Session 1
Local Health Priorities
Activity 3.1.1 – Choosing a Health Focus
For this activity, you need to select a key health challenge in South Africa and explore the literature on this topic. This is an opportunity to see how one health concern might be linked to other heath and social challenges, and to get a snapshot of what the picture is in South Africa and why it is important to draw attention to specific health concerns.
The Targeted Universal Testing for TB (TUTT) study was designed to investigate whether screening everyone with HIV, anyone with a history of TB in the past two years and anyone who reported close contact with a TB case in the past year would increase TB diagnoses by 25%. Preliminary findings from the study, presented at the 2020 Union World Conference on Lung Health, showed that approximately half the TB cases diagnosed using Xpert Ultra MTB/RIF were in people without TB symptoms.
The study was carried out in primary healthcare clinics in KwaZulu-Natal, Western Cape and Gauteng provinces. Thirty clinics were randomised to carry out symptom testing for TB. Thirty were randomised to carry out targeted screening, plus testing of people who did not have a risk factor but had symptoms. People with risk factors were tested using Xpert Ultra MTB/RIF and liquid culture, while people with symptoms in both study arms were tested using Xpert Ultra MTB/RIF.
The study enrolled 32,000 patients in the intervention clinics, 71% living with HIV. Participants were predominantly female (62%) and 28% had TB symptoms. Forty-one per cent had a contact with TB and 5% had been diagnosed with TB in the past two years.
Of those tested, 6% were positive for TB. Rates were 5% among people with HIV, 7.5% among TB contacts and 12.2% among prior TB cases. People with a prior history of TB were twice as likely as those without to test positive, whereas people with HIV were 40% less likely to test positive than HIV-negative people.
Targeted testing revealed that the burden of undiagnosed TB was higher in people with HIV not on antiretroviral treatment, who accounted for 70% of TB cases among people with HIV. They were three times more likely to be diagnosed with TB than people with HIV on antiretroviral treatment.
The investigators calculated that TB diagnoses increased by 17% in intervention clinics compared to the standard-of-care clinics in the follow-up period. In the standard-of-care clinics, TB diagnoses fell by 8% compared with the prior period. These differences were statistically significant.
How South Africa's Health Issues are Characterised
Health and Related Indicators 2022
The South African Health Review 2022 pays attention to the response, mitigation, recovery, and health systems strengthening strategies implemented to rebuild the health system in SA post the COVID-19 pandemic. Information systems are a critical building block in health systems. The WHO outlines a well functioning health information system as “one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status”. This chapter examines the available health information data sources in SA and explores whether they have improved during and after the COVID-19 pandemic. That is more resilient, better resourced and more agile, or whether they are regressing to the state of fragmentation and vulnerability seen in 2020.
An immediate glance suggests the later. The authors point out that health information systems established during the pandemic are being allowed to close, are being defunded, or are becoming less timely and less effective. The lessons of the pandemic are at risk of being lost, before the pandemic has formally been declared over. Pillay et al. pointed that services should not only recover to “2019 levels at least”, but we should use the lessons from COVID-19 to radically transform the SA health system.
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Data Sources:
Box 1 outlines the primary new or updated data sources utilised at both international and national levels. Many indicators were standardised using population-based denominators. Routine data were sourced from the web-based District Health Information System (WebDHIS), focusing primarily on the 2021/22 financial year (April 2021 to March 2022). In several sections below, graphical representations illustrate the differences between expected and actual routine measures, with expected trends projected using the Holt-Winters forecasting method.​​​​​​
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The review highlights that causation is justified when using data over several years. Because data is extracted from multiple sources, care should be taken when assessing trends and changes over time. Differences in methodology and data presentation make comparisons difficult. It is also possible that data from regular surveys may not be comparable over time, as in some cases, revised data for a historical time period may be released.
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Demographic Indicators
There has been much speculation on the impact that the COVID-19 pandemic will have on demographic trends, especially considering population aging is driven by fertility and mortality trends.
