Is South Africa closing the health gaps between districts? Monitoring progress towards universal health service coverage with routine facility data.

BACKGROUND: South Africa is committed to advancing universal health coverage (UHC). The usefulness and potential of using routine health facility data for monitoring progress towards UHC, in the form of the 16-tracer WHO service coverage index (SCI), was assessed. METHODS: Alternative approaches to calculating the WHO SCI from routine data, allowing for disaggregation to district level, were explored. Data extraction, coding, transformation and modelling processes were applied to generate time series for these alternatives. Equity was assessed using socio-economic quintiles by district. RESULTS: The UHC SCI at a national level was 46.1 in 2007-2008 and 56.9 in 2016-2017. Only for the latter period, could the index be calculated for all indicators at a district level. Alternative indicators were formulated for 9 of 16 tracers in the index. Routine or repeated survey data could be used for 14 tracers. Apart from the NCD indicators, a gradient of poorer performance in the most deprived districts was evident in 2016-2017. CONCLUSIONS: It is possible to construct the UHC SCI for South Africa from predominantly routine data sources. Overall, there is evidence from district level data of a trend towards reduced inequity in relation to specific categories (notably RMNCH). Progress towards UHC has the potential to overcome fragmentation and enable harmonisation and interoperability of information systems. Private sector reporting of data into routine information systems should be encouraged.

A geospatial analysis of two-hour surgical access to district hospitals in South Africa.

BACKGROUND: In a robust health care system, at least 80% of a country's population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa. METHODS: All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods. RESULTS: Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities. CONCLUSION: Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.

Diarrhoea in children under five years of age in South Africa (1997-2014).

OBJECTIVE: To present evidence from available reliable published data on the prevalence, incidence and severity of diarrhoea in children aged under five years in South Africa. METHODS: We searched seven electronic databases. Two reviewers assessed the studies independently and extracted outcome data. The heterogeneity of the studies did not allow for a meta-analysis. RESULTS: We found only one nationally representative study conducted in 1998 reporting a diarrhoea prevalence of 13% in children under five. Other studies were conducted in smaller settings across the country. Diarrhoea incidence was 10.13 per 1000 person years in children admitted to a tertiary hospital. Three studies reported severity of diarrhoea; however, they differed across study settings and time period. CONCLUSION: The paucity of nationally representative prevalence data for SA necessitates more national surveys with standardised data-collection methods to allow for more effective comparisons.

Quasi-experimental evaluation of a financial incentive for first-dose COVID-19 vaccination among adults aged ≥60 years in South Africa.

INTRODUCTION: COVID-19 vaccination coverage in South Africa (RSA) remains low despite increased access to vaccines. On 1 November 2021, RSA introduced the Vooma Voucher programme which provided a small guaranteed financial incentive, a Vooma Voucher redeemable at grocery stores, for COVID-19 vaccination among older adults, a population most vulnerable to serious illness, hospitalisation and death. However, the association of financial incentives with vaccination coverage remains unclear. METHODS: We evaluated the association of the conditional economic incentive programme with first-dose vaccination rates among adults (aged ≥60 years) through a quasi-experimental cohort study. The Vooma Voucher programme was a nationwide vaccination incentive programme implemented for adults aged ≥60 years from 1 November 2021 to 28 February 2022. We ran ITS models to evaluate the Vooma Voucher programme at national and provincial levels. We used data between 1 October 2021 and 27 November 2021 in models estimated at the daily level. Individuals who received their first vaccine dose received a text message to access a ZAR100 ($~7) voucher that was redeemable at grocery stores. RESULTS: The Vooma Voucher programme was associated with a 7.15%-12.01% increase in daily first-dose vaccinations in November 2021 compared with late October 2021. Overall, the incentive accounted for 6476-10 874 additional first vaccine doses from 1 November to 27 November 2021, or 8.31%-13.95% of all doses administered to those aged ≥60 years during that period. This result is robust to the inclusion of controls for the number of active vaccine delivery sites and for the nationwide Vooma vaccination weekend initiative (12 November to 14 November), both of which also increased vaccinations through expanded access to vaccines and demand creation activities. CONCLUSIONS: Financial incentives for COVID-19 vaccination led to a modest increase in first-dose vaccinations among older adults in RSA. Financial incentives and expanded access to vaccines may result in higher vaccination coverage. TRIAL REGISTRATION NUMBER SANCTR: DOH-27-012022-9116.

