South Africa

This programme addresses the Expanded Programme on Immunization, vaccine preventable disease surveillance (Acute Flacid Paralysis, measles, neonatal tetanus) and surveillance of adverse events following immunization.

National Professional Officer: Dr Mercy Kamupira
Kamupiram@who.int

 Country Brief printable version [pdf: 267.42 kB]

Country Brief: Expanded Program on Immunisation and Vaccine Preventable Disease surveillance 

Demographics

Table 1. Vaccination Coverage (%)

There are 11 antigens on the SA national immunization schedule. These are against polio, measles, tuberculosis, diphtheria, pertussis, tetanus, haemophilus influenza type b, hepatitis B, rotavirus and pneumococcal infection and the human papilloma virus. Immunization is offered free of charge in all public facilities.  The HPV vaccine is administered via the integrated school health program. In 2015 government spent R1,500,100,000 (about US$96,774,193) in vaccine purchases. This excludes operational costs of the EPI program. There is ongoing monitoring of immunization coverage indicators at all levels. Immunization coverage (FIC) was 91.7% in 2015 (Table 1). Strategies such as the Reach Every Community (REC) strategy are being implemented to address areas of low coverage.  The national advisory group on immunization (NAGI) provides technical advice to the MOH on immunization issues.

Achievements

South Africa has achieved neonatal tetanus elimination as validated by the World Health Organization in 2002.  In 2006, SA was pre-certified polio-free by the Africa Regional Certification Committee. Acute flaccid paralysis surveillance is ongoing with optimal performance at national level (Figures 1 & 2) though district level disaggregation indicates some underperformance in some districts. The National Institute of Communicable Disease houses both the regional reference laboratories for measles and polio.

Challenges

Though access to and utilization of immunization services is generally high; there are still a number of under-immunised children in SA. Sporadic vaccine stock-outs highlight the need to strengthen vaccine supply chain management especially at the lower levels. 

Data quality issues (both numerator and denominator inaccuracies) affect the interpretation of immunization coverage data resulting in discrepancies of over 15% between the WHO/UNICEF estimates of national immunization coverage and the country official estimates.

Key issues

·     The DOH Annual Performance Plan (APP) monitors 4 EPI indicators namely: the Fully Immunized Coverage (Target: 95% in 2019/20); DPT3 containing vaccine to measles first dose dropout rate (Target: <5%), measles incidence per million population (target <1/million total population) and measles second dose (Target: 90% in 2019/20). These indicators are monitored quarterly at all levels. While this is commendable, it is important to note that the quality of immunization and surveillance data is key to effective program performance monitoring. Immunization coverage estimates have been unreliable as a result of perceived poor data quality. The DOH has indicated that the DHS planned in 2015 is anticipated to collect some vital data that may be used to estimate the immunization coverage.

·    Surveillance activities (particularly Acute Flaccid Paralysis (AFP), Measles and Neonatal tetanus surveillance) remain key.

·    The Polio Committees (National Certification Committee (NCC), National Polio Expert Committee (NPEC) and National Task Force (NTF) continue to advocate for a polio-free South Africa especially in the light of the polio endgame.

WHO strategic areas of work 2015-2019

·     Technical support  and capacity building  in: data quality improvement; cold chain capacity assessment and improvement; effective vaccine management; AFP, measles and neonatal tetanus surveillance; Reach Every Community and Data quality self-assessment; immunization practices; adverse events following immunization management among other areas

·     Support the implementation of the activities related to the Polio Endgame e.g. the trivalent Oral Polio Vaccine (OPV) to bivalent OPV switch and the implementation of laboratory containment per the Global Action Plan III.

·     Support the in-country adaptation and implementation of the Regional Strategic Plan for Immunisation and monitor the achievement of the regional targets and  support the development /review/revision of key program guidelines as well as the development of the comprehensive multi-year plan

This programme includes monitoring and evaluation of National Health Accounts, strengthening capacity in analysis of health financing options, and supporting institutions to implement National Health Insurance, the central means by which South Africa aims to achieve universal health coverage.

