For The Lancet South Africa team: Health in South Africa: changes and challenges since 2009

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
The Lancet (Impact Factor: 45.22). 12/2012; 380(9858):2029-2043. DOI: 10.1016/S0140-6736(12)61814-5


Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the world's largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.

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    • "Whilst this is the largest study that has comprehensively evaluated several diagnostic strategies and tools in the same prospective cohort, the sample size was limited in the non-TB group. The small number of non-TB patients reflects the high burden of infectious and HIV-related disease in the South African environment [27]. Although the use of a combined reference standard may introduce a minor degree of selection bias, this consideration is outweighed by the avoidance of misclassification bias when using a culture only reference (data provided in the online supplementary materials). "
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    ABSTRACT: Tuberculous pericarditis (TBP) is associated with high morbidity and mortality, and is an important treatable cause of heart failure in developing countries. Tuberculous aetiology of pericarditis is difficult to diagnose promptly. The utility of the new quantitative PCR test (Xpert MTB/RIF) for the diagnosis of TBP is unknown. This study sought to evaluate the diagnostic accuracy of the Xpert MTB/RIF test compared to pericardial adenosine deaminase (ADA) and unstimulated interferon-gamma (uIFNγ) in suspected TBP. From October 2009 through September 2012, 151 consecutive patients with suspected TBP were enrolled at a single centre in Cape Town, South Africa. Mycobacterium tuberculosis culture and/or pericardial histology served as the reference standard for definite TBP. Receiver-operating-characteristic curve analysis was used for selection of ADA and uIFNγ cut-points. Of the participants, 49% (74/151) were classified as definite TBP, 33% (50/151) as probable TBP and 18% (27/151) as non TBP. A total of 105 (74%) participants were human immunodeficiency virus (HIV) positive. Xpert-MTB/RIF had a sensitivity and specificity (95% confidence interval (CI)) of 63.8% (52.4% to 75.1%) and 100% (85.6% to 100%), respectively. Concentration of pericardial fluid by centrifugation and using standard sample processing did not improve Xpert MTB/RIF accuracy. ADA (≥35 IU/L) and uIFNγ (≥44 pg/ml) both had a sensitivity of 95.7% (88.1% to 98.5%) and a negative likelihood ratio of 0.05 (0.02 to 0.10). However, the specificity and positive likelihood ratio of uIFNγ was higher than ADA (96.3% (81.7% to 99.3%) and 25.8 (3.6 to 183.4) versus 84% (65.4% to 93.6%) and 6.0 (3.7 to 9.8); P = 0.03) at an estimated background prevalence of TB of 30%. The sensitivity and negative predictive value of both uIFNγ and ADA were higher than Xpert-MT/RIF (P < 0.001). uIFNγ offers superior accuracy for the diagnosis of microbiologically confirmed TBP compared to the ADA assay and the Xpert MTB/RIF test.
    BMC Medicine 06/2014; 12(1):101. DOI:10.1186/1741-7015-12-101 · 7.25 Impact Factor
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    • "In South Africa, two decades after apartheid, an inclusive, equitable society remains elusive. High levels of poverty, inequality, unemployment and “everyday suffering” [20-22] persist [5,22,23]. Barriers to inclusive health care include high transport costs, large distances to services [24], and a public sector that services 85% of the population with just 56% of health expenditure [25]. Rude, dismissive, sometimes abusive, provider actions have also been documented [26,27] and the health system remains fragmented and “dysfunctional” [5] characterized by weak stewardship, a human resource crisis, and limited financial, technical and administrative capacity [5,28]. "
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    ABSTRACT: Background As in many fragile and post-conflict countries, South Africa’s social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting. Methods Using in-depth interviews with 45 patients and 67 providers, and field observations from twelve health facilities in one rural and two urban sub-districts, we explore access narratives of those seeking and delivering – negotiating - maternal health, tuberculosis and antiretroviral services in South Africa. Results Although South Africa’s right to access to health care is constitutionally guaranteed, in practice, a post-apartheid health care contract is not automatically or unconditionally inclusive. Access barriers, including poverty, an under-resourced, hierarchical health system, the nature of illness and treatment, and negative attitudes and actions, create conditions for insecure or adverse incorporation into this contract, or even exclusion (sometimes temporary) from health care services. Such barriers are exacerbated by differences in the expectations that patients and providers have of each other and the contract, leading to differing, potentially conflicting, identities of inclusion and exclusion: defaulting versus suffering patients, uncaring versus overstretched