Health trends, inequalities and opportunities in South Africa's provinces, 1990-2019: findings from the Global Burden of Disease 2019 Study.

BACKGROUND: Over the last 30 years, South Africa has experienced four 'colliding epidemics' of HIV and tuberculosis, chronic illness and mental health, injury and violence, and maternal, neonatal, and child mortality, which have had substantial effects on health and well-being. Using data from the 2019 Global Burden of Diseases, Injuries and Risk Factors Study (GBD 2019), we evaluated national and provincial health trends and progress towards important Sustainable Development Goal targets from 1990 to 2019. METHODS: We analysed GBD 2019 estimates of mortality, non-fatal health loss, summary health measures and risk factor burden, comparing trends over 1990-2007 and 2007-2019. Additionally, we decomposed changes in life expectancy by cause of death and assessed healthcare system performance. RESULTS: Across the nine provinces, inequalities in mortality and life expectancy increased over 1990-2007, largely due to differences in HIV/AIDS, then decreased over 2007-2019. Demographic change and increases in non-communicable diseases nearly doubled the number of years lived with disability between 1990 and 2019. From 1990 to 2019, risk factor burdens generally shifted from communicable and nutritional disease risks to non-communicable disease and injury risks; unsafe sex remained the top risk factor. Despite widespread improvements in healthcare system performance, the greatest gains were generally in economically advantaged provinces. CONCLUSIONS: Reductions in HIV/AIDS and related conditions have led to improved health since 2007, though most provinces still lag in key areas. To achieve health targets, provincial governments should enhance health investments and exchange of knowledge, resources and best practices alongside populations that have been left behind, especially following the COVID-19 pandemic.

South African physician emigration and return migration, 1991-2017: a trend analysis.

Although critical for understanding health labour market trends in low- and middle-income countries (LMICs), longitudinal LMIC health worker emigration and return migration trends are not routinely documented. This article seeks to better understand SA's trends in physician emigration and return migration and whether economic growth and related policies affect migration patterns. This study used physician registry data to analyse patterns of emigration and return migration only among SA-trained physicians registered to practice in top destination countries such as Australia, Canada, New Zealand, the USA or the UK between 1991 and 2017, which represent the top five emigration destinations for this group. A linear regression model analysed the relationship between migration trends (as dependent variables) and SA's economic growth, health financing and HIV prevalence (as independent variables). There has been a 6-fold decline in emigration rates from SA between 1991 and 2017 (from 1.8% to 0.3%/year), with declines in emigration to all five destination countries. About one in three (31.8% or 5095) SA physicians returned from destination countries as of 2017. Annual physician emigration fell by 0.16% for every $100 rise in SA GDP per capita (2011 international dollars) (95% confidence interval -0.60% to -0.086%). As of 2017, 21.6% (11 224) of all SA physicians had active registration in destination nations, down from a peak of 33.5% (16 366) in 2005, a decline largely due to return migration. Changes to the UK's licensing regulations likely affected migration patterns while the Global Code of Practice on International Recruitment contributed little to changes. A country's economic growth might influence physician emigration, with significant contribution from health workforce policy interventions. Return migration monitoring should be incorporated into health workforce planning.

Generating statistics from health facility data: the state of routine health information systems in Eastern and Southern Africa.

Health facility data are a critical source of local and continuous health statistics. Countries have introduced web-based information systems that facilitate data management, analysis, use and visualisation of health facility data. Working with teams of Ministry of Health and country public health institutions analysts from 14 countries in Eastern and Southern Africa, we explored data quality using national-level and subnational-level (mostly district) data for the period 2013-2017. The focus was on endline analysis where reported health facility and other data are compiled, assessed and adjusted for data quality, primarily to inform planning and assessments of progress and performance. The analyses showed that although completeness of reporting was generally high, there were persistent data quality issues that were common across the 14 countries, especially at the subnational level. These included the presence of extreme outliers, lack of consistency of the reported data over time and between indicators (such as vaccination and antenatal care), and challenges related to projected target populations, which are used as denominators in the computation of coverage statistics. Continuous efforts to improve recording and reporting of events by health facilities, systematic examination and reporting of data quality issues, feedback and communication mechanisms between programme managers, care providers and data officers, and transparent corrections and adjustments will be critical to improve the quality of health statistics generated from health facility data.

