Field reports South Africa
Health promotion in South Africa Hans Onya1
Abstract: Health promotion first entered the South African health system in 1990. Today, Health Promotion is a Directorate located within the Social Sector Cluster (SSC) within Primary Health Care (PHC), District and Development operations which falls under the Deputy Director General for Health Service Delivery in the National Department of Health (DoH). The first significant piece of new policy for health promotion in South Africa appeared in the African National Congress (ANC) health policy document, health care services including reproductive health care. At the moment, health promotion service delivery is the responsibility of the national, provincial and local governments with provincial and local governments mainly implementing and the National Health Promotion Directorate offering support. Funding for health promotion activities comes from the Department of Health budget allocation by the National Treasury. One major problem for Health Promotion development is infrastructure. There is significant community participation in South Africa including health promotion policy and strategy document development. Health Promotion research and evaluation is limited. The National Department of Health considers the settings approach to be crucial in driving the progress of health promotion. There are very few trained health promotion specialists either capable or in the position to inform politicians and opinion leaders about the relationship between health and social determinants, and the evidence of effectiveness of health promotion action. Mechanisms for demonstrating evidence of health promotion effectiveness in terms of health, social, economic and political impact are lacking and occupational standards for health promotion education and training are needed. (Promotion & Education, 2007, XIV (4): pp 233-237) Key Words: apartheid, community participation, health policy, primary healthcare, Résumé en français à la page 266. Resumen en español en la página 280.
KEY POINTS • Health promotion first entered the South African health system in 1990. • The first policy for health promotion appeared in the African National Congress health policy document. • There is still much misunderstanding of health promotion. • There are very few trained health promotion specialists. • Infrastructure for promoting health should be located at the Presidency.
South Africa has a long history of a commitment to a broader concept of promoting health both before and during legislated apartheid, but the introduction of the modern discipline of health promotion to the health system is fairly recent. Health promotion first entered the South African health system in 1990 (Coulson, 2000). Since then, the South African Government has both undertaken significant institutional transformation, as well as sought to redefine most of the policies that determine the activities of state in the management of social relations and service delivery including health services. Some of the pillars of Apartheid policy, which sought the exclusion of the majority from full participation in all aspects of South African society, had begun to crumble by the late 1980s (Department of Health, 2006). However, since 1994, the qualitative difference is that the state set out systematically and deliberately to dismantle apartheid social relations and create a democratic society based on the principles of equity, non-racism and non-sexism. In line with the prescripts of the new Constitution, new policies and programmes have been put in place to dramatically improve the quality of life of all the people. Key to this programme of action has been the extension of universal franchise and the creation of a democratic state (Constitution of the Republic of South Africa, 1996). This has created the requisite environment to address poverty and inequality, and to restore the dignity,
safety and security of citizens. A comprehensive constitutional, policy and regulatory framework underpin this programme. Defined by the Reconstruction and Development Programme (RDP), the programme has been elaborated in all post 1994 policies cross cutting all spheres of societal development (RDP, 1990). South Africa is classified as a middle income country, with a GDP per capita of approximately R29 422 (or US $4 562), with GDP of R1 374.476 billion (or US $213 100.4 millions) in 2004 and a population estimated at about 46 million (Statistics South Africa, 2003). Since 1994, economic growth has been positive, with the exception of 1998 due to the East Asian crisis. GDP growth is now approaching 4 percent per annum and employment creation is improving (DoH, 2005). There are unique difficulties pertaining to comparative data in South Africa, deriving in the main from the fact that prior to 1994 a number of regions in the country, largely the poorest areas, were classified as independent homelands and therefore excluded from the country’s data. Further, the 1995 Income and Expenditure Survey (IES) was not based on clearly demarcated and adequately mapped enumeration areas, whereas the 2000 IES was based on improved demarcation and listing of households, based on Census 1996. The healthcare provided by the apartheid government was racially based with large well equipped hospitals emerging in Afrikaner strongholds such as Preto-
1. Director of Health Promotion Unit, School of Public Health, University of Limpopo, South Africa. Correspondence to: Private Bag X1106, Sovenga 0699, South Africa. ([email protected]
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Field reports South Africa
tive health care b. sufficient food and water c. Social security, including, if there are unable to support themselves and their dependents, appropriate social assistance.
