Peter Barron

The health and health system of South Africa: historical roots of current public health challenges

The roots of a dysfunctional health system and the collision of the epidemics of communicable and non-communicable diseases in South Africa can be found in policies from periods of the countrys history, from colonial subjugation, apartheid dispossession, to the post-apartheid period. Racial and gender discrimination, the migrant labour system, the destruction of family life, vast income inequalities, and extreme violence have all formed part of South Africas troubled past, and all have inexorably affected health and health services. In 1994, when apartheid ended, the health system faced massive challenges, many of which still persist. Macroeconomic policies, fostering growth rather than redistribution, contributed to the persistence of economic disparities between races despite a large expansion in social grants. The public health system has been transformed into an integrated, comprehensive national service, but failures in leadership and stewardship and weak management have led to inadequate implementation of what are often good policies. Pivotal facets of primary health care are not in place and there is a substantial human resources crisis facing the health sector. The HIV epidemic has contributed to and accelerated these challenges. All of these factors need to be addressed by the new government if health is to be improved and the Millennium Development Goals achieved in South Africa.

Achieving the health Millennium Development Goals for South Africa: challenges and priorities

15 years after liberation from apartheid, South Africans are facing new challenges for which the highest calibre of leadership, vision, and commitment is needed. The effect of the unprecedented HIV/AIDS epidemic has been immense. Substantial increases in mortality and morbidity are threatening to overwhelm the health system and undermine the potential of South Africa to attain the Millennium Development Goals (MDGs). However The Lancets Series on South Africa has identified several examples of leadership and innovation that point towards a different future scenario. We discuss the type of vision, leadership, and priority actions needed to achieve such a change. We still have time to change the health trajectory of the country, and even meet the MDGs. The South African Government, installed in April, 2009, has the mandate and potential to address the public health emergencies facing the country--will they do so or will another opportunity and many more lives be lost?

Laboratory information system data demonstrate successful implementation of the prevention of mother-to-child transmission programme in South Africa

BACKGROUND Monitoring the prevention of mother-to-child transmission (PMTCT) programme to identify gaps for early intervention is essential as South Africa progresses from prevention to elimination of HIV infection in children. Early infant diagnosis (EID) by an HIV polymerase chain reaction (PCR) test is recommended at 6 weeks of age for all HIV-exposed infants. The National Health Laboratory Service (NHLS) performs the PCR tests for the public health sector and stores test data in a corporate data warehouse (CDW). OBJECTIVES To demonstrate the utility of laboratory data for monitoring trends in EID coverage and early vertical transmission rates and to describe the scale-up of the EID component of the PMTCT programme. METHODS HIV PCR test data from 2003 to 2012 inclusive were extracted from the NHLS CDW by year, province, age of infant tested and test result and used to calculate EID coverage and early vertical transmission rates to provincial level. RESULTS Rapid scale-up of EID over the first decade of the PMTCT programme was evident from the 100-fold increase in PCR tests to 350 000 by 2012. In 2012, 73% of the estimated 270 000 HIV-exposed infants requiring an early PCR were tested and the early vertical transmission rate had fallen to 2.4% as a result of successful implementation of the PMTCT programme. CONCLUSIONS Laboratory data can provide real time, affordable monitoring of aspects of the PMTCT programme and assist in achieving virtual elimination of paediatric HIV infection in South Africa.

Elimination of mother-to-child transmission of HIV in South Africa : rapid scale-up using quality improvement

BACKGROUND South Africa (SA) is committed to achieving the goal of eliminating mother-to-child transmission (MTCT) of HIV by 2015. To achieve this, universal coverage of quality antenatal, labour, delivery and postnatal services for all women has to be attained. Over the past decade, the prevention of mother-to-child transmission (PMTCT) programme has been scaled up to reach all healthcare facilities in the country. However, challenges persist in achieving 100% coverage and access to the programme. OBJECTIVES We describe the process undertaken by the National Department of Health (NDoH), in collaboration with partners, to develop, implement and monitor a data-driven intervention to improve facility, district, provincial and national PMTCT-related performance. METHODS Between 2011 and 2013, the NDoH developed and implemented an intervention using data-driven participatory processes to understand facility-level bottlenecks to optimise PMTCT implementation and to scale up priority PMTCT actions nationally. RESULTS There was remarkable improvement across all key indicators in the PMTCT cascade over the 3 years 2011-2013. Simple monitoring tools such as a visual dashboard and data for action reports were successfully used to improve the performance of the PMTCT programme across SA. MTCT has shown a significant downward trend. CONCLUSIONS It is feasible to implement district-level, data-driven quality improvement processes at a national scale to improve the performance of the PMTCT programme at the local level.

