortality between 30-70 years from cardiovascular, Global NCD 2014 27.7 26.8
cancer, diabetes or chronic respiratory disease
Infant mortality rate (deaths under 1 year per 1 000 live ASSA2008 ASSA2008 44.6 42.0 37.8 35.2 34.5 33.8 33.2 32.5 31.9 31.3
20 IL
births) Burden of Disease SA 2010 BoD 34.2
Child Mortality 2015 IGME Inter-agency group 34.0
16 6
RMS 2014 RMS 2014 39.0 35.0 28.0 27.0 29.0 28.0
Stats SA Mid-year mid-year 55.6 53.6 50.8 49.1 47.1 45.1 43.5 36.4 35.3 34.4
Estimates
PM
Maternal mortality ratio (MMR) IHME publications IHME 237.0 91.3 174.1
Maternal Mortality WHO 410.0 300.0 140.0

Repro, maternal, child, adolescent

publication
RMS 2014 RMS 2014 281.0 302.0 267.0 200.0 166.0 155.0
 Indicator Source Group 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Neonatal mortality rate (NNMR) (deaths <28 days old Child Mortality IGME Inter-agency group 21.3 20.3 19.5 18.8 11.0
per 1 000 live births)

Impact Level
DHIS DHIS 11.0 9.9 10.2 10.9 11.6 12.3 12.1 12.2 12.8
IHME publications IHME 17.0

Health status Domain

NaPeMMCo/Saving Babies PPIP all levels 13.6 10.1 10.6
EM
PPIP CHC 2.1 1.6 1.4
PPIP DH 12.3 12.4 10.5
PPIP NC 18.1 26.9 22.3
PPIP PT 16.5 23.0 16.7
BA

Repro, maternal, child, adolescent Subdomain

PPIP RH 13.5 14.9 13.0
RMS 2014
R RMS 2014 14.0 13.0 13.0 11.0 11.0 11.0
Wang et al. 2014 GBD 2013 14.6
Stillbirth rate (per 1 000 total births) DHIS
O G
DHIS 23.8 23.4 22.3 23.0 22.7 22.5 21.8 21.5 20.7
NaPeMMCo 2008-10 Private hospitals 7.5
N
NaPeMMCo/Saving Babies
O PPIP all levels 24.3 24.4 23.1
PPIP CHC 10.1 8.3 8.1 8.4
PPIP DH 20.5 21.3 22.0 20.2
PPIP NC 52.3 54.3 42.9 42.9
4 ED
PPIP PT 36.8 32.1 33.3 39.2
PPIP RH 26.7 28.5 27.6 30.2

S A H R 20 1 6
M U
Perinatal deaths 2011-13 registered 13.0 13.0 14.0 14.0 15.0 14.0 13.0 17.0
registered (updated) 14.4
A N
Under 5 mortality rate (deaths under 5 years per 1 000 ASSA2008 ASSA2008 65.4 61.9 55.7 50.9 49.9 48.8 47.7 46.7 45.7 44.8
live births) Burden of Disease SA 2010 BoD 51.8
Y T
Child Mortality 2015 IGME Inter-agency group 41.0
(2015)
Global Burden of Disease GBD 42.6 40.0 37.0
20 IL
GBD female 50.2 38.2 35.8 32.9
GBD male 50.2 46.8 44.1 40.9
16 6
IHME publications IHME 57.4 57.1 56.0 53.4 50.9 50.7
RMS 2014 RMS 2014 56.0 52.0 40.0 41.0 41.0 39.0
Stats SA Mid-year mid-year 80.9 76.7 72.3 68.5 65.2 62.1 59.5 48.8 46.5 45.1
PM
Estimates
Headcount ratio of catastrophic health expenditure (%) Ataguba et al. 2014 NDoH 42.0

Health
Headcount ratio of impoverishing health expenditure (%) Ataguba et al. 2014 NDoH 72.0

systems
Financing
Health and Related Indicators

33 1
Indicator definitions for data tables presented in this chapter
Type Indicator
Adolescent fertility rate
Demographic
(per 1 000 girls aged 15–19
years)
Age dependency ratio
Ageing index
Average household size
Crude death rate (deaths per
1 000 population)
Total fertility rate
Annual population growth
Population
rate
Population
Population % by province
Population % by population
group
Public sector dependent
population
Area (square km)
Socio-Economic Distribution
Area as a % of total area of
South Africa
BA
Population density (people
per km2)
Air pollution level in cities
(particulate matter [PM])
EM
Human development index
Human development index
rank
Poverty prevalence (%)
Education level: percentage
Education
of population 20 years and
older with no schooling
Literacy rate
Unemployment rate (official
Employment
definition)
332
WHO Core7
Definition
classification
Impact: Health status: Annual number of births to women aged 15-19 years per 1 000 women in that age group.
Fertility It is also referred to as the age-specific fertility rate for women aged 15–19 years.
The adolescent birth rate is generally computed as a ratio. The numerator is the number of live births to women
aged 15–19 years, and the denominator is an estimate of exposure to childbearing by women aged 15–19 years.
The numerator and the denominator are calculated differently for civil registration and survey and census data.
Census data: With census data, the adolescent birth rate is generally computed on the basis of the date of last
birth or the number of births in the 12 months preceding the enumeration. The census provides both the numerator
and the denominator for the rates. In some cases, the rates based on censuses are adjusted for under-registration
based on indirect methods of estimation.
The ratio of the combined child population (0-14 years) and the aged population (65 years and over) - persons in the
dependent ages - to every 100 people of the intermediate age population (15-65 years) - economically active ages.
Where more detailed data are lacking, the age-dependency ratio is often used as an indicator of the economic
burden the productive portion of a population must carry - even though some persons defined as dependent are
producers and some persons in the productive ages are economically dependent.
PM
Ratio of the number of people 65+ to the number under 15 years.
i.e. a value of 16 means there are 16 people aged 65 and over for every 100 under 15 years of age.
Calculated as ([65+/0-14]*100)
Average number of people living in each household where household is defined as a person, or a group of persons,
who occupy a common dwelling (or part of it) for at least four days a week and who provide themselves jointly
16 6
with food and other essentials for living. In other words, they live together as a unit. People who occupy the same
dwelling, but who do not share food or other essentials, are enumerated as separate households.
20 IL
Number of deaths in a year per 1 000 population.
Impact: Health status: The average number of children that a woman gives birth to in her lifetime, assuming that the prevailing rates
Fertility Y T remain unchanged.
The rate at which the population is increasing or decreasing in a given year expressed as a percentage of the base
A N
population size. It takes into consideration all the components of population growth, namely births, deaths and
migration.
Total number of people.
M U
Projected population figures are based on various projection models attempting to quantify the expected effects of
HIV and AIDS on population growth.
4 ED
Proportion of South African population in each province (calculated from population per province and population for
whole of South Africa).
Proportion of South African population in each population (ethnic) group (calculated from number of people per
population group and population for whole of South Africa).
O
This is an adjustment of the total population to the number assumed to be dependent on services in the public
health sector based on medical scheme (health insurance) coverage.
G
It is calculated by subtracting the number of people with medical scheme cover (determined from medical scheme
membership reports, or surveys indicating percentage of population on medical schemes) from the total population.
Land area covered by geographic entity.
Area of province divided by total area of country (South Africa).
Number of people per square kilometre.
O
Outcome: Risk factors: Annual mean concentration of particulate matter of less than 2.5 microns of diameter (PM2.5) [mcg/m3] (or of less
Environment than 10 microns [PM10] if PM2.5 is not available) in cities.
The HDI is a summary measure of human development.
A high value for the HDI represents better human development.
Rank from 1 to end given to each country according to value of HDI.
Value of 1 represents the best (highest) human development index.
Proportion of people/households living in poverty. Depending on the poverty line and the methodology used there
are various estimates of the extent of poverty, therefore caution should be observed in comparing estimates from
different sources, and comparative reliability can be assessed from the rank order correlation between different sets
of estimates.
Percentage of people in a given age group who have received a particular level of education.
People aged 20 years and more with no schooling or with some primary schooling are assumed to be illiterate.
People with more schooling are therefore assumed to be literate.
The official definition of the unemployed is that they are those people within the economically active population
(aged 15-65) who
(a) did not have a job or business during the 7 days prior to the interview,
(b) want to work and are available to work within two weeks of the interview, and
(c) have taken active steps to look for work or to start some form of self-employment in the 4 weeks prior to the
interview.
S A H R 20 1 6

Type Indicator
Drinking Water System (Blue
Household Facilities
Drop) Performance Rating
Percentage of households
by type of housing
Percentage of households
using electricity for cooking
(%)
Percentage of households
with access to piped water
Percentage of households
with no toilet / bucket toilet
Percentage of households
with telephone (telephone in
dwelling or cell phone)
Population using safely Outcome: Risk factors: Population using a basic sanitation facility (flush or pour-flush toilets to sewer systems, septic tanks or pit latrines,
managed sanitation services Environment
(%)
Adult mortality (45q15 -
Mortality
probability of dying between
15-60 years of age)
Life expectancy at birth
Cataract surgery rate (per
Disability
million population)
Prevalence of disability (%)
Prevalence of hearing
disability (%)
Reported cases of cholera/
Infectious
Disease
measles/ rabies
R
BA
Case detection rate (all
Tuberculosis (TB)
forms)
HIV prevalence in TB
EM
incident cases
Incidence of TB (all types)
(per 100 000)
Incidence of TB (PTB new
Sm+) (per 100 000)
Prevalence of multidrug
resistance among new TB
cases (%)
Tuberculosis death rate per
100 000 (in HIV-positive
people)
Tuberculosis mortality rate
Tuberculosis (TB)
per 100 000
Tuberculosis mortality rate
per 100 000 (excluding HIV)
Tuberculosis prevalence rate Impact: Health status:
per 100 000 population Infectious disease
Health and Related Indicators
WHO Core7
Definition
classification
Composite score measuring compliance of water suppliers with water quality management requirements. Includes
microbiological, chemical and physical compliance criteria.
Percentage of households that are categorised as formal, informal, traditional or other.
Outcome: Risk factors: Percentage of households using electricity as their main energy source for cooking.
Environment
Outcome: Risk factors: Includes households with piped water in dwelling, piped water inside yard or piped water on a community stand
Environment (< 200m away or further).
Percentage of households that have no toilet, or were using a bucket toilet.
Percentage of households with a telephone in the dwelling or a cellular telephone.
ventilated improved pit latrines, pit latrines with a slab, and composting toilets) which is not shared with other
PM
households and where excreta are safely disposed in situ (e.g. in a sealed latrine pit until they are safe to handle
and re-use, such as an agricultural input ) or transported to a designated place for safe disposal or treatment (e.g.
treatment facility or hygienically collected from septic tanks or pit latrines by a suction truck or similar equipment
that limits human contact and thereafter transported to a designated location such as a treatment facility or solid
waste collection site).
16 6
The Stats SA General Household Survey defines ‘improved sanitation’ as households that had access to RDP
(Reconstruction and Development Programme) standard toilet facilities, i.e. flush toilets connected to a public
20 IL
sewerage system or a septic tank, and a pit toilet with a ventilation pipe.
Impact: Health status: The probability of dying between the ages of 15 and 60 years of age (percentage of 15-year-olds who die before
General their 60th birthday).
Y T
Impact: Health status: The average number of additional years a person could expect to live if current mortality trends were to continue for
A N
General the rest of that person’s life. (Most commonly cited as life expectancy at birth.)
Cataract operations per million of the total population
M U
Percentage of people reporting moderate to severe disability in a survey where disability is defined as a limitation
in one or more activities of daily living (seeing, hearing, communication, moving, getting around, daily life activities,
learning, intellectual and emotional).
4 ED
Since the 2009 GHS (revised in 2011), Stats SA have also excluded data on children under 5 years old, since it was
thought that these are often categorised as being unable to do the various activities, when this is in fact due to their
level of development rather than any innate disabilities.
In the Census questionnaire, respondents were asked to indicate whether or not there were any people with serious
O
visual, hearing, physical or mental disabilities in the household. The seriousness of the disability was not clearly
defined. Rather, the respondent’s perceptions of seriousness were relied on.
G
Impact: Health status: The number of cases of cholera/ measles/ rabies reported to the Department of Health. Since case reporting of
Infectious disease notifiable diseases has been incomplete and delayed for several years, the number of laboratory-confirmed cases
from NHLS has been included where available, although these would be expected to include only a subset of the
total number of notified cases.
Outcome: Service Proportion of incident cases of TB (all types) that were notified for a given country, it is calculated as the number
coverage: Infectious of notified cases of TB in one year divided by the number of estimated incident cases of TB in the same year, and
O
disease expressed as a percentage.
Percentage of new TB cases that are HIV positive.
Impact: Health status: Estimated number of cases of tuberculosis (all types) per 100 000 population (for the year).
Infectious disease Adjusted for estimated under-reporting of TB cases and other factors.
Estimated number of cases of tuberculosis (pulmonary TB, new smear positive cases) per 100 000 population (for
the year). Adjusted for estimated under-reporting of TB cases and other factors.
Estimated percentage of new cases of TB which are multidrug resistant.
Number of deaths due to TB in HIV-positive people per 100 000 population. Note that these deaths are officially
classified as being caused by HIV/AIDS according to the International classification of diseases.
Impact: Health status: Number of deaths due to tuberculosis (all types) reported per 100 000 population (for the year).
Infectious disease Note that the estimates calculated from the Stats SA cause of death data are not corrected for under-reporting or
ill-defined coding, and are thus not an accurate of mortality due to TB. In addition many deaths in HIV-positive TB
cases are misattributed to TB rather than HIV (according to the ICD-10 rules).
Impact: Health status: Number of deaths due to tuberculosis (all types) reported per 100 000 population (for the year). The reported TB
Infectious disease mortality excludes deaths occurring in HIV-positive TB cases, in accordance with the definition used in ICD-10.
Number of people with TB (all types) per 100 000 population.
S A H R 20 1 6 333

