1. OUTCOME 2: A LONG AND HEALTHY LIFE FOR ALL SOUTH AFRICANS 1

2. 1. Outcome-based approach (1) 14 Outcomes 1.Quality basic education (Chapter 9 of the NDP) 2.A long and healthy life for all (Chapter 10) 3.All people in South Africa are and feel safe (Chapters 12 and 14) 4.Decent employment through inclusive economic growth (Chapter 3) 5.Skilled and capable workforce to support an inclusive growth path (Chapter 9) 6.An efficient, competitive and responsive economic infrastructure network (Chapter 4) 7.Vibrant, equitable, sustainable rural communities contributing to food security for all (Chapter 6) 2

3. 1. Outcome-based approach (2) 8.Sustainable human settlements and improved quality of household life (Chapter 8) 9.Responsive, accountable, effective and efficient local government system (Chapter 13) 10.Protect and enhance our environmental assets and natural resources (Chapter 5) 11.Create a better South Africa, a better Africa and a better world (Chapter 7) 12.An efficient, effective and development oriented public service (Chapter 13) 13.Social protection (Chapter 11) 14.Nation building and social cohesion (Chapter 15) 3

4. 3. Life expectancy Indicator2009 level 2014 targetLatest available measurement Improved life expectancy (LE) 56.5 years58.5 years59.6 years (Stats SA, 2013) 4 Analysis LE target achieved partly due to comprehensive response to HIV & AIDS o However, life expectancy still compares poorly with other countries with similar or lower levels of investment Remaining challenges to further improvements in life expectancy include: o Complexity of quadruple burden of disease (HIV and AIDS, maternal and child mortality, Non-Communicable Diseases (NCDs), and trauma and violence). o Rising prevalence of NCDs, trauma and injury o Increasing impact of social determinants of health (poverty, poor nutrition, limited access to water and sanitation, etc) o Weaknesses with provision of water and sanitation in some areas, which are critical for positive health outcomes

5. 4. Maternal and child health (1) Indicator2009 levelTarget for 2014Latest measurement Infant Mortality Rate (IMR) 40 per 1 000 live births 36 per 1 000 live births 30 per 1 000 live births (MRC, 2011) U-5 mortality rate 56 per 1 000 live births 50 per 1 000 live births 42 per 1 000 live births (MRC, 2011) Neonatal Mortality Rate (<28 days) 14 per 1,000 live births 12 per 1,000 live births 14 per 1,000 live births (MRC, 2011) Maternal mortality ratio 310 per 100 000 live births (2008) 270 per 100 000 live births 300 (World Health Organisation and World Bank, 2010) 5 Note: Stats SA has produced 2013 data on some of these indicators, using a different measurement methodology to that used by the MRC. The Stats SA methodology produces higher baseline and current statistics, but also indicates a downward trend. In the interests of consistency, we have continued to use the MRC data, which was also used in the 2009 baseline in the table above.

6. 4. Maternal and child health continued…(2) 6 Analysis  Progress with meeting targets for child health linked in part to ART and PMTCT  However, maternal and child mortality still unacceptably high  Remaining challenges include: o Community delays in seeking healthcare o Weak management and poor quality of health care offered: -Poor compliance with clinical guidelines, shortage of supplies and poor infection control -Inadequate emergency obstetric care and postnatal care o High levels of malnutrition and stunting among children o Varied performance of immunisation programmes in health districts (ranging from 55,2% in Alfred Nzo District in the Eastern Cape to over 100% (125%) in the City of Johannesburg, in Gauteng)

7. 5. HIV and AIDS and TB (1) Indicator2009 levelTarget for 2014 Latest measurement PMTCT rate <23.5%<2%2.5% (Health, 2012/13) ART coverage1.1 million2.5 million2.2 million TB cure rate63.4%85%73.8% (Health, 2012/13) TB defaulter rate7,9%<5%6,1% (Health, 2012/13) 7

8. 5. HIV and AIDS and TB (2) Analysis  Progress with PMTCT and ART due to:  Bold leadership in turning the tide against HIV&AIDS – acknowledged even by the international community, eg. UNAIDS  Dedicated human resource capacity to accelerate implementation of PMTCT throughout the country  Increased number of facilities providing ART, with dedicated personnel  Social mobilisation and private sector participation  Costs of ARV drugs halved – government can treat more people within same resource envelope  Introduction of the Fixed Drug Combination (FDC) in 2013 will further enhance access to ART  Reported shortage of ARV supplies in some provinces a cause for concern 8

9. 5. HIV and AIDS and TB (3) Analysis continued..  Progress with TB cure rate due to:  8 million people tested for TB and linked to care  Significant reduction in cost of TB medicines  Early detection and diagnosis  Decrease in the TB defaulter rate  Improved TB case finding through GeneXpert Technology  Need to accelerate implementation of internal monitoring system for tracking people on ART and TB treatment  Remaining challenges resulting in difficulty in achieving target:  High TB incidence  High HIV-TB co-infection and limited integration of TB and HIV services  Social determinants of TB such as poverty, crowded housing, etc.  Need more social mobilisation and community involvement in combating TB  Need more district-level analysis and focus on strengthening lower performing districts with regard to TB management 9

10. 6. Quality of health care Indicator2009 levelTarget for 2014 Latest measurement Patient satisfaction (very satisfied) 54%70%61,9% (Stats SA GHS 2011) Proportion of complaints from users of health services resolved within 25 days 60% (2010/11 baseline, Health) 80% 57% (Health, 2012/13) 10 Analysis  Improvements in patient satisfaction due to: -National leadership in development of norms and standards for quality -Health facility audit against the norms and standards -Proactive deployment of facility improvement teams to address gaps -Initiation of health facility inspections  Significant remaining challenges with quality of service  Further improvements would be supported by:  Use of facility audit data as a baseline for on-going monitoring of the quality of health service delivery, both by external monitors, and by facility, district, provincial and national managers  Improving monitoring and resolution of patients’ complaints, and provision of feedback to users of public health services

11. 7. Re-engineering of the health care delivery model (1) Indicator2009 levelTarget for 2014Latest measurement PHC outreach team coverage (ward) No baseline (new prog.) 1 team per 1619 households 1 team per 4,725 households (Additional 945 Ward-based Outreach Teams (WBOT) were established in 2012/13, resulting in a cumulative total of 3058 teams. Given the total of 14,450,161 households in South Africa (Census, 2011), this translates to a ratio of 1 team per 4,725 households) District Clinical Specialist Teams No baseline (new prog.) 80% of total districts with team 34/52 districts (65%) with at least 3 members of the District Clinical Specialist Teams appointed School- based PHC teams No baseline (new prog.) 95% of all Quintile 1 schools Estimated 10,114 schools visited (100%). However, a manual information system was used, which has led to double counting of some schools 11

12. 7. Re-engineering of the health care delivery model (2) 12 Analysis Although progress has been made, significant challenges remain: o Shortage of health professionals and medical specialists o Limited expertise in intersectoral action to address social determinants of health o Limited public awareness about benefits of health promotion and prevention rather than seeking hospital-based treatment The department has a range of initiatives in place aimed at addressing these challenges o Some medium to long term strategies have begun to demonstrate results – e.g. Cuban Medical Training Programme shows improved outputs. o Intake of medical students in RSA has increased through initiatives of the DoH o Some challenges are difficult - e.g. while there has been progress in reducing the rate of exodus of trained health professionals and medical specialists, this remains a challenge because they can obtain better packages elsewhere

13. 8. Strengthening management of health system (1) Analysis  Regulations promulgated for minimum competency criteria for hospital CEOs  102 new hospital CEOs appointed in January 2013, based on regulations  Health Leadership and Management Academy established  National monitoring of non-negotiable provincial budget components to ensure appropriate expenditure for delivery critical health services  Improvement in expenditure on health infrastructure Indicator2009 levelTarget for 2014 Latest measurement Unqualified audits3/1010/102/10 for 2011/2012 (A-G) (NDoH and WC DoH) 13

14. 8. Strengthen management of health system (2) Analysis continued…  Lack of progress in previous financial years towards unqualified audits largely due to weak asset management and supply chain management in provinces  Audit process for 2012/13 still in progress  Additional management challenges include: o Limited delegation of powers by provinces to district and facility health management o Poor maintenance of infrastructure, lack of cleanliness, weaknesses in infection prevention and control, patient safety, staff attitudes o Insufficient operational management capacity (e.g. inefficient business processes for patient registration and drug supply and management, which impacts on patient care and patient waiting times)  Inadequate governance and management at district and sub-district levels 14