Acknowledgement

Funding from the UK Department for International Development (DFID) under the Program for improving countries’ health financing systems to accelerate progress towards universal health coverage is gratefully acknowledged. This support is provided to WCO through the Health financing team in WHO headquarters.

Health Economist: 
Roubalt@who.int

 Country Brief printable version [pdf: 566.5 kB]

Country Brief: Universal Health Coverage through National Health Insurance
Critical issues

·    9% of GDP (US$ 570 per person) is spent on health.

·    Public spending accounts for 48% of total spending, and 15.5% of total government expenditures. Most people (>80%) use public services.

·    Private insurance accounts for 43% of total health expenditures (THE), covers 17% of the population.

·    Out of pocket spending accounts for 7% of THE.

·    In December 2015, the government published a White paper on the implementation of National Health Insurance (NHI) to achieve UHC, focusing on the dual objectives of strengthening quality in public facilities, and reducing the costs/fees of private health care.

National Health Insurance (NHI) is the central means by which South Africa aims to achieve universal health coverage, under the principles of solidarity and equity in access. Under NHI, 6 work streams are establishing the implementation roadmap (i.e., Establishment of NHI Fund, benefit package, purchaser-provider split, role of private medical schemes, finalizing the NHI policy papers, and strengthening of District Health System). To address private cost escalation, a market inquiry investigates the submission of all stakeholders on the cost drivers, market concentration and impacts of regulation on the private market.

The majority of people rely on the public health system where the purchasers and providers are the provinces and districts. At provincial level, health programs face competing priorities for limited budgets resulting in substantial variation across regions. For example, 25% of the provincial budget in Mpumalanga was spent on health compared with 36% in Western Cape.[1]

Revenue generation. It is anticipated that participation in NHI will be mandatory, and poor families will be subsidized. NHI will be financed from general taxation, VAT, payroll taxes, surcharge on taxable income, and excises on tobacco, alcohol, and sugar sweetened beverages.  

Pooling and purchasing. A National Health Insurance Fund (NHIF) will be established to pool existing and new resources. The NHIF will purchase services by contracting with accredited providers (public and private), and use capitation for primary care, Diagnosis Related Groups for inpatient care and price benchmarking for medicines. The purchaser-provider split will require strengthening of the management of public hospitals, and expanding their autonomy, responsibilities and capabilities.

Benefits packages. The government’s list of non-negotiables broadly defines the scope of the basic health services package. The NHI plans to set up a universal benefit entitlement, which will include evidence-based interventions based on the Health Technology Assessment process.

WHO Strategic areas of work in 2015-2019

EU project: WHO CO received 50% funding to support the NHI work streams,through contracting specific technical experts. WHO was requested by the Honorable Minister to provide specific support in close cooperation with the Workstream leads and the NHI unit. Specifically, WHO will support the NHI work streams as follows:

 ·     WS1: analysis of the constitutionality of the NHI and the governance arrangements of the NHI Fund

·      WS2: priority setting for benefits package, phased implementation, and developing Health technology assessment capability

·      WS3: identify mechanisms to pay for high-cost services (i.e., dialysis) as part of contracting arrangements private provider, contracting arrangements.

·      WS4: Establishing a unifying information system for registration and payment; Conceptual and practical solutions for virtual pooling arrangements

·      WS5: Support consultative process of NHI

·      WS6: Develop/strengthen mechanisms for risk-adjusted capitation models.

National Health Accounts (NHAs). Strengthening a systematic approach to measure and analyze health expenditures at national and provincial levels, through National Health Accounts (NHA).

Related articles:

WHO submission to the Health Market Inquiry: responses to comments on the WHO commissioned OECD report on private health care prices.

In response to the OECD working paper on South African private hospital price comparison commissioned by the WHO and presented to the Distinguished Panel for the Health Market Inquiry last February 2016, the WHO received written comments about this study.  The attached letter is WHO’s formal submission to the Panel responding to these comments.

 WHO’s formal submission [pdf: 970.2 kB]

This programme of work provides support to improve HIV care and treatment including clinical outcomes of antiretroviral therapy; treatment monitoring, HIV drug resistance and pharmacovigilance; improved linkages to care; strengthened HIV prevention and improved HIV Counselling and Testing; and promoting Medical Male Circumcision.