Type Indicator
Bacteriological coverage
Case finding
rate (%)
Proportion of extra-
pulmonary TB
Reported cases of MDR-TB
Reported cases of TB (all
types)
Reported cases of TB (all
types) (per 100 000)
Reported cases of TB (PTB
new Sm+)
Reported cases of TB (PTB
new Sm+) (per 100 000)
Reported cases of TB (PTB)
Reported cases of XDR-TB
Retreatment ratio
Smear positivity (% of PTB
cases which are new Sm+)
Case fatality rate (MDR-TB)
(%)
Cure rate (new Sm+ cases)
(%)
Defaulter rate (MDR-TB) (%)
Failed treatment rate (MDR-
TB) (%)
Lost to follow up (defaulter)
rate (new Sm+ cases) (%)
MDR-TB started on
treatment
Smear conversion rate (new
R
Sm+ cases) (%)
Successful completion rate
Case holding
(MDR-TB) (%)
BA
Successful treatment rate
(new Sm+) (%)
TB client lost to follow up
rate (all TB) (%)
EM
TB death rate (all TB) (%)
TB treatment failure (all
TB) (%)
TB treatment success rate
(all TB) (%)
XDR-TB started on
treatment
Case fatality rate: malaria
Malaria
Malaria mortality rate (per
100 000 population)
Reported cases of malaria
Reported cases of malaria
(per 100 000)
Reported deaths from
malaria
33 4
WHO Core7
Definition
classification
The bacteriological coverage rate reflects the percentage of cases of PTB for which sputum microscopy results
were available. As such, it reflects both the availability of laboratory services and compliance with the national TB
guidelines which stress the use of sputum microscopy in the diagnosis of PTB.
Number of extra-pulmonary TB cases divided by total number of TB cases.
HIV-infected individuals are more likely to suffer from extra-pulmonary TB. The rising proportion of extra-pulmonary
TB reflects the effect of the HIV epidemic on patterns of TB infection.
Number of laboratory-diagnosed cases of MDR-TB. MDR-TB is defined as resistance to rifampicin and isoniazid,
with or without resistance to other first-line anti-TB drugs.
Number of cases of tuberculosis (all types) reported to the DoH for the year.
Impact: Health status: Number of cases of tuberculosis (all types) reported to the Department of Health per 100 000 population (for the
Infectious disease year).
Note that reporting rates in some areas are far from complete and this may influence the values quite significantly.
Number of cases of tuberculosis (new smear positive) reported to the DoH for the year.
PM
Number of cases of tuberculosis (pulmonary TB, new smear positive cases) reported to the Department of Health
per 100 000 population (for the year).
Note that reporting rates in some areas are far from complete and this may influence the values quite significantly.
Number of cases of tuberculosis (pulmonary TB) reported to the DoH for the year.
16 6
Number of laboratory-diagnosed cases of XDR-TB. XDR-TB is defined as resistance to rifampicin, isoniazid, any
fluoroquinolone and resistance to one or more of the following injectable anti-TB drugs: kanamycin, amikacin, and
capreomycin.
20 IL
Number of Sm+ retreatment cases divided by the number of Sm+ cases (new + retreatment) expressed as a
percentage.High defaulter rates contribute to high retreatment ratios.
Number of new smear positive PTB cases divided by number of PTB cases.
Y T The percentage of registered MDR-TB patients who die while on treatment.
A N
Percentage of patients who are proven to be cured.
M U
Cured = a pulmonary TB patient with bacteriologically-confirmed TB at the beginning of treatment who was smear-
or culture-negative in the last month of treatment and on at least one previous occasion.
Percentage of patients who defaulted treatment.
4 ED
Percentage of patients who failed treatment.
Percentage of patients who were lost to follow up (of new smear-positive patients).
Lost to follow up = a TB patient who did not start treatment or whose treatment was interrupted for two consecutive
O
months or more.
Number of MDR-TB patients who started treatment
G
Percentage of new smear positive PTB cases who are smear negative after two months of anti-TB treatment and
are therefore no longer infectious.
Percentage of patients who successfully complete treatment.
Percentage of patients who are cured plus those who complete treatment but without laboratory proof of cure (of
new smear positive patients).
O
The percentage of TB clients (all types of TB) who were lost to follow up (defaulted) treatment.
The percentage of TB clients (all types of TB) who died from any cause during treatment.
The percentage of TB clients (all types of TB) who failed treatment.
Failed = a TB patient whose sputum smear or culture is positive at month five or later during treatment.
The percentage of TB clients (ALL types of TB) cured plus those who completed treatment
Number of XDR-TB patients who started treatment
Number of deaths divided by number of cases expressed as a percentage.
The national target is to maintain a CFR below 0.5%.
Impact: Health status: Number of adults and children who have died due to malaria in a specific year, expressed as a rate per 100 000
Infectious disease population.
The number of cases of malaria reported to the Department of Health.
Impact: Health status: The number of cases of malaria reported to the Department of Health per 100 000 population (for the relevant year).
Infectious disease Also known as incidence of malaria.
The number of deaths from malaria reported to the Department of Health or recorded in vital registration (ICD-10
codes B50-B54).
S A H R 20 1 6

Type Indicator
AIDS sick (number of
HIV Prevalence
people with AIDS-defining
conditions)
Antenatal client HIV 1st test
positive rate (%)
HIV incidence (%)
HIV prevalence (%)
(age 15-49)
HIV prevalence (%)
(antenatal)
HIV prevalence (%)
(total population)
People living with HIV
AIDS orphans (maternal
HIV and AIDS
orphans <18 years)
ANC clients tested for
HIV (%)
Antenatal client initiated on
ART rate
Antiretroviral coverage (%)
Antiretroviral treatment
exposure (%)
Early infant diagnosis
coverage
HIV testing coverage (%)
HIV-positive new and
R
relapse TB patients on
antiretroviral therapy (ART)
during TB treatment (%)
BA
Infant 1st PCR test around 6
weeks uptake rate (%)
EM
Infant 1st PCR test positive
around 6 weeks rate (%)
Male circumcision (% of men
who are circumcised)
Mother-to-child transmission
rate of HIV <2 months of age
Percentage of deaths due
to AIDS
TB cases with known HIV
status (%)
Percentage men with painful
STIs
urination, genital symptoms
STI treated new episode
incidence (per 1 000)
Health and Related Indicators
WHO Core7
Definition
classification
Number of people estimated to be living with AIDS-defining conditions.
Antenatal clients tested HIV positive as a proportion of antenatal clients tested for HIV for the first time during the
current pregnancy.
Similar to HIV prevalence (antenatal), except that as more people may already know their status, over time it does
not necessarily provide a representative value for all antenatal clients.
Impact: Health status: The HIV incidence rate is the percentage of people who are uninfected at the beginning of the period who will
Infectious disease become infected over the twelve months.
It refers to the annual diagnosis rate, or the number of new cases of HIV diagnosed each year.
WHOCore indicator is given per 1 000 population rather than %.
Impact: Health status: Percentage of population (age 15-49) estimated to be HIV positive.
Infectious disease
Impact: Health status: Percentage of women surveyed testing positive for HIV.
Infectious disease
PM
Impact: Health status: Percentage of population estimated to be HIV positive.
Infectious disease WHOCore indicator is given per 1 000 population rather than %.
The number of people who are HIV+.
Number of children under 18 years who have lost either a mother (maternal orphan), a father (paternal orphan) or
16 6
both parents (a double orphan) due to HIV/AIDS.
Proportion of women coming for their first antenatal visit who are tested for HIV.
20 IL
Outcome: Service Antenatal clients on ART as a proportion of the total number of antenatal clients who are HIV positive and not
coverage: Infectious previously on ART.
disease Y T Not measuring the same thing as the WHO Core list indicator ‘Prevention of mother-to-child transmission’ which
is the % of all HIV-positive pregnant women who receive ART to reduce mother-to-child transmission during
pregnancy.
A N
Outcome: Service The number of patients receiving ART, divided by the number needing treatment.
coverage: Infectious
M U
The denominator has changed over time, due to changes in treatment guidelines affecting the criteria for treatment
disease eligibility. The latest definition is that all HIV-infected patients should be on ART.
Outcome: Service Percentage of people living with HIV on ART.
4 ED
coverage: Infectious Measured by laboratory testing for antiretroviral drugs in HIV-positive samples.
disease
The numerator is the number of PCR tests performed by the National Laboratory Service for infants 2 months old or
younger, as a proxy for the first PCR test. The estimated number of HIV-exposed infants (denominator) is calculated
by multiplying antenatal maternal HIV prevalence rates by the number of live births.
O
Percentage of target population who have been tested for HIV.
The DHIS indicator ‘HIV testing coverage (including ANC)’ is defined as Clients HIV tested (ANC and other) as
G
proportion of population 15–49 years.
Outcome: Service Number of HIV-positive new and relapse TB patients who received ART during TB treatment, expressed as a
coverage: Infectious percentage of those registered in a specified time period.
disease
Indicator previously called ‘Baby PCR test around 6 weeks uptake rate’. Babies PCR tested 6 weeks after birth as
the proportion of live births to HIV-positive women. (DHIS – National Indicator Data Set)
O
This indicator is a proxy for the coverage of early infant diagnosis.
Indicator previously called ‘Baby PCR test positive around 6 weeks rate’. Babies tested PCR positive 6 weeks after
birth as the proportion of babies PCR tested at 6 weeks. (DHIS)
The percentage of men (15–59 years, unless otherwise specified) who have been circumcised.
This indicator measures the proportion of HIV-exposed infants who received a PCR test under two months of age
who tested positive.
Impact: Health status: Percentage of total deaths attributed to AIDS related causes.
Infectious disease WHOCore indicator is AIDS-related mortality rate (per 100 000 population)
Defined as: Estimated number of adults and children who have died due to AIDS-related causes in a specific year,
expressed as a rate per 100 000 population.
Outcome: Service Percentage of TB cases (all TB) with known HIV status (positive or negative)
coverage: Infectious WHO Core list calls this: HIV test results for registered new and relapse TB patients
disease Defined as: Number of new and relapse TB patients who had an HIV test result recorded in the TB register,
expressed as a percentage of the number registered in
a specified time period.
Percentage of men 15 years and older with painful urination, penile discharge or genital sores in the last 3 months.
Impact: Health status: The number of people per 1 000 population 15 years and older who have been treated for a new STI episode
Infectious disease (previously reported as %)
WHOCore indicator is defined using total population as the denominator.
S A H R 20 1 6 335
 WHO Core7
Type Indicator Definition
classification
Age of first sex under 15 Percentage of people surveyed (of various age groups) who report having first had sexual intercourse at age 14
Contraception and sexual behaviour

years (% having first had sex years or younger. The age cut-off varies slightly between surveys with the HSRC HIV Household survey including
at age 14 or younger) ‘under 15 years’ compared to the NYRBS which includes ‘under 14 years’.
Condom use at last sex (%) Percentage of those, who reported ever having had sex, who used a condom the last time they had sex. Note that
the precise definition of this indicator varies between surveys.
Couple year protection rate The rate at which couples (specifically women) are protected against pregnancy using modern contraceptive
methods INCLUDING sterilisations.
(previously Women year protection rate).
Numerator: Contraceptive years equivalent
Denominator: Target population 15–49 years (couples using females as proxy). Denominator was females 15–44
years in data up to 2010/11.
HIV knowledge: correct The percentage of people who correctly answer a composite measure of accurate knowledge of two questions
knowledge about prevention related to HIV prevention in combination with rejecting four myths and misconceptions about the disease. The two
and rejection of major questions on prevention of HIV transmission were ‘To prevent HIV infection, a condom must be used for every round
misconceptions of sex’ and ‘One can reduce the risk of HIV by having fewer sexual partners’ while the four questions about myths
and misconceptions were ‘There is a cure for AIDS’, ‘AIDS is caused by witchcraft’, ‘HIV causes AIDS’, and ‘AIDS is
cured by having sex with a virgin’.

PM
Male condom distribution The number of male condoms distributed (to patients at the facility or through other channels) per male 15 years
coverage (condoms per and older.
male 15 years and older)
Male condoms distributed Number of male condoms distributed.