providers. Conversely, caring, respectful communication, individual acts of kindness, and institutional flexibility and leadership may mitigate key access barriers and limit threats to the contract, fostering more positive forms of inclusion and facilitating easier access to health care. Conclusions Building health in fragile and post-conflict societies requires the negotiation of a new social contract. Surfacing and engaging with differences in patient and provider expectations of this contract may contribute to more acceptable, accessible health care services. Additionally, the health system is well positioned to highlight and connect the political economy, institutions and social relationships that create and sustain identities of exclusion and inclusion – (re)politicise suffering - and co-ordinate and lead intersectoral action for overcoming affordability and availability barriers to inclusive and equitable health care services.
    Globalization and Health 05/2014; 10(1):35. DOI:10.1186/1744-8603-10-35 · 2.25 Impact Factor
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    • "Foremost among these was the unmoveable legacy of the apartheid health system, one characterised by a strong emphasis on curative and institutional care, the favouring of private health care in government policy, and the rigidly entrenched race- and class-based divisions present within both the provider and the clientele components of the system. However, several commentators [30,31,36,38,75-84] have in recent years attributed this lack of progress to deficiencies and failures in the post-1994 reform process itself. These are summarised by Van Rensburg and Engelbrecht [25] as follows: first, the introduction of the district-based PHC system - as the main lever with which to effect an equitable health dispensation - did not live up to high expectations; second, PHC was implemented rather selectively, with little regard for the original comprehensive approach, and health was narrowly pursued as health care by government and by the health departments, while there was only limited community involvement; third, gaps or disconnects between policy/plans and policy implementation assumed chronic proportions in the public health sphere; fourth, more and more evidence was tabled that the fundamental flaws in the national health system also lay in inadequate stewardship, poor leadership and a lack of management capacity at all levels of the system; fifth, it became clear that the health system’s performance was not commensurate with the huge investments that were being made. "
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    ABSTRACT: The purpose of this contribution is to analyse and explain the South African HRH case, its historical evolution, and post-apartheid reform initiatives aimed at addressing deficiencies and shortfalls. HRH in South Africa not only mirrors the nature and diversity of challenges globally, but also the strategies pursued by countries to address these challenges. Although South Africa has strongly developed health professions, large numbers of professional and mid-level workers, and also well-established training institutions, it is experiencing serious workforce shortages and access constraints. This results from the unequal distribution of health workers between the well-resourced private sector over the poorly-resourced public sector, as well as from distributional disparities between urban and rural areas. During colonial and apartheid times, disparities were aggravated by policies of racial segregation and exclusion, remnants of which are today still visible in health-professional backlogs, unequal provincial HRH distribution, and differential access to health services for specific race and class groups. Since 1994, South Africa’s transition to democracy deeply transformed the health system, health professions and HRH establishments. The introduction of free-health policies, the district health system and the prioritisation of PHC ensured more equal distribution of the workforce, as well as greater access to services for deprived groups. However, the HIV/AIDS epidemic brought about huge demands for care and massive patient loads in the public-sector. The emigration of health professionals to developed countries and to the private sector also undermines the strength and effectiveness of the public health sector. For the poor, access to care thus remains constrained and in perpetual shortfall. The post-1994 government has introduced several HRH-specific strategies to recruit, distribute, motivate and retain health professionals to strengthen the public sector and to expand access and coverage. Of great significance among these is the NHI Plan that aims to bridge the structural divide and to redistribute material and human resources more equally. Its success largely hinges on HRH and the balanced deployment of the national workforce. Low- and middle-income countries have much to learn from South African HRH experiences. In turn, South Africa has much to learn from other countries, as this case study shows.
    Human Resources for Health 05/2014; 12(1):26. DOI:10.1186/1478-4491-12-26 · 1.83 Impact Factor
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