Minister of Health
Deputy Minister of Health Director General
Health Services Delivery
PHC & District Development
Health Promotion Directorate
PC = Provincial Coordinators
Figure 1. Organisational structure within the government health system
ria, Stellenbosch and Bellville, while the facilities in the homelands were under funded, under equipped and understaffed. The legacy for health education and promotion in government was both didactic and racist. In the 1980s progressive health organisation started to emerge (Coulson et al., 1998). People were beginning to be organized through community and workplace issues such as poor housing, lack of health services, poor transport services and campaigns around health were being linked to the broader social and political issues. Today, there is a Directorate of Health Promotion located within the Social Sector Cluster (SSC) within Primary Health Care (PHC), District and Development operations which falls under the Deputy Director General for Health Service Delivery in the National Department of Health (DoH) (see fig. 1). The action area for the SSC includes among others: – Promotion of national identity and social cohesion. – Comprehensive health care – addressing challenges of communicable and noncommunicable diseases. – Meeting the increasing challenge of housing and human settlement. – Food security and nutrition
The government departments that constitute the SSC are: Health, Social Development, Provincial and Local Government, Water Affairs and Forestry, Environmental Affairs and Tourism, Statistics South Africa, Transport, Labour, Education, Public Service and Administration, Housing, Minerals and Energy, Agriculture, the Presidency and National Treasury. The Directorate of Health Promotion is one of several sections representing the DoH in the SSC and is headed by a Director. Each of the nine provincial governments has Health Promotion Focal Persons.
Health promotion policy The first significant piece of new policy for health promotion in South Africa appeared in the African National Congress (ANC) health policy document. Drawing extensively on the policy processes both inside and outside the country, the ANC recognised the significant contribution that health promotion could make to strengthen its commitment to improving the health of South Africans and its vision for Primary Health Care (PHC). Section 27 (1), Chapter 2 of the constitution of South Africa states: Everyone has the right to have access to: a. health care services including reproduc-
Subsection (2) went further to say that, “The state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights” (Constitution of the Republic of South Africa, 1996). The white paper on the transformation of health services published in 1997 pointed to the political and structural changes introduced through the transition to democracy, reconstruction and development and the principles elaborated by the Reconstruction and Development Programme (RDP) as being important cornerstones for developing necessary health promotion initiatives. Principle activity for an effective health promotion strategy were deemed to be the development of public policies and legislation, community action, skills development, promoting a healthy physical and social environment, empowerment of communities and individuals to promote their own health and a focused reorientation of the health services and service delivery (DoH, 1997). The National Commission on Higher Education Report released in 1996 also highlighted the need for capacity building and workforce development which took account of the broader changes envisaged for the healthcare delivery. The document also indicates a need to build educational competence, and intellectual and research capacity in institutions (Department of Education, 1996). The RDP recognised a primary healthcare (PHC) approach as the means to address the imbalances of the past. Health promotion is one of the main pillars of PHC in South Africa, which focuses on social justice and development, and offers a different perspective on achieving Health for All. South Africa health promotion policy, which is based on the Ottawa Charter (World Health Organisation, 1986) has gone through an extensive process of consultation and is now in a final draft. The above policies and others are well aligned across government. To facilitate coordination of health and other sectors policies, the three government cluster sectors (social, security and economic) have task teams that meet regularly to look at policy implementation, review and improvement. The overall policy coordination is the responsibility of the Deputy Director General (DDG) for Policy and Strategic matters in the office of the President. There are sev-
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eral well articulated healthy policies and programmes that have been put in place to dramatically improve the quality of life of all the people of South Africa. One example is the introduction of legislation on tobacco control aimed at reducing morbidity related to smoking. This has been one of the biggest achievements in the area of health promotion in South Africa (Tobacco Product Control Amendment Act., 1999). Surveys suggest that legislation and policies implemented to curb tobacco use amongst both youth and adults have resulted in decrease in smoking prevalence between 1998/99 and 2002 (DoH, 2004).
