Building health resilience in South Africa

The rise of diseases related to unhealthy lifestyles is placing a growing burden on South Africa’s health system. Myles Ritchie, Team Leader of the Better Health Programme, South Africa, (BHPSA), explains how a coordinated programme of disease prevention and treatment can make a difference.

Blue uniformed community health workers (CHWs) are at the frontline in South Africa’s battle against noncommunicable diseases (NCDs), which accounted for 51% of total deaths in South Africa in 2019, according to the World Health Organization. Primarily, this includes cardiovascular diseases, cancers, chronic respiratory diseases and diabetes.

CHWs, who provide basic screening and health support to people in their homes, are well placed to raise awareness about the dangers of NCDs, which are linked to factors such as diet, exercise, smoking, alcohol and air quality.

Early screening and diagnosis as well as the promotion of healthy lifestyles will need to be stepped up massively to get control of these diseases and alleviate pressure on the health system. This has become a major priority for the government of South Africa.

Until now, the threat posed by NCDs has been overshadowed by South Africa’s focus on HIV, tuberculosis (TB) and maternal and child health, which have been the main contributors to mortality rates. However, increasing successes, specifically controlling HIV through lifelong treatment, means that more people are living longer and suffering from age-related NCDs.

During COVID-19, people with NCDs were also found to suffer more severe health outcomes from the virus. Late diagnosis of diabetes in South Africa, which has resulted in increased levels of heart disease, was an additional risk factor for COVID-19.

The strain on the health system over the past two years has strengthened the case for action to improve the prevention and treatment of NCDs through grassroots action, targeted health policies and better data surveillance.

A national plan

The UK government funded Better Health Programme, South Africa, or BHPSA is a three-year programme of technical assistance to strengthen the health system by supporting South Africa’s national NCD plans.

Managed by Mott MacDonald, the programme has helped to create tailored clinical guidelines and training on NCDs, which will be used by the country’s cadre of CHWs. The NCD training module will be integrated into the national curriculum for CHWs and become standard practice in their duties.

Empowering health workers

CHWs have traditionally focused on providing support on HIV and TB as well as maternal and child health services in the community. Now, with tailored training provided through BHPSA, they can integrate screening for high blood pressure and sugar, make referrals for care and educate people about how to prevent or manage these conditions.

The lack of NCD data in South Africa is a real challenge. Without credible data, the government will be unable to track the continuum of care.

Myles Ritchie

Team leader of the Better Health Programme, South Africa, (BHPSA)

Working with specialists in clinical guidelines at the Knowledge Translation Unit (KTU) at the University of Cape Town we created a comprehensive NCD training module that will be integrated into the national curriculum for CHWs.

The module provides CHWs with the right tools to raise community awareness about obesity, diabetes, hypertension and improve early detection of disease. It also provides the enhanced skills needed to screen for a complex set of conditions, often co-morbidities ‒ for example, diabetes can be a risk factor for cardiovascular diseases, strokes or depression.

It was important to avoid too much clinical content to ensure that CHWs could easily access and apply the guidance as part of their routines, rather than adding too much extra to their workloads. For example, we found that many CHWs did not have smartphones or the means to purchase data and could not therefore use an app to record people’s body mass index (BMI).

Instead, they were given battery-operated blood pressure monitors and digital scales as a tangible way to show weight loss and encourage behaviour change. CHWs who were trained on the new modules during a pilot in 2021 showed significant improvements in their understanding of NCDs and their ability to practically apply this knowledge in their work.

Data surveillance

The lack of NCD data in South Africa is a real challenge. Without credible data, the government will be unable to track the continuum of care – from testing through treatment to the control of disease. Identifying alternative sources of health information is necessary as routine data collection has its own set of limitations.

We are supporting a government pilot on NCD surveillance in the Western Cape. The aim is to understand the prevalence of NCDs from alternative data sources, for example, by analysing laboratory data on the number of people given a blood test for diabetes and looking at the results. Another method is to use pharmacy data on the number of people being prescribed drugs for hypertension or diabetes to determine the scale of health need in different areas and help to predict healthcare demand.

Changing behaviour

The South African government is committed to tackling the NCD threat from multiple angles — innovative use of data and strengthening community healthcare will both be part of the long-term solution.

CHWs, with the support of clinical staff and government, need to get the preventative message out powerfully and sensitively at a local level. Convincing people to make better lifestyle choices, particularly when they are younger – consuming less alcohol, less smoking and a better diet – could have major health benefits for individuals.

The work of CHWs also needs to be integrated effectively into the existing health system. For example, when patients are referred to a primary care clinic, it is important that doctors and nurses feel confident about referrals from CHWs, rather than duplicating their efforts.

Improving the status of CHWs in the health system would help with this, including better working conditions and employment terms, and registering CHWs as a formal cadre of the overall workforce. They are currently overworked and underpaid but they could play a key role in ensuring that higher detection of NCDs leads to better prevention, treatment and health outcomes.