Medical Officer: Dr Brian Clever: chirombob@who.int


National Professional Officer: Dr Busi Msimang-Radebe: msimangaradebeb@who.int

 Country Brief printable version [pdf: 664.1 kB]

Country Brief: HIV and Hepatitis
Critical issues

·    6.8 million people were living with HIV in 2014, an increase from 4.6 million in 2008, which can be attributed to new infection estimated annually at 400,000 as well as to the increased survival of people living with HIV as a result of the national ART roll-out. Only 54% of PLHIV in South Africa know their HIV status.

·    3.2 million PLWH accessed ART by December 2015, covering about 58% of those in need in terms of the eligibility criteria of CD4 > 500. About 27% and 53% of people on ART are lost to follow up after 12 and 52 months of initiating ART, respectively.

·  The PMTCT programme has successfully reduced HIV transmission at 6 weeks and 18 months post-partum to 1.5% and less than 5% respectively in 2015.

·    Birth polymerase chain reaction PCR was introduced in 2015 to reach more children timeously, and HIV re-testing policy was revised with more frequent testing for pregnant women and key populations.

·    Pre-exposure prophylaxis (PrEP) will be offered to sex workers starting in June 2016. Government has started a process of developing guidelines for PrEP which are aligned with WHO guidance. There are currently various demonstration projects on PrEP in South Africa looking at key populations and young women. More projects on adolescents and young girls are underway.

·   HIV testing services include screening for hypertension, diabetes, anemia, TB, STIs, and condom provision. The use of trained lay counsellors for HIV testing contributed to the increased rate of 8m per year in 2014 from 2m in 2009.

·    By December 2015, just over 2,3 million medical male circumcisions (MMC) had been done. Massive scale up is needed to achieve the target of 4.3 million by 2016.

HIV Treatment Programme

Timely linkage to care and treatment of newly diagnosed HIV-positive individuals and retention of patients in care constitute major challenges to effective HIV care. The issue of quality of care is also receiving particular attention. In this regard, the NDOH has developed different strategies including for improving adherence. The WHO global report on HIV drug resistance has raised serious concerns about the resistance in high HIV prevalence settings where there was a rapid scale up of ART. South Africa has developed guidelines and protocols for drug resistance and is rolling out the pharmacovigilance plan.   

HIV Prevention Programme

Doctors have trained on MMC as a systematic way of scaling up the MMC programme in the NHI districts. Field studies on the PrePex device have been completed and its implementation is underway.

The PMTCT Cascade indicators show an overall national rate of 44% of pregnant women who come for their first Ante Natal Care (ANC) booking before 20 weeks of pregnancy. This late ANC booking constitutes one of the impediments which PMTCT has to overcome to accelerate the elimination process.

This programme of work encompasses prevention and control of non-communicable diseases (NCDs); risk factor reduction including tobacco control, alcohol harm reduction and overweight, diet and physical activity; mental health; and violence and injuries.

National Professional Officer - Health Promotion: Mr Eugene Mahlehla
Mahlehlaeu@who.int

 Country Brief printable version [pdf: 476.54 kB]

Country brief: Non-communicable Disease Prevention and Control, Risk Factor Reduction, Mental Health and Injury and Violence

Critical issues for South Africa

·       NCDs and injuries account for 49% of mortality, and approximately 2 out of 5 deaths in South Africa (RSA) were attributable to non-communicable disease conditions (NCDs). Some 40% of NCD deaths among men and 29% among women are premature (

·       In 2013, 38,034 people died from cancer related deaths, with cancer ranking 8th out of the top ten contributors to Disability Adjusted Life Years (DALYS).

·       Smoking prevalence is 16.2%, and 26.5% of men smoke. Daily smoking amongst youth is 12.7% overall. Alcohol consumption among people who drink amounts to a staggering 27.1 liters per person per year.

·       One in four adults is obese and over half are overweight. Half of adults are physically inactive.

·       Hypertension affects 42.2% of the population, 10.6% suffer from elevated blood glucose, and 34.0% have high cholesterol.

