Health

[a][i] Infant Mortality Rates [Infant deaths per 1000 live births by calendar year]

Unfortunately, the Department of Home Affairs no longer provides access to death certificates to the municipality or province as of 2014 so it is no longer possible to provide subdistrict level infant mortality rate data. We are now dependent on Statistics South Africa releases for data on the whole district of Cape Town. Of the years mentioned above, we only have data for 2014. There were 1123 infant deaths in 2014 out of 67 325 births which gives an infant mortality rate of 16.7 per 1000 births.

[ii] TB Incidence rates per 100 000 population by calendar year

Sub District	2014	2015	2016
Eastern	710	654	632
Khayelitsha	1 065	897	864
Klipfontein	666	626	609
Mitchell's Plain	750	756	752
Northern	606	534	478
Southern	332	330	331
Tygerberg	530	558	564
Western	536	513	476
Cape Town Overall	631	596	577

Source: City of Cape Town Municipality

Actual number of TB cases per sub-district

Sub District	2014	2015	2016
Eastern	3788	3552	3492
Khayelitsha	4695	4008	3914
Klipfontein	2676	2561	2535
Mitchell's Plain	3304	3385	3415
Northern	2392	2150	1962
Southern	1978	2010	2053
Tygerberg	3338	3582	3681
Western	2632	2567	2425
Cape Town Totals	24803	23815	23477

The recorded data indicates a steady decline of TB incidence.

[iii] HIV/AIDS rate

Number of people on Antiretroviral Treatment [ART] at Public Health Facilities has gone up steadily over time.

Total Clients Remaining on ART at end reporting period	2014/15	2015/16	2016/17
Cape Town Eastern Health sub-District	15570	17217	19736
Cape Town Northern Health sub-District	10316	12144	13377
Cape Town Southern Health sub-District	10040	11232	11851
Cape Town Western Health sub-District	18832	21193	24077
Khayelitsha Health sub-District	32107	35703	39765
Klipfontein Health sub-District	14770	14958	17112
Mitchells Plain Health sub-District	17395	18714	21076
Tygerberg Health sub-District	11253	13019	14521
Grand Total	130283	144180	161515

Source: The provincial repository, Sinjani

The percentage with a positive HIV test has gone down over the last few years.

% tested with outcome positive	2014/15	2015/16	2016/17
Cape Town Eastern Health sub-District	5.9%	4.8%	4.6%
Cape Town Northern Health sub-District	6.1%	4.9%	4.3%
Cape Town Southern Health sub-District	4.1%	4.1%	3.7%
Cape Town Western Health sub-District	6.8%	6.6%	5.2%
Khayelitsha Health sub-District	8.6%	7.8%	5.7%
Klipfontein Health sub-District	5.6%	5.2%	4.0%
Mitchells Plain Health sub-District	4.9%	4.7%	4.7%
Tygerberg Health sub-District	3.4%	3.1%	2.9%
Grand Total	5.7%	5.2%	4.4%

Source: The provincial repository, Sinjani

Antenatal prevalence [% - Latest data available][survey of pregnant women held every October]

Sub District	2012	2013	2014
Eastern	16.3	18.4	17.7
Khayelitsha	34.3	34.4	34.7
Klipfontein	22.3	20.7	27.1
Mitchell's Plain	18.4	16.8	18.4
Northern	21.9	22.2	22.7
Southern	10.3	8.2	13
Tygerberg	11.1	11.9	8.8
Western	20.5	21.9	20.9
Cape Town Totals	20	19.7	20.4

Source: Western Cape antenatal survey 2014. HIV prevalence amongst pregnant women has remained stable for the last few years.

[v] Other living conditions induced diseases rates

Diarrhoea in children under 5 – number of cases per 1000 children under 5 per calendar year.