Obesity trends and risk factors in the South African adult population.

BACKGROUND: Obesity prevalence is increasing globally and contributes substantially to the burgeoning burden of non-communicable diseases. South Africa is particularly affected by this increasing trend and cross-sectional evidence suggests socioeconomic and behavioural variables as possible drivers. However, no large scale longitudinal study has attempted the direct identification of risk factors for progression towards obesity. METHODS: This study analysed data on 10,100 South African adults (18 years and over) randomly selected in 2008 and successfully recontacted in 2010 and 2012. Latent Growth Modelling was used to estimate the average rate of change in body mass index (BMI) during the study period, and to identify baseline characteristics associated with different trajectories. RESULTS: The overall rate of change in BMI during the study period was +1.57 kg/m(2) per decade (95 % CI: 0.93 -2.22), and it was higher among women (+ 1.82 kg/m(2) per decade, 95 % CI: 1.06 -2.58) than among men (+ 1.03 kg/m(2) per decade; 95 % CI: 0.14 -1.93). Female gender, younger age, larger waist circumference, white population group and higher household income per capita were baseline characteristics associated with higher rates of change. The association between tobacco use and obesity was complex. Smoking was associated with greater waist circumference at baseline but lower rates of increase in BMI during the study period. Quitting smoking was an independent predictor of BMI increase among subjects with normal weight at baseline. Among subjects with baseline BMI lower than 25 kg/m(2), rates of changes were higher in rural than urban areas, and inversely related to the frequency of physical exercise. CONCLUSIONS: A strong positive trend in BMI remains in South Africa and obesity prevalence is likely to increase. Trends are not homogeneous, and high risk groups (subjects with high socioeconomic status, rural dwellers, young women) and modifiable risk factors (physical inactivity) can be targeted. Subjects quitting smoking should receive additional weight-loss support in order that the numerous health benefits of cessation are not reduced by increasing BMI. Centrally obese subjects should be targeted in campaigns.

Explaining the role of the social determinants of health on health inequality in South Africa.

BACKGROUND: Action on the social determinants of health (SDH) is relevant for reducing health inequalities. This is particularly the case for South Africa (SA) with its very high level of income inequality and inequalities in health and health outcomes. This paper provides evidence on the key SDH for reducing health inequalities in the country using a framework initially developed by the World Health Organization. OBJECTIVE: This paper assesses health inequalities in SA and explains the factors (i.e. SDH and other individual level factors) that account for large disparities in health. The relative contribution of different SDH to health inequality is also assessed. DESIGN: A cross-sectional design is used. Data come from the third wave of the nationally representative National Income Dynamics Study. A subsample of adults (18 years and older) is used. The main variable of interest is dichotomised good versus bad self-assessed health (SAH). Income-related health inequality is assessed using the standard concentration index (CI). A positive CI means that the rich report better health than the poor. A negative value signifies the opposite. The paper also decomposes the CI to assess its contributing factors. RESULTS: Good SAH is significantly concentrated among the rich rather than the poor (CI=0.008; p<0.01). Decomposition of this result shows that social protection and employment (contribution=0.012; p<0.01), knowledge and education (0.005; p<0.01), and housing and infrastructure (-0.003; p<0.01) contribute significantly to the disparities in good SAH in SA. After accounting for these other variables, the contribution of income and poverty is negligible. CONCLUSIONS: Addressing health inequalities inter alia requires an increased government commitment in terms of budgetary allocations to key sectors (i.e. employment, social protection, education, housing, and other appropriate infrastructure). Attention should also be paid to equity in benefits from government expenditure. In addition, the health sector needs to play its role in providing a broad range of health services to reduce the burden of disease.

Monitoring of non-communicable diseases such as hypertension in South Africa: challenges for the post-2015 global development agenda.

BACKGROUND: Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs. OBJECTIVE: To review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example. METHODS: Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010. RESULTS: The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ≥25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled. CONCLUSION: Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential.