The Department of Health (DoH) derives its mandate from the National Health Act of 2003, which requires that the department provides a framework for a structured and uniform health system for South Africa and sets out the responsibilities of the three levels of government in the provision of health services.
Its mission is to improve health by preventing illness and disease,and promoting healthy lifestyles. It aims to consistently improve the healthcare delivery system by focusing on access, equity, efficiency, quality and sustainability.
The department’s focus over the medium term was on preventing and treating communicable and non‐communicable diseases (NCDs), overseeing primary healthcare (PHC) services, strengthening the health system, supporting tertiary healthcare services, improving health infrastructure, and developing human resources for the health sector.
South Africa has a high burden of communicable and NCDs, many of which require dedicated and targeted prevention and treatment programmes. Funds have been allocated for the prevention and treatment of HIV and tuberculosis (TB). These funds are expected to ensure that a targeted seven million people per year receive antiretroviral treatment by 2025/26.
The National Strategic Plan (NSP) for the Prevention and Control of NCDs and the roll-out of the National NCD Campaign were expected to accelerate the country’s response to the challenges of NCDs. The National NCD Campaign aims to strengthen the district’s community-based response in line with the Integrated People Centred Health Service approach on the prevention and control of NCDs.
The NSP endeavours to lay a foundation for action through a cascading strategy, similar to the 90-90-90 approach for HIV and AIDS, and TB. This strategy was initially be designed to address the burden of diabetes and hypertension and will,be refined and updated progressively to include other NCDs.
The proposed 90-60-50 cascade for diabetes and hypertension are the first steps to improving early detection and treatment of NCDs as follows:
The DoH aimed to have 25 million people screened annually for high blood pressure and elevated blood glucose respectively, to ensure ongoing surveillance and early disease detection and diagnosis.
The department has made significant strides with the fight against HIV and AIDS, TB and Sexually Transmitted Infections (STIs). It had, in terms of the NSP for HIV, TB and STIs (2023 to 2028), developed an acceleration plan which identified 100 facilities in 17 districts in all nine provinces with a high burden of HIV and AIDS.
By focusing on these areas, the department aimed to reach 95-95-95 by 2025 and the elimination of HIV and AIDS as a health threat by 2030. Since the new infection of young people, especially adolescent girls and young women, is a major challenge in South Africa, the DoH aims to reduce HIV and STIs for youth aged 15-24 years by 40% by 2025 through National Youth HIV Prevention Strategy and Campaign called Zikhala Kanjani.
To increase the efficacy and viral suppression, the department has made the drug Tenofovir, Lamivudine and Dolutegravir or TLD more accessible for adults and adolescents, and a number of new, safer and effective treatments have also been added.
A very effective treatment for children called Paediatric Dolutegravir (DTG) has been approved by the South African Health Products Regulatory Authority (SAHPRA). All these new medicines are expected to increase safety and efficacy. TB remains a twin infectious disease and cause of mortality in the world and in South Africa. TB screening is done at health facilities when clients come for other services. The new shorter treatments will see Drug Resistant TB treatment moving from nine months from a previous two years before 2018 to a new six months treatment. Treatment of children with drug-sensitive TB will reduce from six months to four months.
From 1 April 2023, the DoH’s port health services function was shifted from PHC programme to the Border Management Authority, a newly established entity of the Department of Home Affairs. This involves shifting an estimated 295 employees from the programme to the authority.
The department will continue to provide policy guidance to the authority for port health services. Funds have been over the medium term to fund the prevention and treatment of malaria, human papillomavirus and outreach services provided by community health workers.
The NHI Bill is being considered by Parliament. If enacted, it will have considerable implications for how healthcare in South Africa is funded and organised. An amount of R2.2 billion over the medium term is allocated to the direct NHI grant for provincial health departments to contract health professionals and healthcare services, including PHC doctors, oncology services and mental health services.
The DoH also manages the NHI indirect grant, which has three components and a budget of R6.9 billion over the medium term. The non‐personal services component of R2 billion over the next three years supports activities aimed at strengthening the health system, such as health information systems, quality improvement initiatives and the dispensing and distribution of chronic medicines.
