The South African health system is tiered with the minority of the population using private health services and the majority relying mainly on tax-funded health services. South Africa (SA) bears a quadruple burden of disease com-prising tuberculosis, HIV and AIDS, high levels of maternal and child mortality, injuries, and non-communicable dis-eases. The burden of these diseases falls most heavily on the poor. In 2007 the SA government committed itself to implementing National Health Insurance (NHI) in order to move the country toward universal health coverage (UHC). This paper, as part of a series of case studies commissioned by the World Health Organization (WHO) to develop ap-propriate measures of UHC, provides a case study of SA’s current situation in relation to UHC using the WHO-proposed indicator framework. Drawing on different national data sources, the paper shows that disparities exist in the proposed indicators in the SA context. The paper notes that the framework may be more appropriate for monitoring progress towards UHC over time, rather than as a tool for evaluating a country’s status relative to UHC goals at a single point in time. This paper also points to the need to have UHC-related ‘benchmarks’ against which to compare country data. Further, the proposed indicators by themselves do not provide clear insights into health system reforms required to promote UHC; there is need for a more detailed system-level analysis.
Monitoring equity and research policy
The burden of chronic, non-communicable diseases in low-income and middle-income countries is increasing. This study outlines a framework for monitoring of such diseases and reviews the mortality burden and the capacity of countries to respond to them. It draws on World Health Organization (WHO) data and published work for prevalence of tobacco use, overweight, and cause-specific mortality in 23 low-income and middle-income countries with a high burden of non-communicable disease. Although reliable data for cause-specific mortality was scarce, non-communicable diseases were estimated to be responsible for 23.4 million (or 64% of the total) deaths in the 23 countries that were analysed, with 47% occurring in people who were younger than 70 years. Tobacco use and overweight were found to be common in most of the countries and populations we examined, but coverage of cost-effective interventions to reduce these risk factors is low. Capacity for prevention and control of non-communicable diseases, including monitoring and surveillance operations nationally, is inadequate. A surveillance framework, including a minimum set of indicators covering exposures and outcomes, is essential for policy development and assessment and for monitoring of trends in disease, the study argues. However, technical, human and fiscal resource constraints are major impediments to the establishment of effective prevention and control programmes. Despite increasing awareness and commitment to address chronic disease, the study found that concrete actions by global partners to plan and implement cost-effective interventions were inadequate.
This article proposes a new method for evaluating prevention of mother-to-child transmission of HIV (PMTCT) programmes. The authors suggest that HIV-free survival is the gold standard (or ideal measure) for settings with limited resources. It captures not only HIV infections, as well as deaths prevented, but also the benefits of survival for all children exposed to HIV including those that do not become infected. The authors also propose modifying regular country-wide Demographic and Health Surveys (DHS) by including more detailed questions regarding maternal HIV history, PMTCT programme enrolment and interventions received, infant feeding practices and household child mortality. In sampled households, they advocate the addition of a ‘heel stick’ for dried blood spot collection among children less than two years of age. The authors conclude that modifying the DHS as they propose could provide a reliable method for assessing PMTCT effectiveness which could be used Africa-wide. It would also have the added advantage of including women who have not accessed institutional obstetric care and would otherwise have been excluded from most assessments.
As part of its contribution to closing the ‘10/90 gap’, the GFHR conducts studies of the flows of financial resources for health research and the extent to which these address the health needs of the poor and marginalized. This new volume of Monitoring Financial Flows for Health Research looks behind the global totals and examines several facets of the overall picture. The report highlights the revolution of a much broader and more holistic definition of health and the need for a wider and more multisectoral approach to understanding the determinants of health.
Annual global spending on health research has more than tripled in a period of 10 years rising to just under US$106 billion from US$30 billion. Despite this sharp growth, the "10/90 gap" persists. This study of financial flows for Health Research by the Global Forum for Health Research is presented as a contribution to answering the questions on how the world's health research resources are being used. Important gaps will be exposed and action galvanized to close them - namely, by leveraging global health research in a way that genuinely improves global health, i.e. the health of the many - the 90 per cent - not just the few.
This second Global Forum assessment responds to widespread interest on the part of those who fund research, manage and set priorities in different institutions and use our results to try to improve the health of populations around the world. The study presents a new estimate of global spending on health R&D for 2001 but also exposes major gaps in the availability of good quality data from all sectors, disease-specific information and the measure of complex determinants such as poverty, inequity, and gender.
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. The objective was to review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example. 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. 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. 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.
Monitoring pro-poor health policies at the regional level can support countries and regional bodies to identify gaps in addressing poverty and health, strengthen the link between regions and member states and hold actors accountable to their commitments. The Southern African Development Community (SADC) has conducted work in understanding how poor health and poverty coincide, are mutually reinforcing, and socially-structured by gender, age, class, ethnicity and location, with health policy documents on the issues. Yet guidelines and policies have been unevenly implemented. The Poverty Reduction and Regional Integration (PRARI) project seeks to support the development of a monitoring system to measure the contribution of regional governance in the development of pro-poor health policies in collaboration with key stakeholders in the region. The paper describes the system. It builds on existing efforts in the region and focuses on policy areas such as the social determinants of health; HIV/AIDS, TB and malaria; non-communicable diseases; maternal and child health; human resources for health; pharmaceuticals; among others. Global developments such as those related to the incoming Sustainable Development Goals (SDGs) are also considered. In order for this indicator-based monitoring system to be effective and to have an impact, it is argued to require regional ownership, active participation of national and regional experts throughout the process of indicator development, implementation and evaluation and evidence that it will address health priorities for the region.
This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards Universal health coverage (UHC). The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These components link directly to the definition of UHC and measure the direct results of strategies and policies for UHC. The studies also show how UHC monitoring can be fully embedded in often existing, regular overall monitoring of health sector progress and performance. Several methodological and practical issues related to the monitoring of coverage of essential health services, financial protection, and equity, are highlighted. Addressing the gaps in the availability and quality of data required for monitoring progress towards UHC is critical in most countries.
The Millennium Declaration, adopted by the United Nations in 2000, set a series of Millennium Development Goals (MDGs) as priorities for UN member countries, committing governments to realising eight major MDGs and 18 associated targets by 2015. Progress towards these goals is being assessed by tracking a series of 48 technical indicators that have since been unanimously adopted by experts. This concept paper outlines the role member Health and Demographic Surveillance Systems (HDSSs) of the INDEPTH Network could play in monitoring progress towards achieving the MDGs. The unique qualities of the data generated by HDSSs lie in the fact that they provide an opportunity to measure or evaluate interventions longitudinally, through the long-term follow-up of defined populations.