Diarrhoea number of cases per 1000 children under 5	2014	2015	2016
Cape Town Eastern Health sub-District	128	113	112
Cape Town Northern Health sub-District	135	127	130
Cape Town Southern Health sub-District	112	111	158
Cape Town Western Health sub-District	125	119	150
Khayelitsha Health sub-District	137	140	131
Klipfontein Health sub-District	97	92	95
Mitchells Plain Health sub-District	139	136	147
Tygerberg Health sub-District	122	137	159
Cape Town District	125	123	136

Source: The provincial database, Sinjani

Actual number of cases of diarrhoea< 5 years by sub-district

Actual number of cases of diarrhoea under 5 years	2014	2015	2016
Cape Town Eastern Health sub-District	6275	5445	5342
Cape Town Northern Health sub-District	3895	3609	3636
Cape Town Southern Health sub-District	4877	4805	6717
Cape Town Western Health sub-District	4751	4462	5534
Khayelitsha Health sub-District	6338	6387	5922
Klipfontein Health sub-District	3402	3183	3245
Mitchells Plain Health sub-District	6139	5915	6316
Tygerberg Health sub-District	6484	7229	8266
Cape Town District	42161	41035	44978

 

Diarrhoea cases have remained stable but went up slightly in 2016

Severe malnutrition under 5: number of new cases reported per 1000 children under 5 per calendar year

Number of new cases reported per 1000 children under 5	2014	2015	2016
Cape Town Eastern Health sub-District	2	1	2
Cape Town Northern Health sub-District	2	2	2
Cape Town Southern Health sub-District	2	2	1
Cape Town Western Health sub-District	2	4	3
Khayelitsha Health sub-District	1	2	3
Klipfontein Health sub-District	1	2	1
Mitchells Plain Health sub-District	1	2	1
Tygerberg Health sub-District	2	3	3
Cape Town District	2	2	2

Source: The provincial database, Sinjani

Actual number of cases of severe malnutrition

Severe malnutrition under 5	2014	2015	2016
Cape Town Eastern Health sub-District	81	59	95
Cape Town Northern Health sub-District	51	55	50
Cape Town Southern Health sub-District	82	93	52
Cape Town Western Health sub-District	90	133	94
Khayelitsha Health sub-District	56	103	127
Klipfontein Health sub-District	28	53	28
Mitchells Plain Health sub-District	44	76	35
Tygerberg Health sub-District	84	145	156
Grand Total	516	717	637

The malnutrition rate has remained stable.

[b] The below is an extract from the attached Cape Metro District Health Plan 2017/18, which is aimed at addressing the major disease burdens inclusive of preventative and curative strategies. A strong focus on achieving better immunisation coverage and better ART retention in care was highlighted through the First 1000 Days programme and the 90-90-90 HIV/AIDS and TB strategy. In addition, there is ongoing infrastructure development to address the needs of the population as well as the equity in access to health care. Good progress has been made with respect to MDGs with the District performing slightly better than the Provincial average for most indicators. HIV prevalence amongst pregnant women has remained stable while TB incidence continues to decline.

A rapid appraisal has been conducted of the primary health care platform in the Province, which points to key levers for PHC reform such as having a population focus, health system design, people management, information management and governance. Short, medium and long term plans will be developed based on this rapid appraisal.  

In addressing the challenges of infant mortality, TB, HIV/AIDS and other living-conditions-induced diseases, the Department has implemented various structured programmes to improve wellness, safety and reducing social ills. Non-communicable diseases predominate in the Cape Metro district as it does throughout the province. HIV/AIDs and TB and infectious/ parasitic shows a heartening decrease in deaths. However non-communicable diseases [except diabetes] and intentional injuries have shown an increase. The increase in non-communicable diseases may be due to better survival in HIV and TB affected groups. The age standardised mortality rate has come down from the 2009 level [961 per 100 000 population] to 850 per 100 000 population in 2013. This indicates a decreasing rate of death in the District.

Infant health

Infant mortality has shown a downward trend in the Cape Metro District over the 6 years 2008 -2013 and is amongst the lowest when compared to the Province’s other health districts.

A structured programme is in place which includes the following elements:

• • • Provision of good antenatal care including increasing booking [first] visits before 20 weeks.
    • Maternity care to ensure safe delivery of babies and neonatal care services for at risk babies.
    • Post natal visits for mothers
    • Immunisation programme to prevent a range of diseases including TB, polio, diphtheria, tetanus, hepatitis B, haemophilus Influenzae [bacterial infection], pneumonia, rotavirus induced diarrhoeal disease and measles.
    • Weight monitoring to detect nutrition problems early.
    • Encouragement of breastfeeding.
    • Health care for children with acute illnesses including respiratory infections and diarrhoea with appropriate referral pathways.

