Last year a group of health experts published a book on the achievements and challenges of the South Africa health system entitled “South African Health Reform, 2015-2020 – the road ahead”. More than 70 South African authors contributed to the 20 chapters included in the book. The book reviews the five-year period that includes the outbreak of the Covid-19 pandemic and is a follow-on to the previous publication that reviewed the period 2010-2014.

A review of the rights and wrongs of the health system is timely as we go into the last year of the current administration and into electioneering ahead of the 2024 national and provincial elections. While many commentators have lamented the poor quality of care provided by the public health system and the high cost of the private health system as well as the inequities in the health sector, there are many positives that the next administration can build on and many areas that need razor-sharp focus and reconstruction. 

The book highlights both the achievements over the past five years and the work needed to strengthen the health sector. In its concluding chapter, the editors make 34 recommendations. Some of these are highlighted in this article.

The cover of “South African Health Reform, 2015-2020 – the road ahead”. (Photo: samj / Wikipedia)

Impact of Covid on health

Prior to the onset of the Covid-19 pandemic, there were significant improvements in maternal and child mortality as well as a significant increase in the number of people living with HIV that were on life-saving antiretroviral therapy. Life expectancy for men increased from 60.2 years in 2015 to 62.5 years by 2020 and for the same period from 64.3 years to 68.5 years for women. 

However, the Covid-19 pandemic has resulted in some declines — for males this was to 59.3 in 2021 and for females to 64.6. The in-facility maternal mortality ratio also declined from 105.7 deaths per 100,000 live births in 2017 to 88 by March 2020 — again increasing in 2020/21 due to Covid-associated deaths by as much as 30% compared to 2019. 

The infant (IMR) and child (under five) mortality rates also declined between 2015 and 2020. The IMR declined from 28/1000 live births to 21/1000 and the under-five deaths declined from 39/1000 to 28/1000. 

Many of the positive trends will have been affected by the impact of the Covid-19 pandemic such as disruptions in health service provision. In addition to the immediate impact on health, the longer-term impact will come through worsening determinants of health, such as poverty, inequality, unemployment, pandemics, natural disasters and education.

The Department of Health should develop guidelines for provinces and districts on creating consultative engagements for sub-national government stakeholders. These could build on structures and processes that were developed to deal with Covid-19 with documented best practices and many innovations by provincial health departments.

The governance weaknesses in PHC need to be tackled by the formulation of a more coherent sub-district system, meaningful community engagement and empowerment, accompanied by a commitment to establishing stable, skilled and public-interested leadership in PHC and district health systems.

Of great concern is the inadequate uptake of contraceptives and the increasing number of teenage pregnancies. The crisis of teen pregnancies requires a holistic all-of-society response and not merely health sector intervention. 

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The contribution of non-communicable disease (NCDs) to the overall burden of disease now outstrips the contribution of communicable diseases. High-level political support and additional funding are required to implement the recently adopted National Strategic plan for NCDs. It is also now critical to treat HIV as a long-term chronic disease and to integrate HIV programmes with other conditions and programmes in a more patient-centred approach. 

The significant increase in the unmet need for mental health services requires additional funding to provide required services. The mental health treatment gap is 92% — meaning that only 8% of those who need treatment received care. The Department needs to scale up community mental health services in collaboration with other government departments and with community-based organisations. 

Capacity and quality

An overarching coordinated national commitment is required for quality improvement and continuous learning, both in the clinical and corporate management of hospital-level services. The urgent implementation of the quality improvement (QI) strategy should involve engaging all stakeholders, including frontline health workers, civil society and the many current quality-of-care role players who operate within separate health programmes or sectors.

Capacity to deliver healthcare infrastructure must be strengthened either by improving the required staffing capacity in the various Departments of Public Works across the provinces or by moving the function to provincial departments of health along with the necessary capacity. Similarly, the skills and competencies of managers at all levels but especially in public hospitals, district offices and primary health care facilities need urgent strengthening in line with their delegations. 

The passage of the NHI Bill should be fast-tracked alongside strengthening the capacity for its implementation. The government should urgently implement the recommendations of the Health Market Inquiry and advocate for greater multi-sector engagement

A more seamless health service for all requires the national/provincial and province/province interfaces to have specific attention. This could be through co-creating a health governance charter that clarifies the values underpinning this interface, the roles of various actors, the spaces of engagement, and forms of reciprocal accountability. As the country implements NHI, a similar governance charter with the private health sector will also be required. 

Provincial and District Health Councils should be opened beyond current mandates as spaces for engagement with civil society, in addition to strengthening the functionality of clinic committees and hospital boards. At present these committees are merely advisory and have no power to intervene. Lessons from the functioning of school governing bodies may be useful guidance on how to strengthen these structures. 

The National Department should strengthen data governance, including norms and standards for the public release of data to achieve greater transparency and better use of existing data. The Department should invest in systems that make it possible to track patients and access more timely feedback across the health system. As seen during the Covid pandemic the use of data to inform the public and to engage them in seeking solutions to health challenges is powerful. 

The authors argue that while government stewardship is critical active citizenry is required to keep the government accountable. (Photo: Rosetta Msimango /Spotlight)

The health information system needs to be urgently strengthened with both electronic patient medical records and an improved surveillance system. The former will strengthen clinical governance and the latter epidemic and pandemic preparedness and response. 

The National Department of Health should coordinate efforts from all stakeholders across national government to support the implementation of human resources for health plans effectively. This would be helped by the urgent implementation of the Human Resources for Health Strategy and the establishment of a functional National Health Workforce Analysis and Planning Unit drawing on expert workforce planning expertise, and utilising data science opportunities for more predictive and intelligent analytics and decisions. 

The government should continue to expand intersectoral collaboration to both address the social and commercial determinants of health and to improve the effectiveness of health services. All actors in the health landscape should be cognisant of actions needed to unblock bottlenecks 

While government stewardship is critical it is not only the government but also an active citizenry that is required to keep the government accountable in all spheres.

The editors and authors of the South African Health Reforms, 2015-2020, believe that if these recommendations are implemented by government, in partnership with its stakeholders, the health system of the country can be rapidly strengthened. If this effort also addresses the social and commercial determinants of health (including the impact of inequity), health outcomes too will significantly improve for all those living in South Africa. DM/MC

Yogan Pillay (Department of Global Health, Stellenbosch University); Robert (Bob) Fryatt (Lead, International Health, Mott MacDonald), Precious Matsoso (Wits Health Consortium, University of the Witwatersrand); Usuf Chikte (Department of Global Health, Stellenbosch University), Lindiwe Makubalo (World Health Organisation, Africa Region)