15. 8. Strengthen management of health system (3) Analysis continued…  Again, the department has a range of initiatives in place to improve the management of the health system, including for example:  Establishment of the Office of Health Standards Compliance, which has set core health service delivery standards and has started to monitor compliance with these  Appointment of managers who meet minimum qualification and competency requirements  Establishment of the Health Management and Leadership Academy  Additional measures which could further strengthen health system management  Institutionalise use (monitoring and analysis) of health service information by local level managers to improve service delivery  Institutionalise internal (local) monitoring of core health service delivery standards (monitoring of compliance by facility, district and provincial managers)  Provide facility and district level managers with support on how to improve operational management 15

16. 9. Piloting of NHI Analysis  Bold leadership has resulted in significant progress  However, inequitable distribution of resources in the national health system makes establishment of NHI difficult: -Shortage of health professionals in the public sector -Limited expenditure of the NHI conditional grant - the grant has since been split into a direct component (to provinces) and an indirect component (managed by national), with the aim of accelerating expenditure -Huge infrastructure and maintenance backlogs in some districts -Concerns about quality of public health services – Health Facility Improvement Teams established -Spiralling private health care costs -Historical inequities between the private and public health sectors Indicator2009 levelTarget for 2014 Latest measurement NHINew initiative Policy & legislative framework NHI 10 pilot districts NHI 11 pilot districts established (Health) Health systems strengthening and quality improvement interventions are underway in the pilot districts 16

17. 10. World Bank, World Development Indicators 2013 Selected African Countries U5 Mortality Rate (2010) per 1,000 live births Maternal Mortality Ratio Per 100,000 (2010) Prevalence of malnutrition, underweight – % of children under 5 (2010) Incidence of TB per 100,000 people (2010) Selected SADC Countries Angola13545015,6304 DRC16854028,2327 Botswana4916011,2503 Lesotho9762013,5633 Malawi9746013,8219 Mozambique13449018,3544 South Africa 51300 (2009)8,7981 Zambia11944014,9462 Other African countries Algeria10 973,790 Tunisia15563,325 17

18. 10. World Bank, World Development Indicators 2013 BRICS Country Period U5 Mortality Rate per 1,000 live births Maternal Mortality Ratio per 100,000 live births Prevalence of malnutrition, weight for age, % of children under 5 Brazil1990581606 199940 20111656 (2010)2,2 Russia199021503 199920 20111234 (2010)No data India199011241045 199990 201161200 (2010)43,5 China199047559 199937 20111537 (2010)3,4 South Africa199073 150 (SADHS 1998) 9 199958 201142300 (2010)8,7 18

19. 11. Looking Ahead 10 POINT PLAN 2009-20144 NSDA OUTPUTS 2010-2014 MDGS 2000-2015 NATIONAL DEVELOPMENT PLAN (NDP) 1.Provision of Strategic leadership and creation of a social compact for better health outcomes; 2.Implementation of National Health Insurance (NHI); 3.Improving the Quality of Health Services; 4.Overhauling the health care system; 5.Improving Human Resources, Planning, Development and Management; 6.Revitalisation of infrastructure; 7.Accelerated implementation of HIV and AIDS and Sexually Transmitted Infections National Strategic Plan, 2007-2011 and reduction of mortality due to TB and associated diseases; 8.Mass mobilisation for better health for the population; 9.Review of Drug Policy; and 10. Strengthening Research and Development 1. Increasing life expectancy; 2. Decreasing child and maternal mortality rates; 3. Combating HIV and AIDS and STIs and decreasing the burden of disease from Tuberculosis; 4. Enhancing health systems effectiveness MDG Goal 4 MDG Goal 5 MDG Goal Targets for 2030 1.Average male and female priorities increased to 70 years; 2.Tuberculosis prevention and cure rates progressively improved ; 3.Maternal and child mortality rates reduced; 4.Prevalence of chronic Non- Communicable Diseases reduced by 28%; 5.Injury, accidents and violence reduced by 50% from 2010 levels; 6.Health systems reforms completed. 7.Primary Health Care teams deployed to provide care to families and communities; 8.Universal Health Coverage achieved; 9.Posts filled with skilled, committed and competent individuals. 19

20. THANK YOU! 20