Diarrhoeal disease

A comprehensive set of interventions are planned each year and include the following:

• Prevention includes rotavirus vaccination and encouragement of breastfeeding.
• A communications programme aimed at raising awareness about the disease and its treatment.
• Provision of Vitamin A twice a year to children less than 5 reduces the severity of disease.
• All facilities on high alert during the surge season [November to May].
• Dedicated treatment areas available [drip/ hydration rooms]. Zinc therapy has been added to the management of diarrhoeal disease.
• Hospital care available for children with severe diarrhoea.
• Provision of bottles so that caregivers can make up their own hydration solution.
• All severe cases of diarrhoea are investigated by environmental health officers.
• All diarrhoeal deaths are investigated.
• Weekly meetings are held to monitor the occurrence of cases and to run targeted campaigns at hot spots.

Malnutrition

A structured programme is in place which includes the following elements:

• Weight monitoring to detect nutrition problems early.
• Encouragement of breastfeeding.
• Provision of nutritional products to caregivers for at risk children
• Care of children who develop acute illnesses which may worsen the effects of poor nutrition
• NPOs are contracted to support the above activities.

TB

The TB case detection rate per 100 000 shows a downward trend in recent years. The district case load was 23 477 and the case detection rate 577/100 000 in 2016. The district case load was 23 815 with a TB case detection rate of 606/100 000 in 2015. New smear positive cure rates have been above 80% since 2010 but there has been a slight drop off in recent years since the 2011 peak of 84%. New smear positive cure rate was 80% and success rate 85% for 2015.

A structured TB Control Programme is in place which includes the following elements:

• BCG vaccination to prevent TB
• TB screening services for potential TB suspects
• Preventive treatment for those at risk of developing TB
• Diagnostic services to ensure accurate and prompt diagnosis of TB.
• TB treatment for TB sufferers
• TB treatment for TB sufferers with drug resistant TB

HIV/AIDS

The Western Cape antenatal survey report gives the Cape Metro an HIV prevalence of 20.4% for 2014, much lower than the national average of 29.7% [2013] but it is still the highest amongst all the Province’s districts. The HIV prevalence was 18.2% in 2006 but seems to have stabilized at around 20% since 2011.

A structured programme is in place which includes the following:

• Encouragement of prevention through the widespread distribution of condoms and a male circumcision programme.
• Encouragement of HIV testing through a HIV counselling and testing programme.
• Prevention of transmission of HIV to babies through a treatment programme for pregnant HIV positive mothers.
• An antiretroviral treatment programme providing medication to HIV sufferers who are then encouraged to remain on treatment.
• A treatment programme to prevent HIV positive persons from developing TB and opportunistic infections.
• A treatment programme for anyone developing AIDS with hospitalisation when needed.
• A post exposure prophylaxis programme to prevent those exposed to HIV from developing it.
• The HIV and AIDS Conditional Grant contracts NPOs to render front-line services in health care facilities and in the community. The funding to NPOs was utilised to render the following services:
• Interventions in high transmission areas [HTA], i.e. truckers at truck stops; men; refugees; commercial sex workers; lesbian, gay, bisexual, transgender and intersex [LGBTI] groups; deaf community and prisons. 
• Step-down care facilities were funded to render care to clients who are either terminally ill, require palliative care or need support during the initiation of ART.
• HIV counselling and testing [HCT] services through HIV counsellors in all facilities. These counsellors played a critical role in achieving the HCT campaign targets, preparing clients for ART and keeping clients in care by providing adequate adherence support.
• Global Fund Grant transfer payments to non-profit institutions were used to provide adherence counselling services at the eleven ART sites within Khayelitsha sub-district.
• Provide peer education services to modify risk-taking behaviour and to reduce HIV transmission amongst the youth in selected secondary schools in high HIV prevalence areas.
• Fund the Networking AIDS Community of South Africa [NACOSA] for the support of their training, mentoring, networking and support of community based organisations across the Province. 