SA has the highest proportion of elderly people among countries in Africa. Although population ageing is still in its early stages in the country, the proportion of persons aged 60 years and older is increasing over time. This will have implications for the health systems because it will intensify the disease burden related to multiple chronic conditions [9]. Interventions to address this ageing population should be prioritized because older adults have different health needs to a younger population. SA’s burden of communicable and non-communicable diseases results in unhealthy ageing [9]. Internal migration increased, with populations in more rural provinces depleted as people moved to the economic hubs such as Gauteng, Western Cape and Mpumalanga. This will have implications for the allocation of funds.
The crude death rate increased from 8.7 deaths per 1000 to 11.5 deaths per 1000 in 2021 as a result of COVID-19. However, in 2022 the modelled crude death fell slightly to 11.0 which could signal a recovery post-COVID.
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Socio-economic and Environmental Risk Factors
COVID-19 exacerbated pre-existing poverty and inequality on a global scale. As SA is already one of the most unequal countries in the world, it experienced a widening gap between the rich and poor during the pandemic. The poor were affected the most after many lost their jobs and had their incomes reduced. GDP fell by 7% and unemployment increased in 2020.
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Air pollution remains one of the most significant environmental threats to human health. It increases vulnerability to respiratory infections, including COVID-19, and long-term exposure has been linked to a higher risk of chronic diseases such as stroke, lung cancer, ischaemic heart disease, chronic obstructive pulmonary disease (COPD), type 2 diabetes, and even stillbirths. South Africa is among the countries with the highest levels of air pollution globally. In 2019, the death rate associated with household and ambient air pollution in South Africa was estimated at 44.6 (35.4–53.8) per 100,000 people annually. Figure 2 highlights the percentage of cause-specific deaths attributed to air pollution, with COPD and diabetes being the most affected.
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According to the Air Quality Life Index (AQLI), permanently reducing global air pollution to meet WHO guidelines could increase average life expectancy by 2.2 years worldwide and by 1.5 years in South Africa.
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In 2022, the Department of Water and Sanitation published its first Blue Drop Progress Report since 2015, assessing the state and risk trends of municipal potable water-treatment facilities. Only 23 systems achieved a score of 90% or higher, while most rural municipalities struggled, scoring below 50%. Additionally, 39% (334) of municipal wastewater systems were deemed to be in a critical state in 2021. The overall risk associated with water systems has worsened between 2013 and 2021.
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Access to safe and reliable water is essential for public health, as contaminated water and inadequate sanitation are linked to gastrointestinal illnesses such as cholera. During the COVID-19 pandemic, clean water was vital for preventing disease transmission. To mitigate risks, regular water assessments are crucial for ensuring that effective systems and strategies are in place to protect public health.
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Disability
South Africans with disabilities were greatly and uniquely affected by COVID-19. They were at greater risk of poor outcomes from the disease; lockdown periods reduced their access to routine health care and rehabilitation services; and efforts to mitigate the pandemic led to adverse social impacts in this group.
With regard to health-related issues, the report highlighted that persons living with disabilities experienced difficulties with adhering to the mandatory COVID-19 guidelines such as social distancing and wearing of personal protective equipment (PPE), and accessing health care, therapy, medication, specialist care and assistive devices. Figure 3 shows that provision of assistive devices dropped substantially in 2020.
It has been found that people with disabilities are more likely to be older, female, poorer, and to have additional comorbidities than their able peers. As of 2021, more women were classified as disabled (4.9%) than men (4.1%).18 Living with disabilities leads to challenges in all aspects of life, including access to healthcare services, aids or devices, medication and support (for example, when caregivers are infected with COVID-19). These impacts are exacerbated in local and middle-income countries (LMICs), which often face additional challenges of corruption, political instability, lack of suitable transportation, and a general negative attitude to those living with disability, and to disability overall.
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Health status Indicators
Mortality: The South African Medical Research Council (SAMRC) excess death reports showed that there was a total of 339 146 excess deaths (which is defined as “the difference in the total number of deaths in a crisis compared to those expected under normal conditions”) were estimated between May 2020 and December 2022. Life expectancy for both sexes took a dip from 65.4 years in 2020 to 62 years at the height of the COVID-19 pandemic in 2021. There has been a slight recovery in 2022 when it increased to 62.8 years for both sexes.