16 6
(thousands) Data should be interpreted with caution depending on what distribution channel it is for – i.e. condoms distributed
by national to provinces, or number distributed through PHC facilities (since some condoms are distributed to

20 IL
provinces, that are then distributed through several channels including PHC facilities).
Teenage pregnancy (%) Percentage of women aged 15–19 who are mothers or who have ever been pregnant. The percentage of women
who are mothers at the time of the survey is a more restrictive definition.
Y T Note that some of the surveys report this indicator as the percentage who have ever been pregnant of those WHO
HAVE EVER HAD SEX. This is a different denominator to that used by the Demographic and Health Surveys, and
A N
the data can therefore not be directly compared.
ANC coverage (%) Outcome: Service Proportion of pregnant women receiving some antenatal care.
Maternal health

coverage: Repro,
M U

DHIS data source: Estimated from the number of first ANC visits divided by the population under 1 year x 1.15 (as a
maternal, child, proxy for the number of pregnant women).
adolescent
WHO core list of indicators defines this indicator as ‘Percentage of women aged 15?49 years with a live birth in a
4 ED

given time period who received antenatal care, four times or more.’.
Caesarean section rate (%) Percentage of births that are by Caesarean section.
Delivery rate in facility (%) The percentage of deliveries taking place in health facilities under supervision of trained personnel. (The number
of children under one year, factorised by 1.07 due to infant mortality, is used as an estimated proxy denominator for
O

expected deliveries.)
Maternal mortality ratio Impact: Health status: The number of women who die as a result of childbearing, during the pregnancy or within 42 days of delivery or
G

(MMR) Repro, maternal, child, termination of pregnancy in one year, per 100 000 live births during that year.
adolescent
Maternal mortality ratio in Output: Health The number of women who die as a result of childbearing, during the pregnancy or within 42 days of delivery or
R

facility / institutional (iMMR) systems: Quality and termination of pregnancy in one year, per 100 000 live births during that year. Refers only to institutional / facility-
safety based deaths, not representing the entire population. Note that WHO Core list definition is per 100 000 deliveries
BA

(not live births) – Number of maternal deaths among 100 000 deliveries in health facilities/institutions.
Mother postnatal visit within Outcome: Service Mothers who receive postnatal care within 6 days of delivery after discharge from place of delivery as proportion of
6 days rate (%) coverage: Infectious all deliveries in facility.
O

disease WHO Core list defines this for 2 days from childbirth – ‘Percentage of mothers and babies who received postpartum
EM

care within two days of childbirth (regardless of place of delivery).’

Number of maternal deaths The number of women who die as a result of childbearing, during the pregnancy or within 42 days of delivery or
termination of pregnancy in one year. In the International Statistical Classification of Diseases and Related Health
Problems, Tenth Revision, 1992 (ICD-10), WHO defines maternal death as: The death of a woman while pregnant
or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. For
countries using ICD-10 coding for registered deaths, all deaths coded to the maternal chapter (O codes) and A34
(maternal tetanus) were counted as maternal deaths. Note that the system of Confidential Enquiries into Maternal
Deaths (NCCEMD) only captures INSTITUTIONAL deaths, and thus is known to miss deaths occurring at home.
PM (proportion of An alternative measure of maternal mortality, the proportion of deaths among females of reproductive age (PMDF)
deaths among women of that are due to maternal causes, is calculated as the number of maternal deaths divided by the total deaths among
reproductive age that are females aged 15–49 years.
due to maternal causes)
ToP rate (%) Percentage of pregnant women who have had an abortion.
Termination of
Pregnancy

DHIS definition: Termination of pregnancies performed in a health facility as the proportion of all expected
pregnancies in the catchment population.

ToPs (Terminations of The number of terminations of pregnancy.

Pregnancy)

33 6 S A H R 20 1 6
 Health and Related Indicators

WHO Core7
Type Indicator Definition
classification
Age-standardised mean Outcome: Risk factors: Age-standardised mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years.
Nutrition

population intake of salt NCDs and nutrition

(sodium chloride) per day
in grams
Anaemia prevalence in Outcome: Risk factors: Proportion of children with Hb <11g/dl
children (%) NCDs and nutrition
Anaemia prevalence in Outcome: Risk factors: Percentage of women aged 15–49 years with a haemoglobin level less than 120 g/L for non-pregnant women and
women of reproductive NCDs and nutrition lactating women, and less than 110 g/L for pregnant women, adjusted for altitude and smoking.
age (%)
Iron deficiency anaemia Proportion of children with Hb <11g/dl and ferritin <12mcg/l.
prevalence (%)
Iron deficiency prevalence Proportion of children with ferritin <12mcg/l.
(%)
Obesity (%) Outcome: Risk factors: Percentage of people with a body mass index (BMI) (body mass in kg divided by the square of the height in m)
NCDs and nutrition equal to or more than 30kg/m2.
Overweight (%) Outcome: Risk factors: Children:

PM
NCDs and nutrition Proportion of children with weight for height over 2 standard deviations from the norm (reference population
median).
Adults:
Percentage of people with body mass index (BMI) of 25–29.9 kg/m2. BMI is weight in kg divided by the square of
height in m.

16 6
WHOCore indicators for children under 5 years of age and adults (aged 18+ years). Rates in adults to be age-
standardised.

20 IL
Stunting (%) Outcome: Risk factors: Proportion of children with height for age under 2 standard deviations from the norm (reference population median).
NCDs and nutrition
Underweight (%) Y T Children: Proportion of children with weight for age under 2 standard deviations from the norm (reference
population median).Adults: Percentage of people with body mass index (BMI) <18.5 kg/m2. BMI is weight in kg
divided by the square of height in m.
A N
Vitamin A coverage children Outcome: Service Proportion of children 12–60 months receiving vitamin A 200 000 units twice a year. The denominator is thus the
12–59 months (%) coverage: Repro, target population 1–4 years multiplied by 2.
M U

maternal, child, For surveys this indicator is usually given as the percentage of children who received Vitamin A supplements in the
adolescent preceding 6 months.
Vitamin A deficiency (%) Proportion of children with serum retinol <20mcg/dl.
4 ED

Waist-hip ratio (WHR) above Proportion of people with the ratio of waist / hip circumference >= 1.0 (for men) or >=0.85 (for women).
cut-off (%) Body Mass Index does provide an index for obesity, but has limitations in predicting risk for cardiovascular events.
Research has indicated that measurement of WHR enables prediction of cardiovascular risk (Am Heart J 2005 Jan
149: 54–60.)
O

Wasting (%) Outcome: Risk factors: Proportion of children with weight for height under 2 standard deviations from the norm (reference population
NCDs and nutrition median).
G

Child under 5 years Impact: Health status: Children under 5 years newly diagnosed with diarrhoea with dehydration per 1 000 children under 5 years in the
Child Health

diarrhoea with dehydration Infectious disease population

R

incidence (per 1 000) Although reported as a rate per population, this is one example of the general WHOCore indicator: New cases of
vaccine-preventable diseases
BA

Defined as: Number of confirmed new cases of vaccine-preventable diseases that are included in the WHO
N

recommended standards for surveillance of selected vaccine-preventable diseases, and vaccine-preventable

diseases reported on the WHO-UNICEF reporting form in a specified time period.
O

Disease (diphtheria, hepatitis B, pertussis, neonatal tetanus, total tetanus, measles, rubella, congenital rubella
syndrome, mumps, diarrhoea, pneumonia, Japanese encephalitis, yellow fever)
EM

Child under 5 years
pneumonia incidence (per
1 000)
Child under 5 years severe
acute malnutrition incidence
(per 1 000)
Children living far from their
usual health facility (%)
Exclusive breastfeeding
Child Health
Impact: Health status: The number of children under 5 years diagnosed with pneumonia, per 1 000 children in the catchment population.
Infectious disease
The number of children who weigh below 60% expected weight for age (new cases that month) per 1 000 children
in the target population.
Previously called ‘Severe malnutrition under 5 years incidence’.
Input: Health systems: This indicator reflects the distance from a child’s household to the health facility they normally attend. Distance is
Infrastructure measured through a proxy indicator: length of time travelled to reach the nearest health facility, by whatever form of
transport is usually used. The health facility is regarded as ‘far’ if a child would have to travel more than 30 minutes
to reach it, irrespective of mode of transport.
Outcome: Risk factors: Proportion of living children receiving only breast milk from birth to various ages.

rate (%) NCDs and nutrition

Number of orphans Number of children under 18 years whose biological mother, biological father or both parents have died.
Different kinds of orphans are defined as:
maternal orphans – a child whose mother has died, or whose living status is not known, but whose father is alive.
paternal orphans – a child whose father has died, or whose living status is not known, but whose mother is alive.
double/dual orphan – a child whose mother and father have both died, or whereabouts are unknown.
Orphanhood (%) Proportion of children under 18 years whose biological mother, biological father or both parents have died.

S A H R 20 1 6 337

Type Indicator
BCG coverage (%)
Immunisation
DTP3 coverage (%)
Immunisation coverage of
children <1 year (%)
Measles 1st dose coverage
(%)
OPV 1 coverage (%)
PCV7 3rd dose coverage
(%)
RV 2nd dose coverage (%)
Child mortality (deaths
Child mortality and related
between 1–4 years per
1 000 live births)
Infant mortality rate (deaths
under 1 year per 1 000 live
births)
Live birth under 2500g in
facility rate (%)
Neonatal mortality rate
(NNMR) (deaths <28 days
old per 1 000 live births)
Number of under-5 deaths
Perinatal care index
R
(perinatal MR / LBWR)
BA
Perinatal mortality rate
(stillbirths plus deaths <8
days old per 1 000 total
births)
EM
Post-neonatal mortality rate
(deaths 28–365 days age
per 1 000 live births)
Stillbirth rate (per 1 000 total Impact: Health status:
Child mortality and related
births)
Under 5 mortality rate
(deaths under 5 years per
1 000 live births)
33 8
WHO Core7
Definition
classification
Outcome: Service The proportion of expected live born babies that received BCG under 1 year of age (note: usually given immediately
coverage: Repro, after birth)
maternal, child,
adolescent
Outcome: Service Currently called ‘DTaP-IPV/Hib 3rd dose coverage (annualised)’ in DHIS. Previously called ‘DTP-Hib/DTaP-IPV/Hib
coverage: Repro, 3rd dose coverage’ in DHIS.
maternal, child, The proportion of children who received their third DTP-Hib doses (normally at 14 weeks). From approximately
adolescent 2009 when the immunisation schedule changed, this is defined as: The proportion of children under 1 year who
received their DTaP-IPV/Hib (Pentaxim) 3rd dose, normally at 14 weeks – annualised.
Outcome: Service Proportion of children under 1 year who are fully immunised. Calculated from the number of children fully
coverage: Repro, immunised (defined as first visit where all required vaccinations are completed) divided by the population <1 year.
maternal, child,
adolescent
Outcome: Service The proportion of children who received their 1st measles dose (normally at 9 months) – annualised.
coverage: Repro,
maternal, child,
adolescent
PM
Outcome: Service The proportion of children under 1 immunised with OPV dose 1.
coverage: Repro,
maternal, child,
adolescent
16 6
Outcome: Service The proportion of children who received their third PCV7 dose (around 9 months) – annualised.
coverage: Repro,
maternal, child,
20 IL
adolescent
Outcome: Service The proportion of children who received their second RV dose (around 14 weeks) – annualised.
coverage: Repro,
Y T
maternal, child,
adolescent
A N
The number of children aged 12 months to 5 years (i.e. to the end of the 4th year) who die in a year, per 1 000 live
births.
M U
Impact: Health status: The number of children less than one year old who die in a year, per 1 000 live births during that year.
Repro, maternal, child,
4 ED
adolescent
Outcome: Risk factors: Percentage of live births under 2 500g. Was previously called ‘Low birth weight rate’ in DHIS.
Repro, maternal, child,
adolescent
O
Impact: Health status: Number of deaths within the first 28 days of life, in a year, per 1 000 live births during that year.
Repro, maternal, child, Also called Neonatal Deathy Rate (NNDR).
adolescent
G
The estimated number of deaths in children younger than 5 years.
Perinatal mortality rate divided by the Low birth weight rate.
The Perinatal Care Index is a quality of care index that has been validated as a true measure of the quality of care;
the higher the index the poorer the care. The values should be below 1 for CHCs and below 2 for all hospitals.
The number of perinatal deaths per 1 000 births. The perinatal period starts as the beginning of foetal viability
(28 weeks gestation or 1 000g) and ends at the end of the 7th day after delivery. Perinatal deaths are the sum of
O
stillbirths plus early neonatal deaths. These are divided by total births (live births plus stillbirths).
Number of deaths occurring between 28 and 365 days after birth per 1 000 live births in the same period.
Number of stillbirths per 1 000 total births.
Repro, maternal, child, Globally suggested definition:
adolescent For international comparison, WHO uses stillbirth to mean the ICD definitions of late foetal deaths (ie, birthweight of
1 000 g or more with an assumed equivalent of 28 weeks gestation).
However, the birthweight and gestational age thresholds do not give equivalent results.
Lawn et al. therefore propose that for international comparison, the definition should focus on a gestational age
threshold for stillbirths rather than birthweight and that this change be included in ICD 11 to use the 28 weeks or
more
definition for epidemiological estimates of stillbirth. (Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C,
Hogan D, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016;387(10018):587–603.)
DHIS definition of stillbirth (NIDS 2015 revision):
‘Stillbirth is death prior to the complete expulsion or extraction from its mother of a product of conception.
The death is indicated by the fact that after such separation the foetus does not breathe or show any evidence of
life, such as beating of the heart, pulsation of the umbilical cord or definite movement of the involuntary muscles.
Stillbirths should only be counted when the foetus is of 26 or more weeks gestational age and/or weighs 500g or
more. A stillborn foetus might have been dead for a while (macerated) or died just before or during expulsion or
extraction (fresh) from its mother.’
Impact: Health status: The number of children under 5 years who die in a year, per 1 000 live births during the year.
Repro, maternal, child, It is a combination of the infant mortality rate, plus the age 1–4 mortality rate.
adolescent
S A H R 20 1 6