Supporting tertiary healthcare services
Funds have been allocated to subsidise highly specialised services at the country’s 31 tertiary and central hospitals. These hospitals are generally in urban areas and are unequally distributed across provinces, resulting in a large number of referrals of patients from rural provinces to provinces with greater tertiary services capacity.
The grant aims to compensate these provinces for providing hospital care and has a developmental allocation earmarked to establish tertiary services in provinces with limited access to them. For example, oncology services are planned to be rolled out in Mpumalanga and Limpopo to reduce referrals to Gauteng.
Improving health infrastructure
South Africa’s public health infrastructure has many shortcomings, including old and often poorly maintained health facilities in need of repair, refurbishment and sometimes replacement. There is also a need to invest in new infrastructure where there are gaps in service delivery because of historical inequities or demographic changes. By mid-2023, construction of the Limpopo Central Hospital in Polokwane, which will be the first central hospital in the province, was underway.
Developing human resources for the health sector
Compared to other middle‐income countries, South Africa has a shortage of medical doctors and specialists. To improve the country’s doctor‐to‐patient ratio, government has increased the number of doctors trained at domestic medical schools through a combination of bursary schemes that target students from underprivileged areas, and has increased the general intake at medical schools.
As a supplementary measure, government has also funded training for South African doctors in other countries such as Cuba. As part of the final stages of their training, medical students must complete statutory internships and community service in the public sector.
In line with the increased training, the number of medical interns appointed by provinces has increased from 1 500 in 2015 to 2 625 in 2022, and community service doctors from 1 322 to 2 369 over the same period.
Health systems
PHC is at the centre of improving access to and quality of health services. The drive towards all PHC facilities attaining Ideal Clinic status was derailed by the COVID-19 pandemic but is gaining momentum again. In the 2023/24 financial year, the DoH expect 200 more PHCs to attain ideal status, bringing the number to 2 400.
To improve Patient Records management, the Health Patient Registration System has been rolled out in 3 211 public health facilities, out of which 267 PHCs and 2 870 are clinics and 74 hospitals. Building on the learnings from the development and roll-out of the Electronic Vaccination Data System, the department was in 2023 expected to introduce the first module of the Electronics Health Records focusing on HIV and TB.
Emergency medical services (EMS) is an important component of PHC and the department was assessing all provinces for compliance with EMS regulations.
The recently approved NSP for the Prevention and Control of NCDs and the roll of the National NCD Campaign will accelerate the country’s response to the challenges of NCDs.
The National NCDs Campaign has been established to strengthen the district’s community-based response in line with the Integrated People Centred Health Service approach on the prevention and control of NCDs.
The department is participating in the Cluster: Social Protection, Community and Human Development, which coordinates implementation of cross cutting focus areas that affect women, youth and persons with disabilities. One of the outcomes is to increase access to development opportunities for children, youth and parents/guardians including access to menstrual health and hygiene for all women and girls.
The DoH’s flagship programme, the CCMDD or fondly called by patients as “Dablap meds”, meaning short cut, creates an alternative access to chronic medication. Now that people live longer, the burden of costly long-term chronic conditions and preventable illnesses that require multiple complex interventions over many years continues to grow. This is a positive impact informing one of the overarching goals of the National Development Plan, which focuses on raising the life expectancy of South Africans to at least 70 years by 2030.
The DoH plans to do more to increase public knowledge on mental health issues including early signs of mental illness, avoiding preventable risk factors, early help seeking behaviour for mental illness symptoms and where people should go for help and treatment.
Unlike other disciplines that require mostly sophisticated technologies to diagnose and treat illnesses, mental health require mostly human resources to diagnose, care, treat and rehabilitate mental illnesses. There is a need to continuously upskill health professionals to ensure that they have the required capacity for early identification and treatment of mental illnesses.
By mid-2023, a total of 2 393 medical doctors and professional nurses had been trained on basic clinical mental health skills.
The department had motivated for funds from National Treasury to contract private mental healthcare professionals to complement the already existing staff and render mental health services at PHC.