Infectious Diseases: Despite the impact of COVID-19, the number of malaria cases and deaths remained stable across the world as countries intensified their fight against malaria. South Africa saw a 33.7% reduction in 2021 compared to 2020. However, this reduction could be explained by the reduced testing caused by the lack of movement during the lockdown periods.
South Africa, like the rest of the world, saw a surge in the number of measles cases as many children missed vaccination doses after the pandemic because parents feared exposing their children to COVID-19. SA experienced a measles outbreak in October 2022 in all provinces except the Eastern Cape. In response, the NdoH initiated a national measles vaccination.
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Tuberculosis
Before the COVID-19 pandemic, TB was one of the leading causes of death among infectious diseases. Worldwide, COVID-19 had a significant impact on TB services as progress towards reducing TB halted and in some cases reversed. In SA, TB resources were redirected to address the demands posed by the pandemic.
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According to WHO estimations,57 304,000 people in South Africa developed TB in 2021, of whom only 181 699 were diagnosed and started on treatment. TB-related deaths were estimated at 55,000 in 2021, with 33 000 of those having a TB/HIV co-infection due to the high double burden of HIV and TB in South Africa, and people living with HIV being at higher risk of contracting TB. The number of newly diagnosed drug-sensitive TB patients decreased by 29%, reversing the progress that had been made in the TB programme. The public health facilities heeded the call to action by integrating COVID-19 services and TB services, among other evidence-based interventions, which resulted in the number of new diagnoses growing in the following financial year, to 195 640 (April 2021 - March 2022). This represents an 84% recovery towards the 2019 financial year TB diagnosis and treatment numbers.
South Africa's Health Priorities during the COVID-19 Pandemic
​The NDoH developed a National TB Recovery Plan with the aim of closing the gaps created by COVID-19, and leveraging good practices born from the response to COVID-19. Phase 1 (preparatory period) of the plan took place between January 2022 and June 2022, and Phase 2. The plan outlined the following:
Finding undiagnosed people with TB through evidence-based interventions that scaled up community TB screening.
COVID-19
The frequency at which COVID-19 statistic are reported has dropped considerably as the COVID-19 disease burden has reduced in SA. Most tellingly, the Daily Hospital Surveillance (DATCOV) reporting system is no longer functioning. This system had been highlighted as a prime example of collaboration between the public and private sectors, with 100% of all hospitals in each sector contributing data.
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Non-communicable Diseases
In 2022 the NDoH published the National Strategic Plan for the Prevention and Control of Non-Communicable Diseases, 2022-202787 to fast-track their response towards the prevention and control of non-communicable diseases (NCDs), risk factors and mental conditions. This was also in recognition of the gaps that COVID-19 exposed in the delivery of NCD services as mortality and hospitalization rates were much higher for those living with NCDs (both known and unknown) and among obese people in the country. The NSP proposed a cascade-based strategy similar to the 90-90-90 approach for HIV and AIDS, and TB. The proposed 90-60-50 cascade states that:
• 90% of all people over 18 will know whether or not they have raised blood pressure and/or raised blood glucose.
• 60% of people with raised blood pressure or blood glucose will receive intervention.
• 50% of people receiving interventions are controlled.
As mentioned before, South Africa’s population is ageing and those living with HIV are living longer due to the successful uptake of antiretroviral therapy (ART), which means that the NCD burden on the country will also increase as old age is a risk factor for developing an NCD.
Data on NCDs continues to be difficult to find though, as NCDs are not notifiable medical conditions (NMC).
According to the International Disability Alliance’s report37 on COVID-19 and diabetes, diabetes was a strong risk factor for adverse COVID-19 outcomes; individuals with diabetes were more likely to be hospitalized or die as a result of COVID-19 infections than those not living with the disease. The International Diabetes Federation (IDF) 2021 Atlas estimated that South Africa has the highest number of people living with diabetes in Africa, with an estimate of 4.2 million people in 2021. Twelve years ago, in 2011, this figure was estimated at just 1.9 million. According to routine data collected in the webDHIS between 2020/21 and 2021/22, there were noticeable drops in the number of new diabetes and hypertension treatment clients in the public sector. This was another indication of potential under-screening and under-diagnosing due to disruptions to health services caused by COVID-19.