Type Indicator
Cervical cancer screening
Chronic Diseases
coverage (%)
Diabetes prevalence (%)
Diabetes prevalence (per
1 000)
Hyperlipidaemia prevalence
(per 1 000)
Hypertension prevalence
(%)
Hypertension prevalence
(per 1 000)
Hypertension treatment
coverage (%)
Mortality between 30–70
years from cardiovascular,
cancer, diabetes or chronic
respiratory disease
Prevalence of abnormal lipid
profiles (%)
Prevalence of mental
disorders
Prevalence of raised blood
pressure (%)
Suicide rate (per 100 000
population)
Alcohol dependence (%)
Behaviour &
Awareness
Currently drink alcohol (%)
Ever drank alcohol (%)
BA
Ever smoked cigarettes (%)
Ever used drugs (%)
Frequent smokers (%)
EM
Health and Related Indicators
WHO Core7
Definition
classification
Outcome: Service Women 30 years and older with a cervical (Pap) smear done for screening purposes according to the national
coverage: Repro, policy of screening all women in this age category every 10 years, as the proportion of all women 30 years and older
maternal, child, in the target population. The denominator is 10% of the female target population 30 years and older.
adolescent
Outcome: Risk factors: Percentage of people with diabetes.
NCDs and nutrition Defined in SANHANES as those with HbA1c > 6.5%
WHOCore indicator is: Age-standardised prevalence of raised blood glucose/diabetes among persons aged 18+
years or on medication for raised blood glucose
Defined as:
fasting plasma glucose value ≥7.0 mmol/L (126 mg/dL) or on medication for raised blood glucose among adults
aged 18+ years).
Number of people with diabetes per 1 000 people in the target population.
Number of people with hyperlipidaemia per 1 000 people in the target population.
Data for the private sector are based on the number of people being TREATED for this condition.
Percentage of people with hypertension, where hypertension is usually defined as individuals with systolic
PM
blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mm Hg and/or who reported the current use of
antihypertensive medication.
Number of people with hypertension per 1 000 people in the target population.
Data for the private sector are based on the number of people being TREATED for this condition.
16 6
The measured prevalence of hypertension was defined as those with BP equal or above 140/90 mmHg and/or
taking anti-hypertensive medication.
20 IL
Outcome: Service Hypertension is defined as usual systolic blood pressure over 140 mm Hg and/or diastolic blood pressure over
coverage: NCDs and 90 mmHg, or ‘currently taking medication for hypertension’. Hypertension treatment coverage is defined as the
nutrition proportion of people with hypertension who are currently taking medication.
Impact: Health status:
Y T Unconditional probability of dying between exact ages 30 and 70 from any of cardiovascular disease, cancer,
NCDs and nutrition diabetes, or chronic respiratory disease.
A N
Deaths from these four causes will be based on the following ICD codes: I00–I99, COO–C97, E10–E14 and J30–
J98.
According to WHOCore indicators: Modelling, using multiple inputs, is often used if no complete and accurate data
M U
are available.
Age standardization is done for comparability over time and between populations.
Percentage of people with raised cholesterol or other abnormal lipid profiles.
4 ED
Percentage of the population suffering from any common mental disorders.
Outcome: Risk factors: Percentage of people with systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg.
O
NCDs and nutrition
Impact: Health status: Suicide rate per 100 000 population in a specified period (age-standardised).
G
Injury and violence
Proportion of people who show signs of alcohol dependence See source publications for more details.
Proportion of people who currently drink alcohol.
Proportion of people who ever drank alcohol.
Outcome: Risk factors: Proportion of people who have ever smoked a cigarette, even one or two puffs.
NCDs and nutrition
O
Proportion of people who have ever used drugs.
Outcome: Risk factors: Proportion of people who smoked (cigarettes) on 20 or more days of the past 30 days.
NCDs and nutrition
S A H R 20 1 6 339

Type Indicator
Number of admissions for
Behaviour & Awareness
alcohol and other drug
abuse
Percentage participating in
insufficient physical activity
Prevalence of smoking (%)
Primary drug of abuse as %
of all drugs of abuse
Smoking age of initiation <10
years (%)
Total alcohol per capita (age Outcome: Risk factors: Total alcohol per capita is the total amount (sum of recorded alcohol per capita three-year average and unrecorded
15+ years) consumption NCDs and nutrition
(litres)
Watch TV more than 3 hours
per day (%)
Always wear a seat belt
Injuries
when driven by someone
else (%)
Drove after drinking alcohol
(%)
Road accident fatalities per
100 000 population
Percentage of users of
Health Services
private health services
highly satisfied with the
service received
Percentage of users of
public health services highly
satisfied with the service
received
Average length of stay
Health Facilities
(ALOS)
R
Inpatient bed utilisation rate
– total (BUR)
BA
Inpatient crude death rate
EM
Tracer items stock-out rate
(fixed clinic/CHC/CDC)
Usable beds per 1 000
population
Utilisation rate PHC
Utilisation rate PHC <5
years
Number of (health
Health
population Personnel
professionals)
Number of (health
professionals) registered
(Health professionals) per
Personnel per
100 000 population
3 40
WHO Core7
Definition
classification
Number of patients admitted for treatment by treatment centres who are part of the SACENDU Project sentinel
surveillance system.
Outcome: Risk factors: Proportion of those surveyed who did not participate in either vigorous or moderate physical activity that would have
NCDs and nutrition been sufficient to gain any health benefit, in the 7 days preceding the survey.
Vigorous activity is defined as activities for 20 or more minutes on 3 or more of the 7 days preceding the survey
such as soccer, netball, rugby or basketball. Moderate activity is defined as 30 or more minutes on 5 or more of the
7 days preceding the survey such as fast walking, slow bicycling, skating, mopping or sweeping floors.
Outcome: Risk factors: Proportion of population who currently smoke.
NCDs and nutrition This indicator is also known as ‘Current smokers (%)’
Note that the indicator may be given just for cigarettes or for other tobacco products.
Percentage breakdown of the primary drug of abuse reported by patients admitted to treatment centres that are part
of the SACENDU sentinel surveillance system.
Note that poly-substance abuse is high, with 34% of patients in treatment centres in Gauteng and 55% in Cape
Town reporting more than one substance of abuse.
Proportion of people who first smoked cigarettes before the age of 10 years (of those who have ever smoked).
PM
alcohol per capita) of alcohol consumed per adult (15+ years) in a calendar year, in litres of pure alcohol. Recorded
alcohol consumption refers to official statistics (production, import, export, and sales or taxation data), while
16 6
unrecorded alcohol consumption refers to alcohol which is not taxed and is outside the usual system of government
control. In circumstances in which the number of tourists per year is at least the number of inhabitants, tourist
consumption is also taken into account and is deducted from a country’s recorded alcohol per capita.
20 IL
Proportion of those surveyed (who have access to a TV, video or computer games) who spent 3 hours or more
watching TV or playing video/computer games during an average school day.
Proportion of people who always wear a seat belt when driven in a car by someone else.
Y T
A N
Proportion of people who drove after drinking alcohol (in the month preceding the survey, of those who indicated
they drive a vehicle.
M U
Impact: Health status: Number of fatalities due to road accidents per 100 000 population.
Injury and violence
Percentage of users of private health services highly satisfied with the service received.
4 ED
Percentage of users of public health services highly satisfied with the service received.
O
G
Average duration of patient stay in health facility. Numerator: Inpatient days + 1/2 Day patients. Denominator:
Inpatient separations (currently defined as: Discharges + Deaths + Transfers out).
Measure of the occupancy of the beds available for use.
Numerator: (Inpatient days + 1/2 Day patients) x 100
Denominator: Inpatient bed days available (Useable beds x days in period).
Output: Health Proportion of admitted clients/separations who died during hospital stay. Inpatient separations is the total of day
O
systems: Quality and clients, Inpatient discharges, Inpatient deaths and Inpatient transfer outs.
safety
Output: Health The proportion of all fixed clinics, CHCs and CDCs that had stock out of ANY tracer item for any period.
systems: Access and
availability
Input: Health systems: The number of usable beds divided by the population x 1 000. Where this is calculated for public health sector beds,
Infrastructure the population used is the public sector dependent (uninsured) population.
Output: Health Number of visits per person to PHC health facilities per year. Calculated from PHC headcount divided by total
systems: Access and population.
availability
Number of visits per person <5 years to PHC health facilities per year. Calculated from PHC headcount <5 years
divided by population <5 years.
Number of this category of health professional working in the specified sector.
Number of this category of health professional registered with the relevant professional council. This number
includes those working in the public or private sector as well as those registered but not working or overseas.
Input: Health systems: Ratio of the number of personnel to the population (per 100 000).
Workforce Note that the measure of the number of personnel may differ for the public and private sectors and also that the
population may be adjusted to be the population assumed to be dependent on that sector.
S A H R 20 1 6