Provinces have used this indirect grant to contract psychiatrists, psychologists, occupational therapists, social workers and registered counsellors to render mental health services at PHC. The contracted clinical psychologists and psychiatrists also conduct forensic mental observations of accused referred by the courts in terms of the Criminal Procedures Act of 1977.
Mental health content has been integrated into the curriculum of community healthcare workers, to assist in identifying and referring those that need mental health services as they visit households.
The DoH has integrated mental health into the general health services environment in compliance to international standards in the area of mental health.
Among others are the following:
The department aimed to continue strengthening its collaboration with the Department of Correctional Services, Department of Justice and Constitutional Development, South African Police Service and the National Prosecuting Authority to improve outcomes in the area of forensic mental health.
It aimed to continue strengthening community based mental health services by licensing and providing subsidies to these facilities which are mostly run by the civil-society organisations. By mid-2023, there were 297 residential and 133 day care community-based mental health facilities that are licensed and subsidised by provincial departments of health in terms of Regulation 43 of the General Regulations of the Mental Health Care Act of 2002, as amended.
According to Statistics South Africa’s Census 2022, the population of South Africa increased from 51,7 million in 2011 to more than 62 million in 2022; a growth rate of 1,8% in the intercensal period. Females constituted 51,5% of the total population, while 48,5% were males. Gauteng and KwaZulu-Natal had the highest populations at 15 million and 12,4 million respectively, while the Northern Cape had the smallest (1,3 million).
Black Africans remain the dominant population group at 81,4%, followed by the coloured population at 8,2%. The white population percentage declined to 7,3% in 2022 from 8,9% observed in 2011, while that for Indians/Asians increased slightly from 2,5% in 2011 to 2,7% in 2022. The median age increased to 28 years from 25 years in 2011, suggesting a consistent increase over time and an overall increase of three years.
In 2022, Gauteng recorded the highest population (15 099 422) followed by KwaZulu-Natal (12 423 907) in 2022, while Northern Cape (1 355 946) and Free State (2 964 412) reported the lowest population sizes among the provinces.
Gauteng is the only province where the proportion of females has been consistently below 50% since 1996. Limpopo (52,8%) and Eastern Cape (52,6%) had the highest proportion of females, more than the other seven provinces and the national percentage (51,5%). The black African population remains the biggest population group across all provinces since 1996. The black African population was highest in Gauteng (12 765 312) and KwaZulu-Natal (10 535 830), and lowest in the Northern Cape province (679 383).
The highest number of the coloured population was in the Western Cape over time; proportionally, they also remained the highest in the Western Cape at 42% in 2022, although they declined from 56% in 1996.
The largest concentration of the white population group was recorded in Gauteng (1 509 800) followed by the Western Cape (1 217 807) in 2022. However, the proportion of the white population declined gradually within each province over time; for instance, the white population constituted 22% of the population in Gauteng in 1996, but declined to only 10% in that province in 2022. It was 21,4% of the Western Cape population in 1996 and declined to just above 16% of the total population in that province in 2022.
The total number of the Indian/Asian population recorded in 2022 was 1 697 505; provincially, the highest number of the Indian/Asian population remains in KwaZulu-Natal (1 157 542) followed by Gauteng (329 736). This population group remained steady within these two provinces at just below 10% in KwaZulu-Natal and only 2% of the Gauteng population.
The NHI aims to ensure that all citizens and residents of South Africa, irrespective of socio-economic status, have access to good-quality health services provided by both the public and private sectors, thereby eradicating financial barriers to healthcare access. The NDP envisions a health system that works for everyone, produces positive health outcomes and is accessible to all.
By 2030, the NDP expects South Africa to have, among other things, raised the life expectancy of South Africans to at least 70 years; produced a generation of under-20s that is largely free of HIV; achieved an IMR of less than 20 deaths per thousand live births, including an U5MR of less than 30 per thousand; achieved a significant shift in equity, efficiency and quality of health service provision.
Potential benefits from the NHI Fund would include:
By August 2023, there were over 71 registered medical schemes in South Africa,with over eight million beneficiaries. There were also 32 administrators, R233 billion in member contributions, 43 managed-care organisations, 7 567 accredited healthcare brokers and 2 185 accredited healthcare brokerages.