are health promotion (Andrew & Pillay, 2005). Currently, health promotion service delivery is the responsibility of the national, provincial and local governments with provincial and local governments mainly implementing and the National Health Promotion Directorate offering support. There are also national NGOs (such as SOUL CITY, LOVElife) and CBOs operating across the country providing health promotion services. The result is that health promotion services are grossly proliferated with no single body coordinating activities. There is, therefore, a need for a well coordinated monitoring and evaluation of health promotion services.
Health promotion services Health promotion in South Africa is based on intersectoral collaboration. The governments (national, provincial and local) recognise that good health and wellbeing rely on a range of factors, many of which lie outside the health sector itself. The Health Sector strategic framework, 2004-2009 has 10 priorities most of which
Health promotion funding and resources Funding for health promotion activities comes via the Department of Health budget allocation from the National Treasury. This however, is not the only source of funding for health promotion in South Africa. International donor agencies, such as the United
Nations Agencies, bilateral Aid Agencies and various Foundations support health promotion intervention and research, technically and financially. There is funding in South Africa to build capacity for action on health promotion and social determinants to increase understanding and to develop a skilled workforce. However, the allocation or utilization of these funds for such purposes has not received priority attention from DoH. Some donor agencies as well as provincial governments have provided funding for training in health promotion, but only to assist in short in-service training of local health workers; some national workshops and recently re-training of former Community Liaison Officers (CLOs) and other community based health workers in basic health promotion. The relationship between health and social determinants is well known to politicians and opinion leaders in South Africa. There is a commitment to doing something about health promotion by Health Ministers, with a desire to strengthen lifestyle
Table 1. Number of Health Promoting Schools launched by province and activities Province
No of Health Promoting Schools
Total No of Schools
Creating supportive environment, partnership formation, working with business, media etc. Anti Tobacco programmes (in 20 schools), Paraffin safety (in three districts). Promotion of food kitchen, HIV and AIDS programmes life skills education
Development of healthy life-style, creating healthy & safe environment. Community-School health Service, Stakeholders mobilization & networking
Peer education programme, Vegetable gardening, Soup kitchen, Food parcels, Scholar patrols and road safety, Water saving, School safety programme.
28 launched 36 awarded HPS Status 64 Total
Nutrition and physical activity, Essay compilations, Collaboration with clinics DOE/DOH & local municipalities
Advocacy, Strengthening intersectoral collaboration, Capacity-building
Planning, Policy development, Community involvement, Stakeholders involvement, Child-to-child education, Health displays.
32 in the process
Still establishing school-based committees and frames.
Widening stakeholders scope, Developing database to monitor service, Developing provincial policy.
