Non-communicable diseases (NCDs) appear to be rising in priority for the first time in more than two decades since the publication of the South African National Development Plan (NDP). The recent NDP 10-year review seems to frame NCDs in a different light by making this recommendation:O
Department of Health should implement the legislative and regulatory interventions recommended by the Strategic Plan for the Prevention and Control of Non-Communicable Diseases.” page 39
The recommendation appears to open the way for a national policy shift, moving NCDs out of the rut that considers them solely lifestyle conditions managed by a mixture of behaviour changes with a mix of policy and fiscal measures. This NDP framing institutionalised the limited allocation of national budget resources for NCDs interventions officially sanctioned as primordial and primary prevention. In reality, it resulted in NCD denialism despite them being the leading cause of death in South Africa since 2009, once ARVs impacted the tragic and callous loss of life due to HIV.
The use of the term lifestyle conditions is unacceptable for the HIV and TB community. People living with NCDs+ find it equally demeaning as it places the responsibility mainly on the person to live a better life.This bogus notion disregards the wider or social determinants of health and a public health system that fails to prevent and treat NCDs in a comprehensive way in all primary care facilities.
Very little changed for 20 years with subsequent NDP iterations of health priorties which continue to feature the Millennium Development Agenda identified conditions and South Africa’s much delayed and controversial version of universal health coverage. National Health Insurance (NHI) draft legislation focuses only finacial mechanism and fails to deal with quality and equity for NCDs and mental health.
Be still my heart NCDs equity indicator
Being a cynic in NCDs matters, when I look at policies I look first at the list of acronyms which usually feature up front. Very quickly I notice that the acronym NCDs does not appear in this standard feature South African policy documents. In most health-related policies, NCDs, the acronym, is missing with little or no mention within the policy and, unsurprisingly, even less action.
I made my first indicator of NCDs policy equity to be the inclusion of NCDs in the list of acronyms. Why? It give a snapshot of the framing from the perspective of the policymakers. So it is a huge milestone to have NCDs finally made the acronym indicator cut. NCDs has appear in this review and, be still my heart, in the recently update HIV/TB & STIs national strategic plan. Using the criterion in reverse, it is intriguing that neither HIV nor AIDS makes this list, but TB does. Perhaps is shows the extent to which HIV is institutionalised in South African society.
It took the South African NCDs+ Alliance 10 years and lots of activism to be included in the development of the NCDs+ National Strategic Plan. Real blood, sweat and tears stuff. We had to take extreme measures including delaying tactics and staking sham policy consultations. After 5 years of delays it was finally passed and launched last year. It does allow scope for increasing the priority of NCDs prevention and treatment. However, without futher clarification of the NDP review recommendation is nuanced. What do “legislative and regulatory interventions” mean? Is it just another way of maintaining the status quo?
Make this cynic think paranoid thoughts. Especially as the health minister and officials havent responded to letters for years. What do you think?
11 April 2022 Minister in the Presidency, Mondli Gungubele, says a key issue commissioners appointed to the National Planning Commission (NPC) will be expected to address is the slow progress in the implementation of the National Development Plan (NDP) and to identify solutions to make sure that the country fast tracks its route to the NDP goals.
The Minister, who serves as chairperson of the NPC, was speaking during a first media briefing of the third NPC which was appointed in December last year. “One of the shortcomings that [the NPC] has identified…was the incapacity of the state to implement the proposals of the NDP. This often combined with poor leadership that pay lip-service to the NDP without understanding its goals has acted as an obstacle to implementation of developmental objectives.
“As government, we are clear that the greatest challenge has been around implementation and in the discussions held to date, this was my emphasis to guide the discussions,” Gungubele said.
The National Development Plan – which was adopted ten years ago – was created as an action plan for government to tackle several challenges facing the country including unemployment, poverty, inequality, safety and healthcare. “The NDP was designed to change the lives of all South Africans by taking a comprehensive approach where the reality of 2012 [would] become a different one by 2030. We must recognise that we have not met the goals as we intended 10 years ago, that is true.
“Recognising this is the first step to asking: how do we do things differently to change the trajectory that we are on. This is where [the commission] will assist us as we tackle this challenge where implementation of our plans has not met the targets,” he said.
NPC Deputy Chairperson, Professor Tinyiko Maluleke, said the third NPC begins its term at a precarious moment in our country’s history and the “tall order” it faces in bringing the country closer to what the NDP envisioned. “There is, of course, a reason why we are called the NPC…and not the National Implementation Commission. But if implementation is slow or non-existent, planning alone, is clearly insufficient. Given that ours is a tenure that is closest to the finish line of 2030, we cannot afford to be dismissive, smug or philosophical about implementation.
“We have to probe why it is, why it has been so hard to coordinate, to cohere, to cascade down, to streamline and pinpoint down the necessary catalytic interventions which will embed and institutionalise the NDP within the departmental, provincial and municipal plans,” he said.
Professor Maluleke said the NPC will also give attention to identifying catalytic areas for government to pursue. “Countries which have successfully achieved their national developmental goals and targets are those at the heart of whose plans are clear catalytic priorities around which the whole state machinery is mobilized.