Type Indicator
Claims ratio (%)
Health Financing
Headcount ratio of
catastrophic health
expenditure (%)
Headcount ratio of
impoverishing health
expenditure (%)
Health as percentage of total
expenditure
Medical scheme
beneficiaries
Medical scheme coverage
(%)
Pensioner ratio (%)
Per capita expenditure (non-
hospital PHC)
Per capita health
expenditure
Ratio of private to public
sector per capita health
expenditure
R
Total current expenditure
on health as percentage of
BA
gross domestic product
EM
Health and Related Indicators
WHO Core7
Definition
classification
Proportion of member contributions that has been utilised for the payment of benefits claimed by members of
medical schemes, as opposed to allocation of contributions for non-health benefits and the building of reserves.
Impact: Health Proportion of the population (or sub-population) facing catastrophic health expenditures.
systems: Financing Headcount ratios are the estimated total number of households facing catastrophic health expenditures over the
total number of households.
A household is identified as facing catastrophic health expenditures when its out-of-pocket health expenditures
represent 40% or more of its capacity-to-pay. Capacity-to-pay is estimated as total expenditure net of a subsistence
level of food expenditure. The latter is calculated as the average food expenditure per equivalent adults of
households in the 45th–55th food budget share distribution. When actual food spending falls below this amount,
capacity-to-pay is defined as total expenditures net of actual food spending.
Impact: Health Proportion of the population (or sub-population) facing impoverishing health expenditures.
systems: Financing Headcount ratios are the estimated total number of households facing impoverishing health expenditures over the
total number of households.
A household is identified as facing impoverishing health expenditures when its out-of-pocket health expenditures
push it below a poverty line (i.e. a household is above the poverty line when taking its total expenditure gross of
out-of-pocket payments but below the poverty line when taking total expenditure net of out-of-pocket payments).
PM
The poverty line is defined as subsistence level food expenditure estimated as the average food expenditure per
equivalent adults of households in the 45th–55th food budget share distribution. When actual food spending falls
below this amount, then capacity-to-pay is defined as total expenditures net of actual food spending.
Proportion of total (government) expenditure on health.
16 6
Provinces with central hospitals have a higher share.
Number of medical scheme beneficiaries, as reported by the Medical Schemes Council.
20 IL
Proportion of population covered by medical schemes.
Y T Proportion of members of medical schemes who are 65 years or older, in registered medical schemes.
Amount spent on non-hospital PHC services by the public sector per person without medical aid coverage
A N
(in Rand).Includes provincial expenditure from sub-programmes 2.2–2.7 (clinics, community health centres,
community-based services and other community services, nutrition and HIV) under District Health Services, plus
net Local government expenditure on health services. Expenditure is divided by the population without medical
M U
scheme coverage. Expenditure may be given in nominal terms (prices for the year of expenditure) or real terms
(inflation adjusted prices to a particular base year).
Amount spent on health per person (in Rand)
4 ED
For the public sector, this is often calculated for the population without medical aid coverage (public sector
dependent population). For the private sector this is usually calculated for the number of medical schemes
beneficiaries.
Note that attention should be given to the notes for each data item, since financial indicators are affected by
O
inflation, and expenditure may be reported according to currency value for a particular year to facilitate comparison
of real differences.
G
Total private per capita expenditure divided by total public sector per capita expenditure.
Public health sector expenditure is divided by the population covered (public sector dependent population)
Private sector is total medical scheme expenditure divided by number of beneficiaries.
Input: Health systems: Proportion of national Gross Domestic Product that is spent on healthcare.
Financing
O
S A H R 20 1 6 341
References
1 Murray CJL. Choosing indicators for the health-related SDG
targets. Lancet. 2015;386(10001):1314–7.
2 United Nations. Global Sustainable Development Report.
2015 edition. New York: United Nations; 2015.
3 Jha A, Kickbusch I, Taylor P, Abbasi K, Sustainable DGs
working group. Accelerating achievement of the sustainable
development goals. BMJ. 2016;352:i409.
4 National Coordinating Committee for the Millennium
Development Goals. Millennium Development Goals: Country
Report 2015. Pretoria: Statistics South Africa; 2015.
5 Way C, editor. The Millennium Development Goals Report
2015. New York: United Nations; 2015.
6 Boerma JT, Mathers C, AbouZahr C, Chatterji S, Hogan D,
Stevens G, et al. Health in 2015: from MDGs, Millennium
Development Goals to SDGs, Sustainable Development Goals.
Geneva: World Health Organization; 2015.
7 World Health Organization. Global Reference List of 100
16 6
Core Health Indicators, 2015. Geneva: World Health
Organization; 2015.
20 IL
8 Institute for Health Metrics and Evaluation. Financing Global
Health 2014: Shifts in Funding as the MDG Era Closes.
Seattle, WA: IHME; 2015.
9
Y T
Statistics South Africa. Recorded live births 2014. Statistical
A N
release P0305. Pretoria: Statistics SA; 2015.
10 Statistics South Africa. Mortality and causes of death in South
M U
Africa, 2014: Findings from death notification. Statistical
release P0309.3. Pretoria: Statistics SA; 2015.
4 ED
11 National Committee on the Confidential Enquiries into
Maternal Deaths. Saving Mothers 2011–2013: Sixth report
on confidential enquiries into maternal deaths in South Africa.
Short report. Pretoria: National Department of Health; 2015
O
[cited 11 June 2015].
URL: http://www.kznhealth.gov.za/mcwh/Maternal/Saving-
Mothers-2011-2013-short-report.pdf
G
12 South African National Department of Health. National
R
Consolidated Guidelines for the prevention of mother-to-child
transmission of HIV (PMTCT) and the management of HIV
in children, adolescents and adults. Pretoria: National
BA
N
Department of Health; 2015.
O
13 AbouZahr C, Adjei S, Kanchanachitra C. From data
to policy: good practices and cautionary tales. Lancet.
EM
2007;369(9566):1039–46.
14 Kollodge R, editor. The State of World Population 2015.
Shelter from the Storm. New York: United Nations Population
Fund; 2015.
15 Statistics South Africa. Census 2011 Population Dynamics in
South Africa. Report No. 03–01–67. Pretoria: Statistics SA;
2015.
16 Mathee A, Naicker N. The socioeconomic and environmental
health situation of international migrants in Johannesburg,
South Africa. S Afr Med J. 2015;106(1):70.
17 Statistics South Africa. Census 2011: Fertility in South Africa.
Report 03–01–63. Pretoria: Statistics SA; 2015.
18 Beard J, Officer A, Cassels A. World Report on Ageing and
Health: World Health Organization; 2015.
19 Statistics South Africa. Census 2011. Statistical release
P0301.4. Pretoria: Statistics SA; 2012.
20 Statistics South Africa. Mid-year population estimates 2015.
Statistical release P0302. Pretoria: Statistics SA; 2015.
3 42 S A H R 20 1 6
21 Statistics South Africa. General Household Survey 2014.
Statistical release P0318. Pretoria: Statistics SA; 2015.
22 Council for Medical Schemes. Annual Report 2014/15. 15
years on the pulse. Pretoria: Council for Medical Schemes;
2015.
23 Statistics South Africa. General Household Survey 2013.
Statistical release P0318. Pretoria: Statistics SA; 2014.
24 Jahan S. Human Development Report 2015. Work for Human
Development. New York: United Nations Development
Programme; 2015.
25 Rees N, Anthony D, editors. Unless we act now. The impact
of climate change on children. New York: United Nations
Children’s Fund; 2015.
PM
26 South African Department of Water and Sanitation. 2014
Blue Drop Report. South Africa: Department of Water and
Sanitation; 2016.
27 Statistics South Africa. Quarterly Labour Force Survey. Quarter
3: 2015. P0211. Pretoria: Statistics SA; 2015.
28 De Lannoy A, Swartz S, Lake L, Smith C, editors. South
African Child Gauge 2015. Cape Town: Children’s Institute,
University of Cape Town; 2015.
29 Statistics South Africa. Census 2011: Income dynamics
and poverty status of households in South Africa. Report
03–10–10. Pretoria: Statistics SA; 2015.
30 Statistics South Africa. Census 2011: A profile of educational
enrolment, attainment and progression in South Africa. Report
03–01–812011. Pretoria: Statistics SA; 2015.
31 Statistics South Africa. Gender Series Volume II: Education
and Gender, 2004–2014. Report No. 03–10–12
(2004–2014). Pretoria: Statistics SA; 2015.
32 Department of Environmental Affairs. 2014 State of Air Report
and National Air Quality Indicator. 9th Annual Air Quality
Governance Lekgotla; 6 October; Durban, KwaZulu-Natal:
Department of Environmental Affairs; 2014.
33 South African Department of Water Affairs. 2012 Blue Drop
Report. South Africa: Department of Water Affairs; 2012.
34 Statistics South Africa. Poverty Trends in South Africa. An
examination of absolute poverty between 2006 and 2011.
Report No. 03–10–06. Pretoria: Statistics SA; 2014.
35 Statistics South Africa. Quarterly Labour Force Survey.
Statistical release P0211. Pretoria: Statistics SA; time series.
36 Kyu HH, Pinho C, Wagner JA, Brown JC, Bertozzi-Villa A,
Charlson FJ, et al. Global and National Burden of Diseases
and Injuries Among Children and Adolescents Between 1990
and 2013: Findings From the Global Burden of Disease 2013
Study. JAMA Pediatr. 2016;170(3):267–87.
37 GBD 2013 Country Profile: South Africa. [Internet] Seattle:
Institute for Health Metrics and Evaluation; 2015 [cited 25
November 2015].
URL: http://www.healthdata.org.za/south-africa
38 Johnson LF, Dorrington RE, Laubscher R, Hoffmann CJ, Wood
R, Fox MP, et al. A comparison of death recording by health
centres and civil registration in South Africans receiving
antiretroviral treatment. J Int AIDS Soc. 2015;18(1):20628.
39 Statistics South Africa. Census 2011: Estimation of Mortality
in South Africa. Report No. 03–01–62. Pretoria: Statistics SA;
2015.
40 Dorrington R, Bradshaw D, Laubscher R, Nannan N. Rapid
mortality surveillance report 2014. Cape Town: South African
Medical Research Council; 2015.

41 Msemburi W, Pillay-van Wyk V, Dorrington R, Neethling I,
Nannan N, Groenewald P, et al. Second national burden
of disease study for South Africa: Cause-of-death profile
for South Africa, 1997–2010. Cape Town: South African
Medical Research Council; 2014.
42 Global Burden of Disease Study 2013 Group. Global
Burden of Disease Study 2013 (GBD 2013) Age-Sex Specific
All-Cause and Cause-Specific Mortality 1990-2013 [dataset].
Seattle: Institute for Health Metrics and Evaluation (IHME);
2014.
43 GBD 2013 DALYs and HALE collaborators. Global, regional,
and national disability-adjusted life years (DALYs) for 306
diseases and injuries and healthy life expectancy (HALE) for
188 countries, 1990–2013: quantifying the epidemiological
transition. Lancet. 2015;386(10009):2145–91.
44 Noack R, Gamio L, Cai W. These charts show how much
of your life you will spend being sick. The Washington Post.
September 19 2015.
45 South African National Department of Health. District Health
Information System (DHIS) database [dataset]. Pretoria:
16 6
National Department of Health; time series.
46 Statistics South Africa. General Household Survey 2012.
20 IL
Statistical release P0318. Pretoria: Statistics SA; 2013.
47 Shisana O, Labadarios D, Rehle T, Simbayi L, Zuma K,
Dhansay A, et al. South African National Health and Nutrition
Y T
Examination Survey (SANHANES-1). Cape Town: HSRC
Press; 2013.
A N
48 National Institute for Communicable Diseases. Communicable
M U
Diseases Surveillance Bulletin. Volume 13, No. 4, Novemer
2015. Johannesburg: National Institute for Communicable
Diseases; 2015.
4 ED
49 Magaisa K, Taylor M, Kjetland EF, Naidoo PJ. A review of
the control of schistosomiasis in South Africa. S Afr J Sci.
2015;111(11/12 Art. #2014–0427):1–6.
O
50 Kew M. Hepatitis B virus infection: The burden of disease in
South Africa. South Afr J Epidemiol Infect. 2008;23(2):4–8.
G
51 Amponsah-Dacosta E, Lebelo RL, Rakgole JN, Selabe SG,
Gededzha MP, Mayaphi SH, et al. Hepatitis B virus infection
R
in post-vaccination South Africa: occult HBV infection and
circulating surface gene variants. J Clin Virol. 2015;63:12–7.
BA
N
52 National Institute for Communicable Diseases. Communicable
Diseases Communique. Volume 14(9), September 2015.
O
Johannesburg: National Institute for Communicable Diseases;
EM
2015.
53 National Institute for Communicable Diseases. Communicable
Diseases Communique. Volume 15(1), January 2016.
Johannesburg: National Institute for Communicable Diseases;
2016.
54 National Institute for Communicable Diseases. Communicable
Diseases Surveillance Bulletin. Volume 13, No. 1, April 2015.
Johannesburg: National Institute for Communicable Diseases;
2015.
55 Aponte J, Aregawi M, Cibulskis R, Fergus C, Lynch M,
Mintcheva R, et al. World Malaria Report 2015. Geneva:
World Health Organization; 2015.
56 Newman R, Reeder J, Alonso P. Global Technical Strategy for
Malaria 2016–2030. Geneva: World Health Organization;
2015.
57 Statistics South Africa. Mortality and causes of death in South
Africa, 2011: Findings from death notification. Statistical
release P0309.3. Pretoria: Statistics SA; 2014.
58 Statistics South Africa. Mortality and causes of death in South
Africa, 2012: Findings from death notification. Statistical
release P0309.3. Pretoria: Statistics SA; 2014.
S A H R 20 1 6
Health and Related Indicators
59 Statistics South Africa. Mortality and causes of death in South
Africa, 2013: Findings from death notification. Pretoria:
Statistics SA; 2014.
60 Murray CJ, Ortblad KF, Guinovart C, Lim SS, Wolock TM,
Roberts DA, et al. Global, regional, and national incidence
and mortality for HIV, tuberculosis, and malaria during
1990–2013: a systematic analysis for the Global Burden of
Disease Study 2013. Lancet. 2014;384(9947):1005–70.
61 World Health Organization. Global tuberculosis report 2015.
Geneva: World Health Organization; 2015.
62 Stop TB Partnership. The Paradigm Shift | 2016–2020.
Global Plan to End TB. Geneva: Stop TB Partnership, United
Nations Office for Project Services; 2015.
63 Theron G, Jenkins HE, Cobelens F, Abubakar I, Khan AJ,
Cohen T, et al. Data for action: collection and use of local
data to end tuberculosis. Lancet. 2015;386(10010):2324–
PM
33.
64 Barnhart S. PEPFAR: is 90-90-90 magical thinking? Lancet.
2016;387(10022):943–4.
65 Seddon JA, Jenkins HE, Liu L, Cohen T, Black RE, Vos T, et al.
Counting children with tuberculosis: why numbers matter. Int J
Tuberc Lung Dis. 2015;19 Suppl 1:9–16.
66 Ballif M, Renner L, Claude Dusingize J, Leroy V, Ayaya
S, Wools-Kaloustian K, et al. Tuberculosis in Pediatric
Antiretroviral Therapy Programs in Low- and Middle-Income
Countries: Diagnosis and Screening Practices. J Pediatric
Infect Dis Soc. 2015;4(1):30–8.
67 Massyn N, Peer N, Padarath A, Barron P, Day C, editors.
District Health Barometer 2014/15. Durban: Health Systems
Trust; 2015.
68 Ndjeka N. Multi-Drug Resistant Tuberculosis. Strategic
Overview on MDR-TB Care in South Africa. South Africa:
National Department of Health; 2014 [cited 27 March
2014].
URL: http://www.health-e.org.za/wp-content/
uploads/2014/03/Strategic_overview_of_MDR_TB_RSA.pdf
69 South African National Department of Health. The 2013
National Antenatal Sentinel HIV Prevalence Survey South
Africa. Pretoria: National Department of Health; 2015.
70 Child K. Sex workers HIV infection shock. TimesLIVE. 14
December 2015.
71 UCSF, Anova Health Institute, Wits Reproductive Health
and HIV Research Institute. South African Health Monitoring
Study (SAHMS), Final Report: The Integrated Biological and
Behavioural Survey among Female Sex Workers, South Africa
2013–2014. San Fransicso: University of California, San
Francisco (UCSF); 2015.
URL: http://www.health-e.org.za/wp-content/
uploads/2016/03/South-African-Health-Monitoring-Survey-
An-Integrated-Biological-and-Behavioral-Survey-among-Female-
Sex-Workers-South-Africa-2013-2014.pdf
72 Gonzalez LL. Stalking a virus among the shadows. Health-e.
March 14 2016.
73 Joint United Nations Programme on HIV/AIDS. 2015 Progress
Report on the Global Plan towards the elimination of new HIV
infections among children and keeping their mothers alive.
Geneva: Joint United Nations Programme on HIV/AIDS;
2015.
74 Goga A, Jackson D, Singh M, Lombard C. Early (4–8
weeks postpartum) Population-level Effectiveness of WHO
PMTCT Option A, South Africa, 2012–2013. 2012–2013
SAPMTCTE Report. South Africa: South African Medical
Research Council and South African National Department of
Health; 2015.
3 43
75 Joint United Nations Programme on HIV/AIDS. On the
Fast-Track to end AIDS by 2030: Focus on location and
population. Geneva: Joint United Nations Programme on HIV/
AIDS; 2015.
76 Bor J, Rosen S, Chimbindi N, Haber N, Herbst K, Mutevedzi
T, et al. Mass HIV Treatment and Sex Disparities in Life
Expectancy: Demographic Surveillance in Rural South Africa.
PLoS Med. 2015;12(11):e1001905.
77 Kharsany AB, Cawood C, Khanyile D, Grobler A, McKinnon
LR, Samsunder N, et al. Strengthening HIV surveillance in
the antiretroviral therapy era: rationale and design of a
longitudinal study to monitor HIV prevalence and incidence
in the uMgungundlovu District, KwaZulu-Natal, South Africa.
BMC Public Health. 2015;15(1):1149.
78 Johnson LF, Rehle TM, Jooste S, Bekker LG. Rates of HIV testing
and diagnosis in South Africa: successes and challenges.
AIDS. 2015;29(11):1401–9.
79 Johnson L. HIV testing in South Africa: successes and
challenges. September 2015. Stellenbosch: South African
Centre for Epidemiological Modelling and Analysis
16 6
(SACEMA); 2015.
80 South African National Department of Health. Annual Report
20 IL
2014/15. Pretoria: National Department of Health,; 2015.
81 Eaton JW, Bacaër N, Bershteyn A, Cambiano V, Cori A,
Dorrington RE, et al. Assessment of epidemic projections
Y T
using recent HIV survey data in South Africa: a validation
analysis of ten mathematical models of HIV epidemiology
A N
in the antiretroviral therapy era. Lancet Glob Health.
2015;3(10):e598–e608.
M U
82 AIDS Committee of the Actuarial Society of South Africa.
ASSA2008 Model: ProvOutput. AIDS and Demographic
4 ED
Model. South Africa: Actuarial Society of South Africa
(ASSA); 2011 [cited 26 March 2011].
URL: http://www.actuarialsociety.org.za/Societyactivities/
CommitteeActivities/AidsCommittee/Models.aspx
O
83 Shisana O, Rehle T, Simbayi L, Zuma K, Jooste S, Zungu
N, et al. South African National HIV Prevalence, Incidence
G
and Behavioural Survey, 2012. Pretoria: Human Sciences
Research Council; 2014.
R
84 Rehle T, Johnson L, Hallett T, Mahy M, Kim A, Odido H, et
al. A Comparison of South African National HIV Incidence
BA
Estimates: A Critical Appraisal of Different Methods. PloS one.
2015;10(7):e0133255.
O
85 South African National Department of Health. The 2012
EM
National Antenatal Sentinel HIV & Herpes Simplex Type-2
Prevalence Survey in South Africa. Pretoria: National
Department of Health; 2014.
86 Johnson LF. THEMBISA version 1.0: A model for evaluating
the impact of HIV/AIDS in South Africa. Centre for Infectious
Disease Epidemiology and Research Working Paper February
2014. Cape Town: University of Cape Town; 2014.
87 Massyn N, Day C, Peer N, Padarath A, Barron P, English R.
District Health Barometer 2013/14. Durban: Health Systems
Trust; 2014.
88 Maughan-Brown B, Lloyd N, Bor J, Venkataramani A.
Increasing access to HIV testing: Impacts on equity of
coverage and uptake from a national campaign in South
Africa. Working Paper Number 145. Cape Town: Southern
Africa Labour and Development Research Unit (SALDRU);
2015.
344 S A H R 20 1 6
89 Higher Education and Training HIV/AIDS Programme
(HEAIDS) and Networking HIV/AIDS Community of South
Africa (NACOSA). National Student Sexual Health HIV
Knowledge, Attitude and Behavious Survey: Focusing on
Student Men who have Sex with Men at 14 Higher Education
Institutions in South Africa. Pretoria: HEAIDS, NACOSA;
2014.
90 Johnson S, Kincaid D, Figueroa M, Delate R, Mahlasela L,
Magni S. The Third National HIV Communication Survey,
2012. Pretoria: Johns Hopkins Health and Education in South
Africa (JHHESA); 2013.
91 Southern Africa Labour and Development Research Unit.
National Income Dynamics Study 2012, Wave 3 [dataset].
In: Southern Africa Labour and Development Research Unit
(SALDRU), editor. Version 1.2 ed. Cape Town: DataFirst;
2014.
PM
92 Dorrington RE, Bradshaw D. Acknowledging uncertainty
about maternal mortality estimates. Bull World Health Organ.
2016;94(2):155–6.
93 The Maternal Mortality Estimation Inter-Agency Group
(MMEIG), Alkema L, Gemmill A. Trends in maternal mortality:
1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World
Bank Group and the United Nations Population Division.
Geneva: World Health Organization; 2015.
94 Bustreo F, Kuruvilla S, editors. The Global Strategy for
Women’s, Children’s and Adolescent’s health (2016–2030).
Italy: Every Woman Every Child; 2015.
URL: http://www.who.int/life-course/publications/global-
strategy-2016-2030/en/
95 McGee SA, Chola L, Tugendhaft A, Mubaiwa V, Moran N,
McKerrow N, et al. Strategic planning for saving the lives of
mothers, newborns and children and preventing stillbirths in
KwaZulu-Natal province South Africa: modelling using the
Lives Saved Tool (LiST). BMC Public Health. 2016;16(1):49.
96 Tunkyi K, Moodley J. Prevalence of anaemia in pregnancy
in a regional health facility in South Africa. S Afr Med J.
2015;106(1):101.
97 Wise J. Target rates for caesarean section may be too low,
say researchers. BMJ. 2015;351:h6439.
98 Amnesty International. Struggle for maternal health. Barriers
to antenatal care in South Africa. London, UK: Amnesty
International; 2014.
99 Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford
KA, Steiner C, Heuton KR, et al. Global, regional, and
national levels and causes of maternal mortality during
1990–2013: a systematic analysis for the Global Burden of
Disease Study 2013. Lancet. 2014;384(9947):980–1004.
100 Pattinson R, Fawcus S, Moodley J. Tenth interim report on
Confidential Enquiries into Maternal Deaths in South Africa.
Pretoria: National Department of Health; 2013.
101 National Committee on the Confidential Enquiries into
Maternal Deaths. Saving Mothers 2011–2013: Sixth report
on confidential enquiries into maternal deaths in South Africa:
Fact sheet. Pretoria: National Department of Health; 2015
[cited 11 June 2015].
URL: http://www.kznhealth.gov.za/mcwh/Maternal/Saving-
Mothers-2011-2013-Fact-Sheet.pdf
102 National Committee for Confidential Enquiries into Maternal
Deaths. Saving Mothers 2008–2010: Fifth report on
Confidential Enquiries into Maternal Deaths in South Africa
(summary). Pretoria: National Department of Health; 2012
[cited 17 October 2012].
URL: http://www.doh.gov.za/docs/reports/2012/
savingmothersshort.pdf