Has HP performance group, De-worming, Annual HPS
*31 ready to be launched bring the total to 58 SOURCE: National Health promoting Schools Conference summary report of proceedings UWC-Bellville, 2006
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campaigns and develop a more robust set of programmes around non-communicable diseases and specifically around such issues as proper nutrition, hypertension and diabetes. There is also a commitment to intensify efforts to combat TB, to strengthen the implementation of the comprehensive plan for HIV and AIDS and to improve mental health services (DoH, 2005). There is a stable structure for health promotion service delivery, at the national government level (The Directorate of Health Promotion) and health promotion focal persons in each province. However, there are disparities between provincial infrastructures. With the exception of one province (Mpumalanga), that has a career structure for Health Promotion Practitioners (HPPs), other provinces have either one officer or a skeletal staff responsible for health promotion with no established career path. Although the Mpumalanga example is not perfect, it offers some encouragement. Health Promotion practice seems to be strong in Mpumalanga compared to other provinces. There is a career structure that makes it possible for HPPs to progress to Deputy Director’s position. A recent audit in Mpumalanga (Jooste, 2006) places the number of HPPs at 120 with 34 that have received basic diploma training and 86 still undergoing training. This remarkable advancement of health promotion can be attributed to the dedication of the leadership of health promotion and political will on the part of the provincial authorities. One major problem in health promotion development in South Africa, however, is infrastructure. The level where health promotion is located both in the national and provincial governments’organisational structure is low. The location of health promotion as a Directorate within a cluster inhibits effective influence on policy development and programmes implementation. An example can be seen in the fact that the National Health Promotion policy development that started in 1997 has been stalled at the cluster level. The same goes for the Health Promotion Foundation initiative that started in 2002. Both documents are in their final draft stages at a level beyond the Directorate. Compounding this problem is the rate at which leadership changes take place at the national level. Between 1994 and 2007 the Directorate has witnessed four changes in its leadership. The effect is that high-level decisions on health promotion are made with little influence from health promotion professionals. High level advocacy and lobbying is also compromised. There is a gross inadequacy of trained human resources for health promotion work within the Department of Health, and indeed in South Africa as a whole. This sit-
uation is difficult to justify given the financial resources available that can be utilized for manpower development in the country. For example, the expenditure on programmes has seen steady growth, rising from R5,6 billion (about US$086 billion) in 2001/02 to an expected R8,7 billion (about US$1.3 billion) in 2007/08, an annual average increase of 7,6 percent (DoH, 2005). It is therefore plausible to conclude that there are resources to develop the technical capacity of health promotion professionals to provide expert policy advice and to implement programmes. To contribute to addressing the human resources problem, six universities are currently offering courses in health promotion in South Africa. In addition, a number of short courses ranging from one day to two weeks are offered to in-service officers from government departments and non-government organizations. The universities offer diploma and certificate courses, with one university offering undergraduate Bachelor of Science (BSc) degree and two universities offering Master of Science (MSc) degrees in health promotion. These courses are aimed to develop knowledge and skills in health promotion practice. At the moment student intake is low and the curriculum is not streamlined or standardised. Attempts to establish a Standard Generating Body (SGB) that would generate standards for health promotion training met stiff opposition from the Public Health Association of South Africa.
Community participation in health Community involvement in health is mainly through the work of community based organisations and mobilisation efforts of community health workers. As a democratic state, policies and guidelines for health actions receive wide consultation before they become operational. Although most health programmes are vertical programmes, links and partnership with the community are developed. Communities are empowered to manage economic, environmental, social and cultural diversity. Most of this work is done by NGOs. There is significant community participation in policy and strategy development including the health promotion policy and strategy document development. Stakeholders from civil society organizations, community leaders, private sector organizations and business are widely consulted through series of meetings in the policy development process.
Research and information There is routine monitoring and surveillance of the state of the public health
at the national level through, for example, the South African Demographic and Health Survey. In addition, public health research is conducted by the following: – National Research Institutions (Medical Research Council (MRC), Human Sciences Research Council (HSRC), Health Systems Trust (HST)) – Academic Institutions – The Media and other Government information systems. The research results are published and are readily available for use. The MRC has a Health Promotion Research and Development Group that focuses on health promotion research. The first national Youth Risk Behaviour Survey (YRBS) and the Global Youth Tobacco Survey (GYTS), (Reddy, 2003) among others were conducted by this group. In addition, independent researchers have evaluated some health promotion interventions (for example Usdin et al., 2000; Visser et al., 2000; Pelzer et al, 2004 & Kleep et al, 2006). The few evaluations of specific health promotion interventions were randomised controlled trials. One of the major problems with studies employing this design is the contamination of the control group. This poses a serious dilemma in that the practice of health promotion relies strongly on the diffusion of the effects of the intervention through the target community. The South African SOUL CITY 4 is an example of a community-based intervention in South Africa. Whether the health gain was influenced by diffusion of the intervention, or the intervention effects were produced by secular trends, cannot be determined by looking at the SOUL CITY 4 outcome measures alone. Specific Health Promotion research and evaluation reports on interventions carried out in South Africa are limited. Although there is a credible international evidence base on health promotion, its applicability has not been significantly tested. Above all, this international evidence base is not trusted in South Africa, suggesting that a conceptually sound evidence base for interventions that aim to promote health is urgently required. What constitutes evidence in London or New York may differ in Pretoria or Durban. We need to document and demonstrate local evidence of health promotion effectiveness to politicians and funders in South Africa and indeed, in the African continent as a whole.