Involvement of other sectors [taken from the Provincial Annual Performance Plan 2011/12]

It follows from an understanding of the burden of disease that the Western Cape Department of Health cannot solely be responsible for increasing wellness. Indeed even collaborative action across all of government is not enough. What is needed is a whole-of-society approach that mobilises the resources, knowledge, creativity and concern of all role-players – including all three spheres of government, civil society, business, and individual citizens.

In order to structure our approach to increasing wellness coherently we have identified those areas of work which require collaboration between a number of government departments, and sometimes the whole of society, and separated these from those areas of work that are the core responsibility of the Department of Health.

During the course of 2011 the Premier hosted a summit on reducing the burden of disease. The purpose of the summit was:

[1] to review the latest available data on the burden of disease

[2] to review the overall response to the burden of disease by all levels of government and by role-players outside of government in the private sector and civil society

[3] to identify an action agenda for implementation designed to advance the collective effort of all role-players to reduce the burden of disease.

[c] The budget allocations for the District are set out below. More details are available on request

	DOH	COCT Transfer	COCT Own	Total
Budget 2014/2015	R3 795 839 000	R397 341 000	R516 416 928*	R4 312 255 928
Budget 2015/2016	R3 897 611 000	R440 649 000	R516 416 928*	R4 414 027 928
Budget 2016/2017	R3 992 180 000	R461 878 000	R617 056 280	R4 609 236 280
Budget 2017/2018	R4 505 409 000	R520 665 000	R643 161 959	R5 148 570 959

Source: BAS and City of Cape Town Finance Department. DOH excludes Global fund and Conditional Grant contributions. *Estimates

ADDENDUM 1:

CAPE METRO DISTRICT HEALTH PLAN 2017-18

ADDENDUM 2:

PROVINCIAL STRATEGIC GOALS

The Provincial Strategic Goals [PSG] include a focus to increase wellness and tackle social ills in the province. Improving wellness in all corners of our province will assist us in alleviating the pressure we are currently experiencing in the system. Within the PSG3, the Department has taken a lead in various programmes like the Western Cape on Wellness [WoW!], First 1000 Days and Women of Worth. Addressing the upstream factors that result in poor health outcomes require a whole of government and whole of society approach. The work being done around Provincial Strategic Goal 3 has created a vehicle to test more integrated approaches in targeted communities.

Extract from the Annual Performance Plan [APP] 2017/18: Table A.1: Strategic Objectives

STRATEGIC GOAL 1	To promote health and wellness
Goal Statement:	To promote health and wellness with the aim of increasing the life expectancy of citizens in the Western Cape.
Outcome 1.1.	Comprehensive, efficient health services
Priority Strategies	Strengthen the continuum of care across the health system Person-centred approach to care provision Improving the waiting experience Comply with the National Core Standards Nurturing a culture of continuous quality improvement
Outcome 1.2.	Effective Primary Health Care Services as part of a resilient, comprehensive health system
Priority Strategies	Service Re-design Strengthening Care Pathway Co-ordination Enhancing the health system’s capability for prevention Strengthen strategies to retain patients, with a chronic condition, in care

Provincial Government Initiatives

Strategic Goal 3: Increasing Wellness & Safety, and Tackle Social Ills

The current state of wellness [including physical, psychological, financial and social] in the province contributes to escalating pressure on demands for health and social services, community safety and policing, education, and human settlements. In complex, socially challenging environments, there is no choice but to closely collaborate as a whole of government and whole of society. This requires, most importantly, a commitment to co-create enabling environments in order to positively influence individual behaviours and lifestyle choices; to initiate broad system and community-wide improvements towards building and optimising sustainable human development; and to improve wellness and the quality of life through resilient communities, active and resilient citizenry.

WoW!