103 Qureshi ZU, Millum J, Blencowe H, Kelley M, Fottrell E, Lawn
JE, et al. Stillbirth should be given greater priority on the
global health agenda. BMJ. 2015;351:h4620.
104 Frøen JF, Lawn JE, Heazell AEP, De Bernis L, Kinney MV,
Blencowe H, et al. The Lancet Ending Preventable Stillbirths
Series 2016. Lancet. 2016.
105 de Bernis L, Kinney MV, Stones W, Ten Hoope-Bender P, Vivio
D, Leisher SH, et al. Stillbirths: ending preventable deaths by
2030. Lancet. 2016;387(10019):703–16.
106 Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C,
Hogan D, et al. Stillbirths: rates, risk factors, and acceleration
towards 2030. Lancet. 2016;387(10018):587–603.
107 United Nations Children’s Fund (UNICEF). For every child, a
fair chance. The promise of equity. New York: UNICEF; 2015.
108 Victora CG, Bahl R, Barros AJ, Franca GV, Horton S,
Krasevec J, et al. Breastfeeding in the 21st century:
epidemiology, mechanisms, and lifelong effect. Lancet.
2016;387(10017):475–90.
109 World Health Organization. Africa advances toward a
16 6
polio-free continent. Geneva: World Health Organization;
2015 [cited 7 March 2016].
20 IL
URL: http://www.who.int/topics/poliomyelitis/polio-free/
en/#
110 Mathews S, Jamieson L, Lake L, Smith C. South African Child
Cape Town; 2014.
Y T
Gauge 2014. Cape Town: Children’s Institute, University of
A N
111 Wang H, Liddell CA, Coates MM, Mooney MD, Levitz CE,
Schumacher AE, et al. Global, regional, and national levels
M U
of neonatal, infant, and under-5 mortality during 1990–2013:
a systematic analysis for the Global Burden of Disease Study
4 ED
2013. Lancet. 2014;384(9947):957–79.
112 You D, Hug L, Ejdemyr S, Beise J. Levels and Trends in Child
Mortality: Report 2015. New York: United Nations Children’s
Fund (UNICEF); 2015.
O
113 National Perinatal Morbidity and Mortality Committee.
National Perinatal Morbidity and Mortality Committee
G
(NaPeMMCo) Short Report 2014. (Showing data for
2010–2013). Pretoria: National Department of Health; 2015.
R
114 You D, Hug L, Chen Y. Levels and Trends in Child Mortality:
BA
Report 2014. New York: United Nations Children’s Fund
N
(UNICEF); 2014.
O
115 Statistics South Africa. Perinatal deaths in South Africa,
2011–2013. Statistical release P0309.4. Pretoria: Statistics
EM
SA; 2015.
116 WHO vaccine-preventable diseases: monitoring system. 2015
global summary [database on the Internet]. World Health
Organization. 2015 [cited 10 Sep 2015].
URL: http://apps.who.int/immunization_monitoring/
globalsummary
117 Ryan J, Leibbrandt M. Multidimensional Food Insecurity
Measurement. Working Paper Series Number 160. Cape
Town: Southern Africa Labour and Development Research
Unit, University of Cape Town; 2015.
118 United Nations Food and Agriculture Organization (FAO),
International Fund for Agricultural Development (IFAD) and
World Food Programme (WFP). The State of Food Insecurity
in the World. Meeting the 2015 international hunger targets:
taking stock of uneven progress. Rome: Food and Agriculture
Organization of the United Nations (FAO); 2015.
119 Alarcon D, Grundleger J, Joehnk TF, Kock B, Lake J, Luft J, et
al. Global Food Security Index 2015. An annual measure of
the state of global food security. New York: The Economist
Intelligence Unit; 2015.
S A H R 20 1 6
Health and Related Indicators
120 Alarcon D, Grundleger J, Joehnk TF, Kock B, Lake J, Luft J,
et al. Global Food Security Index 2015. Key findings. New
York: The Economist Intelligence Unit; 2015.
121 National Treasury. Minister Pravin Gordhan: 2016 Budget
Speech. Cape Town: South African Government; 2016 [cited
24 February 2016].
URL: http://www.gov.za/speeches/minister-pravin-gordhan-
2016-budget-speech-24-feb-2016-0000
122 National Treasury. Budget Review 2016. Pretoria: National
Treasury; 2016.
123 Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati
M, Mozaffarian D, et al. Estimated Global, Regional,
and National Disease Burdens Related to Sugar-
Sweetened Beverage Consumption in 2010. Circulation.
2015;132(8):639–66.
124 South African National Department of Health. Strategy
PM
for the Prevention and Control of Obesity in South Africa
2015–2020. Pretoria: National Department of Health; 2015.
125 Cois A, Day C. Who is getting fat in South Africa: Obesity
trends and risk factors in the South African adult population.
Report prepared in response to the call for interest 2013:
Improving the Understanding of the Dynamics of Poverty and
Inequality Reference: PSPPD2/CoI1/2013. Durban: Health
Systems Trust; 2015.
126 Cois A, Day C. Obesity trends and risk factors in the South
African adult population. BMC Obesity. 2015;2(1).
127 GBD 2013 Risk Factors Collaborators. Global, regional,
and national comparative risk assessment of 79 behavioural,
environmental and occupational, and metabolic risks or
clusters of risks in 188 countries, 1990–2013: a systematic
analysis for the Global Burden of Disease Study 2013. Lancet.
2015;386(10010):2287–323.
128 Fritschel H, Carter T, Stedman-Edwards P, Whitehead
J, editors. Global Nutrition Report 2015: Actions and
Accountability to Advance Nutrition and Sustainable
Development. Washington, DC: International Food Policy
Research Institute; 2015.
129 von Grebmer K, Bernstein J, de Waal A, Prasai N, Yin A,
Yohannes Y. 2015 Global Hunger Index: Armed conflict and
the challenge of hunger. Bonn/Washington, DC/Dublin:
Welthungerhilfe/International Food Policy Research Institute
(IFPRI)/Concern Worldwide; 2015.
URL: http://www.ifpri.org/publication/2015-global-hunger-
index-armed-conflict-and-challenge-hunger
130 World Health Organization. Report of the Commission
on Ending Childhood Obesity. Geneva: World Health
Organization; 2016.
131 Symington EA, Gericke GJ, Nel JH, Labadarios D. The
relationship between stunting and overweight among children
from South Africa: Secondary analysis of the National Food
Consumption Survey – Fortification Baseline I. S Afr Med J.
2015;106(1):65.
132 Eksteen G, Mungal-Singh V. Salt intake in South Africa: a
current perspective. Journal of Endocrinology, Metabolism and
Diabetes of South Africa. 2015;20(1).
133 Wentzel-Viljoen E, Steyn K, Ketterer E, Charlton K. “Use
salt and foods high in salt sparingly”: a food-based
dietary guideline for South Africa. S Afr J Clin Nutr.
2013;26(3):S105–S13.
134 McHiza ZJ, Steyn NP, Hill J, Kruger A, Schonfeldt H, Nel J,
et al. A Review of Dietary Surveys in the Adult South African
Population from 2000 to 2015. Nutrients. 2015;7(9):8227–
50.
3 45
135 Omardien R, Reddy S, James S, Kambaran N, Sifunda S,
Ellahebokus A, et al. Umthente Uhlaba Usamila – The 3rd
South African National Youth Risk Behaviour Survey 2011.
Cape Town: South African Medical Research Council; 2013.
136 Wandai M, Day C. Trends in risk factors for non-
communicable diseases in South Africa. Durban: Health
Systems Trust; 2015.
137 Ng M, Fleming T, Robinson M, Thomson B, Graetz N,
Margono C, et al. Global, regional, and national prevalence
of overweight and obesity in children and adults during
1980–2013: a systematic analysis for the Global Burden of
Disease Study 2013. Lancet. 2014;384(9945):766–81.
138 Schmidt H, Barnhill A. Equity and Noncommunicable Disease
Reduction under the Sustainable Development Goals. PLoS
Med. 2015;12(9):e1001872.
139 Clark SJ, Gomez-Olive FX, Houle B, Thorogood M, Klipstein-
Grobusch K, Angotti N, et al. Cardiometabolic disease risk
and HIV status in rural South Africa: establishing a baseline.
BMC Public Health. 2015;15:135.
140 Ware LJ, Rennie KL, Gafane LF, Nell TM, Thompson JE, Van
16 6
Rooyen JM, et al. Masked Hypertension in Low-Income South
African Adults. J Clin Hypertens (Greenwich). 2016.
20 IL
141 Roth GA, Huffman MD, Moran AE, Feigin V, Mensah
GA, Naghavi M, et al. Global and Regional Patterns in
Cardiovascular Mortality From 1990 to 2013. Circulation.
Y T
2015;132(17):1667–78.
A N
142 Roth GA, Nguyen G, Forouzanfar MH, Mokdad AH,
Naghavi M, Murray CJ. Estimates of Global and Regional
M U
Premature Cardiovascular Mortality in 2025. Circulation.
2015;132(13):1270–82.
4 ED
143 Shepard D, VanderZanden A, Moran A, Naghavi M, Murray
C, Roth G. Ischemic Heart Disease Worldwide, 1990 to
2013: Estimates From the Global Burden of Disease Study
2013. Circulation. Cardiovascular quality and outcomes.
O
2015;8(4):455–6.
144 Cavan D, da Rocha Fernandes J, Makaroff L, Ogurtsova K,
G
Webber S, editors. IDF Diabetes Atlas. Seventh edition, 2015.
Brussels, Belgium: International Diabetes Federation; 2015.
R
145 Beran D, Ewen M, Laing R. Constraints and challenges in
access to insulin: a global perspective. Lancet Diabetes
BA
Endocrinol. 2016;4(3):275–85.
146 Pinkney-Atkinson V. Civil Society Status Report 2010–2015.
O
Mapping South Africa’s response to the epidemic of
EM
non-communicable diseases. Johannesburg: South African
Non-communicable diseases alliance; 2015.
147 Dreyer G, Van der Merwe FH, Botha MH, Snyman
LC, Constant D, Visser C, et al. School-based human
papillomavirus vaccination: An opportunity to increase
knowledge about cervical cancer and improve uptake of
screening. S Afr Med J. 2015;105(11):912–6.
148 Naik R, Kaneda T. Noncommunicable diseases in Africa:
Youth are key to curbing the epidemic and achieving
sustainable development. Washington, DC: Population
Reference Bureau; 2015 [cited 12 February 2016].
URL: http://www.prb.org/pdf15/ncds-africa-policybrief.pdf
149 Morgan S, Barnwell G, Daniels I, Kanda M, Mapukata C,
Phomane M, et al. The Rural Mental Health Campaign Report.
Cape Town: Rural Mental Health Campaign; 2015 [cited 15
October 2015].
URL: http://www.ruresa.com/
uploads/1/2/6/3/12635826/_rural_mental_health_
campaign_report_2015_low_res.pdf
150 Guariguata L, Nolan T, Beagley J, Linnenkamp U, Jacqmain
O, editors. IDF Diabetes Atlas. Sixth edition, 2013. Brussels,
Belgium: International Diabetes Federation; 2013.
346 S A H R 20 1 6
151 International Diabetes Federation. IDF Diabetes Atlas update
poster, sixth edition. Brussels, Belgium: International Diabetes
Federation; 2014.
152 Mendis S, Armstrong T, Bettcher D, Branca F, Lauer J, Mace
C, et al. Global status report on noncommunicable diseases
2014. Geneva: World Health Organization; 2014.
153 Andersson LM, Schierenbeck I, Strumpher J, Krantz G,
Topper K, Backman G, et al. Help-seeking behaviour,
barriers to care and experiences of care among persons with
depression in Eastern Cape, South Africa. J Affect Disord.
2013;151(2):439–48.
154 Global Health Observatory [database on the Internet]. World
Health Organization. 2016 [cited 14 February 2016].
URL: http://apps.who.int/gho/data/view.main.2485
155 South African National Cancer Registry. Summary statistics
of cancer diagnosed histologically in 2010. South Africa:
PM
National Cancer Registry; 2015.
156 Katzmarzyk PT, Barreira TV, Broyles ST, Champagne CM,
Chaput JP, Fogelholm M, et al. Physical Activity, Sedentary
Time, and Obesity in an International Sample of Children.
Med Sci Sports Exerc. 2015;47(10):2062–9.
157 South African Medical Research Council. South Africa 2011
(Ages 13–15) Global Youth Tobacco Survey (GYTS) Fact
Sheet. Cape Town: South African Medical Research Council;
2012.
158 Reddy P, Zuma K, Shisana O, Jonas K, Sewpaul R. Prevalence
of tobacco use among adults in South Africa: Results from the
first South African National Health and Nutrition Examination
Survey. S Afr Med J. 2015;105(8):648–55.
159 Dada S, Harker Burnhams N, Parry C, Bhana A, Timol F,
Wilford A, et al. Alcohol and Drug Abuse Trends: January
– June 2013 (Phase 34). Update (December 2013). Cape
Town: South African Community Epidemiology Network on
Drug Use (SACENDU); 2013.
160 Dada S, Harker Burnhams N, Erasmus J, Parry C, Bhana A,
Timol F, et al. Alcohol and drug abuse trends: January – June
2015 (Phase 38). Update (November 2015). Cape Town:
South African Community Epidemiology Network on Drug Use
(SACENDU); 2015.
161 Reddy P, James S, Sewpaul R, Yach D, Resnicow K, Sifunda
S, et al. A decade of tobacco control: The South African case
of politics, health policy, health promotion and behaviour
change. S Afr Med J. 2013;103(11):835–40.
162 Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-
Lindgren L, Thomson B, et al. Smoking prevalence and
cigarette consumption in 187 countries, 1980–2012. JAMA.
2014;311(2):183–92.
163 World Health Organization. WHO Report on the Global
Tobacco Epidemic, 2015. Raising taxes on tobacco. Geneva:
World Health Organization; 2015.
164 World Health Organization. Global status report on alcohol
and health 2014. Geneva: World Health Organization;
2014.
165 Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H,
Mullany EC, et al. The global burden of injury: incidence,
mortality, disability-adjusted life years and time trends
from the Global Burden of Disease Study 2013. Inj Prev.
2016;22(1):3–18.
166 Toroyan T. Global status report on road safety 2015. Geneva:
World Health Organization; 2015.
167 Road Traffic Management Corporation. Road Traffic
Management Corporation Annual Report 2014–2015.
Pretoria: Road Traffic Management Corporation; 2015.
 Health and Related Indicators