Health promotion programmes Based on the experiences of current health promotion activities in South Africa, the National Department of Health considered the settings approach to be crucial in
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driving the progress of health promotion. Since its implementation in 1999, the Health Promoting Schools initiative is considered by the National Health Promotion Directorate to be one of their greatest breakthroughs. It was reported that a total of 580 schools (see table 1 below) had been launched across the country (see the report of 2006 National Health Promoting Schools Conference proceedings, at www.uwc.ac.za). The Departments of Education and Health worked together to develop and implement the school health programmes in 1999 and the Primary health care package of South Africa (standards and norms) of 2001 was and is still used as a guide to enhance the process. The World Health Organisation’s (WHO) Health Promoting Schools Initiative (HPSI) documents provided a guideline for HPS development in South Africa. The Department of Health, Department of Education, Department of Social Development and Population Welfare implemented a primary school nutrition programme and school food gardens for increasing food security in the families of the school children in need. A common feature of health promotion in schools is that sanitation facilities have been installed in many schools and the process of covering the remaining rural schools is being facilitated through intersectoral collaboration with the relevant social cluster, the reconstruction and development programme and the rural area development and renewal projects.
Conclusions Health promotion based on the Ottawa Charter (WHO, 1986) is an important core intervention strategy within the South African National Health System. It also forms a central framework for action to improve health within policies of the national, provincial and local governments. The key social determinants of health in South Africa include low levels of literacy, especially among women, poor sanitation and inadequate nutrition. These factors are linked to poverty, and to address them requires continued commitment and collaboration among the relevant government and private sectors. Health promotion is misunderstood and yet to establish itself as a distinct discipline. There are very few trained health promotion specialists capable and in the position to inform politicians and opinion leaders about the relationship between health and social determinants, and the evidence of effectiveness of health promotion action. An infrastructure other than the National Directorate of Health Promotion is needed to catalyse national, provincial and local actions to stimulate
non-health sectors, to avoid random interventions and to provide long-term vision. Establishing a National Health Promotion Foundation (SAHEALTH) was considered in 2002, but is currently frozen at the Department of Health. The infrastructure for promoting health should be located at the level of the Presidency and capable of harmonising, monitoring and evaluating the implementation of health promotion programmes across sectors and clusters. Such infrastructure should be approved by parliament, should be independent of the Department of Health and have dedicated funding from the National Treasury. There are sufficient grounds to believe that adequate legislative frameworks, political will and resources are available in South Africa for the effective promotion of the health of its citizens. However, mechanisms for demonstrating evidence of health promotion effectiveness in terms of health and of social, economic, and political impact need to be established. A career path for health promotion practitioners needs to be launched and standards for health promotion education and training need to be generated. The National Health Promotion Forum (NHPF) should be resuscitated or a similar body, such as a Health Promotion Union affiliated with the International Union of Health Promotion and Education [IUHPE]) should be formed. Finally, a health promotion evidence base must be developed and made accessible to, and be used by, practitioners. While practitioners need to be more critical and to substantiate their decisions with evidence, key messages must also be disseminated clearly and unequivocally to influence practice.
Acknowledgements The contributions of Kgwiti Mahlako, Rebecca Matlatla, Prudence Monyelo and Leonard Mudzanani (all of the National Directorate of Health Promotion) in the development of this report are highly appreciated.
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