“The third NPC will help to enhance the ability of the state to identify and pursue catalytic priorities which will expedite the attainment of NDP goals,” he said. According to Maluleke, another focus area for the NPC will be mobilizing the country’s support for the NDP and its goals.
“Although the NDP is a plan for the whole country, it has not been sufficiently adopted by all sectors at all times. As we mark its tenth anniversary in September, the NPC is urging all South Africans to rally behind the NDP to ensure its implementation and to call government to account on the basis of the promise contained in the NDP. “To that end, the NPC is committed to building partnerships broadly across society and to pursing engagements that should ensure active citizenry and strong leadership for development,” he said.
Today is the health budget speech at 14:00, and in the interests of transparency and inclusivity, it would be great if we, the people, had a look at it beforehand. The budget speech is a version of the Annual Performance Plan (APP) for the financial year to 31 March 2023.
So we are already into the financial year, and the APP23 s already in progress. Having asked for said APP23 PDF, and scouring government and parliamentary websites, we are still in the dark. The closest we came to is a presentation from the health portfolio committee.
The most positive aspect for NCDs+ is that NCDs+ are still in stream, branch or programme 3 along with communicable diseases. At least it hasn’t be shoved back in Programme 4 Primary Health Care where it languished without food or water.
Mind you it is unlikely to change much since the Medium Term Strategic Framework 2019-2024 (MTSEF24) does not prioritise NCDs+ or allocate funding. Except in the most peripheral way. I call this the legacy of 3M era: MDGs, Motsoaledi and Mkhize. Too bad that we are in SDG times and need different action to achieve universal health coverage (UHC target 3.8) and there is more than the target 3.4to achieve action on NCDs.
Joy there is a change to the number of outcomes and outputs covering NCDs+ in the APP23. That means a lot without a programme budget and an implementation plan.
A retake on the NDP with a summary biased towards NCDs with the following key quotes:
“Evidence suggests multiple system failure across a range of programmes, including maternal and child health, HIV/AIDS, tuberculosis and other, with a devastating combined impact. At the heart of this failure is the inability to get primary health care and the district health system to function effectively” (p. 301).
One of the key issues here is collaboration across sectors p. 303 “the health sector should engage with partners and departments to ensure that the negative impact of other policies on health outcome s is understood and minimised.” Mostly it is a list of government departments and is not outward looking to what broader civil society can offer. One wonders who they mean by partners.
Three main sections: demographics and health, health systems and social determinants of health.
Note the emphasis: The section on health is interesting and includes long bits on the re-engineering of primary health care and what the teams and structure will look like. It is also a vision statement. This makes if like a look and feel statement. It is not policy but just how the thinking goes.
The discussion about NCDs is limited to population (primary prevention) methods: stop smoking, be more active, eat better and probably less, limit alcohol intake.
However, most of the messaging still remains about HIV/AIDS its prevention, treatment and complications. Clearly a great deal has to be done to capture the attention of the national planning commission.
Targets are listed as follows and primarily related to the MDGs p. 36
• Demographics and health:
NCDs (emphasis in the document are on those of relating to lifestyle – the bang for the buck for prevent) are seen as one part of SA’s quadruple burden of disease (others HIV/AIDS , maternal and child mortality, violence and injuries)
Health targets are on page 218 and those relating to NCDs are preventable (depends what is meant by preventable). Reduce by 28% by 2030
o Cardiovascular diseases
o Chronic respiratory diseases
Risk factors linked to these NCDs include the normal list tobacco smoking, physical inactivity, raised BP, raised blood glucose, objesity and raised cholesterol.
When HIV/AIDS is mentioned, so too are related issues like TB, STDs, Perhaps there should be a related list NCD list
• Health systems the introduction is scathing.
“Evidence suggests multiple system failure across a range of programmes, including maternal and child health, hive/aids, tuberculosis and other, with a devastating combined impact. At the heart of this failure is the inability to get primary health care and the district health system to function effectively.” p. 301
Access to health care is the rationale behind the national health insurance.
Health systems include health finance, workforce, infrastructure, technology, information and governance.
• Social determinants and ecology
At last a full recognition of the role of social determinants of health. One of the key issues here is collaboration across sectors p. 303 “the health sector should engage with partners and departments to ensure that the negative impact of other policies on health outcome s is understood and minimised” Mostly it is a list of government department and is not outward looking to what broader society can offer. One wonders who they mean by partners.
Partnerships are highlighted again p.304 in relation to health system strengthening and quotes the DBSA report that calls for those partnerships that can help to leverage funding.
Health lifestyles (diet and exercise) highlighting partners (one assumes) such as schools and employers. (p.303)
Prevent and reduce disease burdens and promote health p. 306
Note emphasis of this report. Prevention and only issues mentioned directly are “treating HIV/AIDS ” and “alcohol abuse” and unspecified other “new epidemics”.This is a clear case for NCDs advocacy. The epidemic of NCDs is hardly mentioned.
Health financing deals with the universal access to health care (NHI) issue takes up a large proportion.