168 Statistics South Africa. Victims of Crime Survey 2014/15.
Statistical release P0341. Pretoria: Statistics SA; 2015.
169 Prinsloo M, Matzopoulos R, Laubscher R, Myers J, Bradshaw
D. Validating homicide rates in the Western Cape Province,
South Africa: Findings from the 2009 Injury Mortality Survey.
S Afr Med J. 2016;106(2):193–5.
170 Matzopoulos R, Prinsloo M, Pillay-van Wyk V, Gwebushe
N, Mathews S, Martin LJ, et al. Injury-related mortality in
South Africa: a retrospective descriptive study of postmortem
investigations. Bull World Health Organ. 2015;93(5):303–
13.
171 Road Traffic Management Corporation. Road Traffic Report
31 December 2010. Pretoria: Road Traffic Management
Corporation; 2011.
URL: http://www.rtmc.co.za
172 Arrive Alive. [Internet] South Africa [cited 9 March 2016].
184 Bateman C. Managing the fiscal beast – admin-to-clinician
ratio now 3:1. S Afr Med J. 2016;106(2):131.
185 Van der Merwe LJ, Van Zyl GJ, St Clair Gibson A, Viljoen M,
Iputo JE, Mammen M, et al. South African medical schools:
Current state of selection criteria and medical students’
demographic profile. S Afr Med J. 2015;106(1):76.
186 South African Pharmacy Council (SAPC). Statistics for
registered persons and organisations. Pretoria: SAPC; time
series [cited 9 March 2016].
URL: http://sapc.za.org/B_Statistics.asp
187 Health Professions Council of South Africa (HPCSA). HPCSA
Statistics. South Africa: HPCSA; time series.
URL: http://www.hpcsa.co.za/
188 Personnel and Salary Information System (PERSAL) [database
on the Internet]. National Treasury – Vulindlela. time series
[cited 30 April 2015].

URL: http://www.arrivealive.co.za/
173 Thom A, Low M, editors. NSP Review 13: Eastern Cape
Health. Still not a pretty picture. Cape Town: Treatment Action
Campaign (TAC) and Section27; 2015.
PM
URL: http://www.vulindlela.gov.za/
189 South African Nursing Council (SANC). Statistics of South
African Nursing Council. South Africa: SANC; time series
[cited 9 March 2016].

16 6
URL: http://www.sanc.co.za/stats.htm
174 South African Human Rights Commission. Access to

20 IL
Emergency Medical Services in the Eastern Cape Hearing 190 Jowett M, Kutzin J. Raising revenues for health in support of
Report. Durban: South African Human Rights Commission; UHC: strategic issues for policy makers. Health Financing
2015. Policy Brief No 1. Geneva: World Health Organization;
Y T 2015.
175 World Health Organization. A standards-driven approach to
improve the quality of health care services for adolescents. 191 Doherty J, McInytre D. #FeesMustFall and the campaign for
A N
Policy Brief. Geneva: World Health Organization; 2015. universal health coverage. S Afr Med J. 2015;105(12):1014.
176 World Health Organization (WHO) and Joint United Nations
M U

192 McIntyre D, Kutzin J. Health financing country diagnostic: a

Programme on HIV/AIDS (UNAIDS). Global standards foundation for national strategy development. Geneva: World
for quality health-care services for adolescents. Volume 1: Health Organization; 2016.
4 ED

Standards and criteria. Geneva: World Health Organization;

2015. 193 Foster N, Vassall A, Cleary S, Cunnama L, Churchyard G,
Sinanovic E. The economic burden of TB diagnosis and
177 Mahomed OH, Asmall S. Development and implementation of treatment in South Africa. Soc Sci Med. 2015;130:42–50.
an integrated chronic disease model in South Africa: lessons
O

in the management of change through improving the quality 194 Ataguba JE, Day C, McIntyre D. Full Case Study: Monitoring
of clinical practice. Int J Integr Care. 2015;15(Oct–Dec). and evaluating progress towards Universal Health Coverage
in South Africa. PLoS Med. 2014;11(9).
G

178 Kutzin J, Sparkes SP. Health systems strengthening, universal

health coverage, health security and resilience. Bull World 195 South African National Treasury. Provincial Budgets and
R

Health Organ. 2016;94(1):2. Expenditure Review 2010/11 – 2016/17. Pretoria: National

Treasury; 2015.
BA

179 Steinhobel R, Massyn N, Peer N. The Ideal Clinic Programme

N

2015/16. Durban: Health Systems Trust and South African 196 Council for Medical Schemes. Annual Report 2013/14.
National Department of Health; 2015. Protecting the interests of members. Promoting an accountable
O

industry. Pretoria: Council for Medical Schemes; 2014.