Cost and impact of scaling up interventions to save lives of mothers and children: taking South Africa closer to MDGs 4 and 5.

Background South Africa has made substantial progress on child and maternal mortality, yet many avoidable deaths of mothers and children still occur. This analysis identifies priority interventions to be scaled up nationally and projects the potential maternal and child lives saved. Design We modelled the impact of maternal, newborn and child interventions using the Lives Saved Tools Projections to 2015 and used realistic coverage increases based on expert opinion considering recent policy change, financial and resource inputs, and observed coverage change. A scenario analysis was undertaken to test the impact of increasing intervention coverage to 95%. Results By 2015, with realistic coverage, the maternal mortality ratio (MMR) can reduce to 153 deaths per 100,000 and child mortality to 34 deaths per 1,000 live births. Fifteen interventions, including labour and delivery management, early HIV treatment in pregnancy, prevention of mother-to-child transmission and handwashing with soap, will save an additional 9,000 newborns and children and 1,000 mothers annually. An additional US

HIV and Tuberculosis in Prisons in Sub-Saharan Africa

370 million (US

The role of quality improvement in achieving effective large-scale prevention of mother-to-child transmission of HIV in South Africa.

7 per capita) will be required annually to scale up these interventions. When intervention coverage is increased to 95%, breastfeeding promotion becomes the top intervention, the MMR reduces to 116 and the child mortality ratio to 23. Conclusions The 15 interventions identified were adopted by the National Department of Health, and the Health Minister launched a campaign to encourage Provincial Health Departments to scale up coverage. It is hoped that by focusing on implementing these 15 interventions at high quality, South Africa will reach Millennium Development Goal (MDG) 4 soon after 2015 and MDG 5 several years later. Focus on HIV and TB during early antenatal care is essential. Strategic gains could be realised by targeting vulnerable populations and districts with the worst health outcomes. The analysis demonstrates the usefulness of priority setting tools and the potential for evidence-based decision making in the health sector.Background South Africa has made substantial progress on child and maternal mortality, yet many avoidable deaths of mothers and children still occur. This analysis identifies priority interventions to be scaled up nationally and projects the potential maternal and child lives saved. Design We modelled the impact of maternal, newborn and child interventions using the Lives Saved Tools Projections to 2015 and used realistic coverage increases based on expert opinion considering recent policy change, financial and resource inputs, and observed coverage change. A scenario analysis was undertaken to test the impact of increasing intervention coverage to 95%. Results By 2015, with realistic coverage, the maternal mortality ratio (MMR) can reduce to 153 deaths per 100,000 and child mortality to 34 deaths per 1,000 live births. Fifteen interventions, including labour and delivery management, early HIV treatment in pregnancy, prevention of mother-to-child transmission and handwashing with soap, will save an additional 9,000 newborns and children and 1,000 mothers annually. An additional US

Valuing human resources: Key to the success of a national health insurance system

370 million (US

Cost and Impact of Voluntary Medical Male Circumcision in South Africa: Focusing the Program on Specific Age Groups and Provinces

7 per capita) will be required annually to scale up these interventions. When intervention coverage is increased to 95%, breastfeeding promotion becomes the top intervention, the MMR reduces to 116 and the child mortality ratio to 23. Conclusions The 15 interventions identified were adopted by the National Department of Health, and the Health Minister launched a campaign to encourage Provincial Health Departments to scale up coverage. It is hoped that by focusing on implementing these 15 interventions at high quality, South Africa will reach Millennium Development Goal (MDG) 4 soon after 2015 and MDG 5 several years later. Focus on HIV and TB during early antenatal care is essential. Strategic gains could be realised by targeting vulnerable populations and districts with the worst health outcomes. The analysis demonstrates the usefulness of priority setting tools and the potential for evidence-based decision making in the health sector.

Can disease control priorities improve health systems performance in South Africa

Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.