·       Lifetime prevalence for a mental health condition has been estimated at 30.3% (2004). Neuropsychiatric disorders are ranked 3rd in overall burden of disease.

Governance. The National Department of Health (NDOH) is setting up a multi-sectoral co-ordinating body, the National Health Promotion Foundation, which will address risk factors, NCDs, violence and injuries. The Strategic Plan for the Prevention and Control of NCDs 2013-17 is closely aligned to the WHO Global Health Action Plan. WHO is supporting the national cancer strategy, as well as clinical guidelines and SOPs for CVDs, diabetes and cancers (breast and prostate). The SA Mental Health Policy Framework and Strategic Plan 2013-2020 was released by NDOH in 2013.

Tobacco. RSA emerged in the 1990s as a global leader in tobacco control with the Tobacco Products Control Act. This act addressed smoking in public places, warnings on packaging and modest restrictions on advertising and sponsorship. Post 1994, RSA established tax and regulatory measures that have reduced smoking prevalence of smoking. Despite this, smoking rates are among the highest in the continent. The NODH is revising its regulations to enforce plain packaging and clean air regulations, regulate e-cigarettes, and increase taxes to revitalize efforts to reduce tobacco use.

Alcohol. An Inter-ministerial Committee (IMC) was established in 2010 to oversee policies and interventions to      reduce harmful use of alcohol. The government strongly articulated its intention to implement zero-tolerance to Blood Alcohol Content (BAC) when driving. A national liquor policy drafted by the Department of Trade and Industry (DTI) includes increasing the legal drinking age from 18 to 21 years, and banning advertising and sales near schools and public places.

Diet and physical activity. WHO supported the National Strategy for the Prevention and Control of Obesity (to be released in 2016), focusing on population measures to improve diet and physical activity. South Africa has legislation that mandates firms to reduce salt and transfats added to processed foods. A tax on sugar sweetened beverages will be implemented in 2017.

Violence and Injuries. Violence, traffic crashes, burns, falls or drowning are responsible for 9% of all deaths. Alcohol has been found to be a prominent factor in violence and injuries including interpersonal violence, domestic violence, sexual assault and road traffic injuries. The NDOH is developing clinical guidelines on sexual assault. There is also a national road traffic strategy closely aligned to pillars of the Decade of Action on road safety. 

The Human Resources for Health programme focuses on three themes, namely supply of health professionals and equity of access; education, training and research; and the working environment of the health workforce.

Health System Advisor: 

Country Brief:

 HSS-HRH Program Country brief [pdf: 397.65 kB]

This programme addresses TB surveillance, monitoring and evaluation, drug resistant TB, and strengthening capacity in TB prevention and pharmacovigilance.  

National Professional Officer: 
 

  Country Brief printable version

Country brief: Understanding the South Africa Tuberculosis epidemic and targeting response: Doing the basics better

Critical issues

·       Tuberculosis remains a major public health challenge, with estimated TB incidence rates at 834 cases per 100,000 population (Global Report, 2015)

·      Declining trends in notified TB cases since 2009-400,000(2009) to 306 166 (2014) with routine data show some under-reporting in the routine TB surveillance system and duplications in laboratory TB data due to lack of unique identifier.

·       Treatment success rate is 78% for new and relapse cases registered in 2013.

·      18 734 Rifampicin Resistance/MDR-TB cases have been reported, contributing 15% of the global burden of MDR-TB and about 73% of the AFRO burden (2014). 62% of MDR-TB confirmed cases initiate treatment, with 49% treatment success.

·       61% of TB patients are living with HIV; 79% are on ARVs.

·      RSA has good TB laboratory capacity with the highest coverage of Drug Sensitivity Testing (DST) in Africa region. The Centre for Tuberculosis of the National Institute for Communicable Diseases (NICD) in Johannesburg is recognised by the WHO Global TB Programme as a full member of the TB Supranational Reference Laboratory Network

·       South Africa is in the process of developing a new integrated National Strategic Plan for HIV, STI and TB 2017-2021.

 Figure 1: Notified TB cases plotted over ART coverage estimates from 2005 - 2013