180 Treatment Action Campaign, Doctors without Borders/
EM

Medecins San Frontieres, Rural Health Advocacy Project,

Rural Doctors Association of Southern Africa, SECTION27,
Southern Africa HIV Clinician’s Society. Stock Outs in South
Africa. Second Annual Report. 2014 Stock Outs Survey. South
Africa: Treatment Action Campaign; 2015.
181 Willcox ML, Peersman W, Daou P, Diakite C, Bajunirwe F,
Mubangizi V, et al. Human resources for primary health care
in sub-Saharan Africa: progress or stagnation? Hum Resour
Health. 2015;13:76.
182 Labonte R, Sanders D, Mathole T, Crush J, Chikanda A,
Dambisya Y, et al. Health worker migration from South Africa:
causes, consequences and policy responses. Hum Resour
Health. 2015;13(1):92.
183 Rural Health Advocacy Project. Causes, implications and
possible responses to the implementation of staffing moratoria
in the public health system in South Africa during times of
budget austerity (Version 2). Johannesburg: RHAP; 2016
[cited 9 March 2016].
URL: http://www.rhap.org.za/wp-content/
uploads/2016/02/RHAP_Working_Paper_V2_Frozen_posts_
February_2016.pdf

S A H R 20 1 6 3 47
348
EM
BA
R
O G
N O
4 ED

S A H R 20 1 6
M U
A N
Y T
20 IL
16 6
PM
Abbreviations
A
AFFIRM The Africa Focus on Intervention research for Mental Health
AHPCSA Allied Health Professions Council of South Africa
AHS Annual Health Statistics
AIDS Aquired Immune Deficiency Syndrome
ALOS average length of stay
AMD acid mine drainage
AMRH African Medicines Regulatory Harmonization
AMS antimicrobial stewardship
ANC African National Congress
ANC antenatal care
application programming interface

PM
API
ART antiretroviral therapy/ treatment
ARVs antiretroviral drugs
B

16 6
BCEA Basic Conditions of Employment Act
BDCT Birth Defects Collection Tool

20 IL
BFHI Baby-Friendly Hospital Initiative
BMI body mass index
BPCP Breastfeeding Peer-Counselling Programme
BUR
C
bed utilisation rate
Y T
A N
CAIR Centre for Artificial Intelligence Research
M U

CCGs community caregivers

CDA Clinical Document Architecture
CDC Centers for Disease Control and Prevention
4 ED

CDs congenital disorders

CEWG Consultative Expert Working Group
CHCs community health centres
O

CHILD PIP Child Healthcare Problem Identification Program

CHITEP Community Health Interpreter Training and Employment Programme
G

CHW community health worker

CMS Council for Medical Schemes
R

COCs combined oral contraceptive pills

COHSASA Council for Health Service Accreditation of Southern Africa
BA

COIDA Compensation for Occupational Injuries and Diseases Amendment Act

CoMMiC Committee on Mortality and Morbidity in Children
O

COPC Community-Orientated Primary Care

EM

COPD chronic obstructive pulmonary disease

CPHM College of Public Health Medicine
CPI consumer price index
CPR Contraceptive Prevalence Rate
CSIR Council for Scientific and Industrial Research
CT computed tomography
CYP couple years of protection rate
D
DAASA Dental Assistants Association of South Africa
DAFF Department of Agriculture, Forestry and Fisheries
DALYs disability adjusted life-years
DAS WHO–Disability Assessment Scale
DCSTs District Clinical Specialist Teams
DEA Department of Environmental Affairs
DFID Department for International Development (United Kingdom)
DHIS District Health Information System
DHS district health system
DMPA or Depo depot medroxyprogesterone acetate
DoH Department of Health
DPH Doctors with Public Health diplomas

S A H R 20 1 6 3 49
DPME Department of Performance Monitoring and Evaluation
DSD Department of Social Development
DST Department of Science and Technology
DWS Department of Water and Sanitation
E
EBF exclusive breastfeeding
EEA Employment Equity Act
eHealth electronic health
EHOs Environmental health officers
EHS Employee Health Services
EIMC early infant male circumcision
EMERALD Emerging mental health systems in low- and middle-income countries
EML Essential Medicines List
EMS Emergency Medical Services
Ens enrolled nurses

PM
EPDS Edinburgh Postnatal Depression Scale
EPI Expanded Programme of Immunisation
EPWP Extended Public Works Programme
EU European Union

16 6
F
FAS fetal alcohol syndrome

20 IL
FFC Financial and Fiscal Commission
FHIR Fast Healthcare Interoperability Resources
Food-EPI Food Environment Policy IndexY T
FP2020 Family Planning 2020
A N
FPL food poverty line
G
M U

GDB Global Burden of Disease

GDP Gross Domestic Product
GEAR Growth, Employment and Redistribution
4 ED

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GFHR Global Forum for Health Research
GHS General Household Survey
O

GNI Gross National Income

GPP Good Pharmacy Practice
G

H
HAI Health Action International
R

HALE healthy life expectancy

HCT HIV counselling and testing
BA

HDU High Dependency Unit

HE2RO Health Economics and Epidemiology Research Office
O

HeAL Health Architecture Laboratory

EM

HiAP Health-in-All Policies

HIE health information exchange
HISPSA Health Information Systems Programme, South Africa
HIV Human Immunodeficiency Virus
HL7 Health Level Seven
HNSF Health Normative Standards Framework
HPCSA Health Professions Council of South Africa
HPF Health Promotion Foundation
HRH human resources for health
HRM Human Resource Management
HRM Health Risk Manager
HST Health Systems Trust
HTA health technology assessment
HWS Health Workers Society
I
IALCH Inkosi Albert Luthuli Central Hospital
IBBS integrated HIV biological behavioural surveillance
ICER incremental cost-effectiveness ratio
ICF Inner City Fund
ICTs information and communication technologies

35 0 S A H R 20 1 6
 Abbreviations

ICU intensive care unit

IES Income and Expenditure Survey
IGFR Intergovernmental Relations and Fiscal Arrangements
IGME Inter-agency Group for Child Mortality Estimation
IHE Integrating the Healthcare Enterprise
IHME Institute for Health Metrics and Evaluation
IHR International Health Regulations
IMCI Integrated Management of Childhood Illness
IMF International Monetary Fund
IMR infant mortality rate
INFORMAS International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support
INP Integrated Nutrition Programme
IOM International Organization for Migration
IOM Institute of Medicine
IPT isoniazid preventive therapy

PM
IPTp Intermittent preventive therapy for malaria during pregnancy
IRS indoor residual spraying
ISCOLE International Study of Childhood Obesity, Lifestyle and the Environment
ISS Injury severity score

16 6
IUCD intrauterine contraceptive device
IYCF infant and young child feeding

20 IL
IYCN infant and young child nutrition
J
JMP Joint Monitoring Project Y T
JSON JavaScript Object Notation
A N
K
KMC Kangaroo Mother Care
M U

KZN KwaZulu-Natal
L
LBPL lower-bound poverty line
4 ED

LCBOs low cost benefit options

LMICs low and middle-income countries
LRA Labour Relations Act
O

M
M&E monitoring and evaluation
G

MAC Ministerial Advisory Committee

MAMA Mobile Alliance for Maternal Action
R

MBFI Mother-Baby-Friendly Initiative

MCC Medicines Control Council
BA

MD mean difference
MDB Municipal Demarcation Board
O

MDG Millennium Development Goal

EM

MDR-TB multidrug-resistant tuberculosis

MEDUNSA Medical University of South Africa
MFII Multidimensional Food Insecurity Index
MGEP Medical Genetics Education Programme
MHD Mobile Access to Health Document
mHealth mobile health
mHM mobile maternal health
MI-PST motivational interviewing and problem-solving therapy
MLICs middle and low-income countries
MMC medical male circumcision
Mmed Master of Medicine
mMH mobile maternal health
MMR maternal mortality ratio
MNCH Maternal, Newborn and Child Health
MNCWH Maternal, Newborn, Child and Women’s Health
MNOs Mobile Network Operators
MNS mental health, neurological and substance use disorders
MOH Medical Officer of Health
MOI mechanism of injury
MOU Midwife Obstetric Unit

S A H R 20 1 6 35 1
MPH Master of Public Health
MPI master patient index
MPI Multidimensional Poverty Index
MRC Medical Research Council
MSDs musculoskeletal disorders
MSP multiple sexual partners
MTCT mother-to-child transmission of HIV
MTEF Medium-term Expenditure Framework
N
NACOSA Networking HIV and AIDS Community of South Africa
NAMDA National Medical and Dental Association
NaPeMMCo National Perinatal Mortality and Morbidity Committee
NAPHISA National Public Health Institute of South Africa
NCCEMD National Committee on Confidential Enquiries into Maternal Deaths
NCD non-communicable disease

PM
NCS National Core Standards
NDoH National Department of Health
NDP National Development Plan
Net-EN norethisterone enanthate

16 6
NGO non-governmental organisation
NHA National Health Act

20 IL
NHI National Health Insurance
NHIS National Health Information Systems
NHLS National Health Laboratory Service
Y T
NHRC National Health Research Committee
A N
NHRD National Health Research Database
NHRO National Health Research Observatory
M U

NHS National Health Service

NICD National Institute for Communicable Diseases
NICE National Institute for Health Care and Excellence
4 ED

NIDS National Indicator Data Set

NiDS National Income Dynamics Study
NIV National Institute of Virology
O

NLP National Language Project

NMR neonatal mortality rate
G

NNDR neonatal death rate

NNMR neonatal mortality rate
R

NPBSA Normalise Public Breastfeeding in South Africa

NPPHCN National Progressive Primary Health Care Network
BA

NRF National Research Foundation

NTDs neural tube defects
O

NWA National Water Act

EM

O
OASSSA Organisation of Appropriate Social Services in South Africa
OECD Organisation for Economic Co-operation and Development
OHSC Office of Health Standards Compliance
ORS oral rehydration solution
OSD Occupation-specific Dispensation
OSS Operation Sukuma Sakhe
P
PC101 Primary Care 101
PCC Presidential Coordination Committee
PDD Principles for Digital Development
PEPFAR United States President’s Emergency Plan for AIDS Relief
PFIP Partnership Framework Implementation Plan
PGWC Provincial Government of the Western Cape
PH public health
PHC primary health care
PHCP Primary Health Care Providers
PHEIC Public Health Emergency of International Concern
PHM Public Health Medicine
PILIR Policy and procedure on Incapacity Leave and Ill-health Retirement

352 S A H R 20 1 6
 Abbreviations

PMBs Prescribed Minimum Benefits

PMDF proportion of deaths among females of reproductive age
PMHP Perinatal Mental Health Project
PMTCT prevention of mother-to-child transmission of HIV
PN professional nurse
PNMR perinatal mortality rate
PPIP Perinatal Problem Identification Programme
PrEP pre-exposure prophylaxis
PRICELESS SA Priority Cost-effective Lessons for System Strengthening South Africa
PRIME Programme for Improving Mental Health Care
PSA Public Service Act
PSCBC Public Service Co-ordinating Bargaining Council
PSF Brazilian Family Health Programme
R
R&D research and development

PM
RCT randomised controlled trial
RDP Reconstruction and Development Programme
RDT rapid diagnostic tests
RECs Regional Economic Communities

16 6
RHAP Rural Health Advocacy Project
RIMS Road Incident Management System

20 IL
RIMS Research Information Management System
RMS Rapid Mortality Surveillance
RTMC Road Traffic Management Corporation
Y T
S
A N
SA South Africa
SACENDU South African Community Epidemiology Network on Drug Use
M U

SADA South African Dental Association

SADC Southern African Development Community
SADHS South Africa Demographic and Health Survey
4 ED

SAG South African Government

SAGE Study on Global Ageing and Adult Health
SAHPRA South African Health Products Regulatory Authority
O

SAID South African National Identifier

SAMA South African Medical Association
G

SAMDC South African Medical and Dental Council

SANAC South African National AIDS Council
R

SANHANES South African National Health and Nutrition Examination Surveys

SANS South African National Standard
BA

SASH South African Stress and Health

SASPRI South Africa Social Policy Research Institute
O

SBCC Social and behaviour change communication

EM

SDG Sustainable Development Goal

SEP Single Exit Price
SES socio-economic status
SHR shared health record
SMS Short Message Service
SATI South African Translators’ Institute
SRH sexual and reproductive health
STAs scientific and technological activities
STIs sexually transmitted infections
STRIVE Substance use and TRauma InterVEntion
SU Stellenbosch University
SW NSP National Strategic Plan for HIV Prevention, Care and Treatment for Sex Workers
T
TAC Treatment Action Campaign
TB tuberculosis
TE technical efficiency
TFR total fertility rate
THO Traditional Healers Organisation
THPs traditional health practitioners
TMs traditional medicines

S A H R 20 1 6 353
ToPs terminations of pregnancy
TSSA Trauma Society of South Africa
TST Test test for latent TB
U
U5MR under-5 mortality rate
UBPL upper-bound poverty line
UCT University of Cape Town
UHC universal health coverage
UK United Kingdom
UKZN University of KwaZulu-Natal
UMIC upper middle-income countries
UN United Nations
UNAIDS United Nations Programme on HIV and AIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund

PM
UN-Habitat United Nations Human Settlements Programme
UNICEF United Nations Children’s Fund
UPFS Uniform Patient Fee Schedule
US United States

16 6
USAID United States Agency for International Development
USSD Unstructured Supplementary Service Data

20 IL
UTT universal test-and-treat
V
VAT
VOCS
Value Added Tax
Victims of Crime Survey
Y T
A N
W
WBOTs Ward-based Outreach Teams
M U

WC Western Cape
WC DoH Western Cape Department of Health
4 ED

WHA World Health Assembly

WHO World Health Organization
WHR waist-hip ratio
WiCE Wits Centre for Ethics
O

X
XDR-TB extensively drug-resistant tuberculosis
G

Y
YLD years lived with disability
R

YLLs years of life lost

Z
BA

ZAR South African Rand

O
EM

35 4 S A H R 20 1 6
 PM
For more information:

16 6
20 IL
Web: http://www.hst.org.za
Email: webmaster@hst.org.za
Y T
A N
M U

Or contact one of our offices:

4 ED

Durban (Head office)

34 Essex Terrace, Westville, 3630
Tel: +27 (0)31 266 9090
O

Fax: +27 (0)31 266 9199

G

Johannesburg
R

1st Floor, Block J, Central Park,

BA

400 16th Road, Midrand, 1682

O

Tel: +27 (0)11 312 4524/23

EM

Fax: +27 (0)11 312 4525

Cape Town
Block B, Aintree Office Park,
Doncaster Road, Kenilworth, 7700
Tel: +27 (0)21 762 0700
Fax: +27 (0)21 762 0701