This novel partnership initiative promotes and activates healthy lifestyles at population level towards the prevention, reduction and better self-management of non-communicable diseases [NCDs], including obesity. WoW! currently involves other provincial departments, the 3 universities in the city, multiple NPOs and a number of private sector sponsors. The overarching purpose is to create a culture of wellness and promote healthy lifestyles; increased health-related physical activity or fitness; healthy eating and healthy weight management; food security though the establishment of home, community and school food gardens; supporting delivery of the Life Orientation curriculum, supporting availability of healthy foods in government buildings and schools; and ensuring an inclusive communication platform to enable access to healthy lifestyles-promoting information. Using a settings-based [Schools, Communities, Worksites, Primary Health Care Facilities and Public Spaces] and life cycle [from Pregnancy to Senior Citizen] approach, WoW! aims to co-create a culture of wellness in the Western Cape.

Integrated Service Delivery Pilot

Targeted integrated service delivery in the Drakenstein Municipality, with a concentrated effort and pooling of resources by all departments, the municipality and the NGO VPUU [Violence Prevention through Urban Upgrading] to increase wellness and safety, and to reduce social challenges. This would be a pilot and will identify the method, costs, success factors and the expected outcomes that can be achieved and provide a replicable model. As part of the ISDM workgroup, the Department of Health responsibilities in line with the SG 3 strategic objectives would be the following:

Inclusive Safe and Healthy Communities

• The Western Cape on Wellness project is being rolled out in the Drakenstein pilot
• To provide a support function to the Alcohol Harms Reduction Game Changer as part of the ISDM. This includes participation in the Local Drug Action Committee as hosted by Drakenstein Municipality.
• To provide Teachable moments intervention as part of the Alcohol Harms Reduction Game Changer

Resilient and Healthy Families

• Delivering a comprehensive PHC service in Drakenstein
• Supporting the ECD registration initiative through training and development support to ECDs in conjunction with the ISDM Workgroup.

Engaged and Healthy Youth

• The Drakenstein youth is supported with outreach service for sexual reproductive health and other relevant health services at the Paarl East Thusong Center, to improve accessibility to the VPUU drainage area.

Safe and Healthy Children

• Implementing the 1st 1000 Days as an inter-sectoral initiative. In terms of health-specific services the subdistricts are improving the antenatal booking rate; providing a risk-screening service as part of the antenatal care package at selected facilities; providing ante-natal care groups to improve maternal-child bonding and stimulation and play opportunities of the unborn child and supporting inter-sectoral initiatives through training, awareness raising and health promotion interventions.

Similar integrated initiatives will be developed in Saldahna, Gunya and Town 2 in Khayelitsha; over the medium to long term as part of the Joint Planning Initiative. Planning sessions have identified reproductive health services and teenage pregnancy as priority focus areas in this regard. These priorities are captured in the District Health Plans.

Addressing the harmful impact of alcohol on communities is a joint initiative in partnership with the City of Cape Town and Drakenstein municipalities and other key stakeholders. A multi-sectoral approach, including community engagement, will be tested to plan and deliver evidenced-based interventions for scalability over the next few years. Community-based action led by Department of Community Safety [DOCS] and supported by the departments of Health, Social Development and Cultural Affairs and Sport is being facilitated to reduce the supply of alcohol and increase the safety in communities.

Department of Health Interventions towards achieving SG3

Teachable Moments

The Health Department will be implementing brief motivational interviewing interventions [also called Teachable Moments] in Emergency Centres at Paarl, Khayelitsha and Heideveld CHC. The teachable moment project will provide screening, brief motivational interventions and Problem solving Therapy to persons presenting with injuries due to possible substance abuse at these Emergency Centers in the province. The evidence-based data obtained from the pilot project will be used to evaluate the effectiveness of the intervention. In 2017/18 the Department aims to screen 70% of injured people presenting at our emergency centres and to get at least half of those screened to agree to a brief motivational intervention.

First 1000 Days of Life

The WCG Health has designed and is implementing a campaign that raises awareness and facilitates action at the community and service provision levels concerning the first 1000 days of a child’s life [from conception to two years of age] that is the most critical period to their health, development and chances of success in later life. The First 1000 Days Initiative is situated within the Safe and Healthy Children and within the Safe and Healthy Families sub-components of PSG3, both ultimately impacting on the Safety and Wellbeing of Communities. A life course approach has been applied and the 3 key foundation areas have been grouped in our context as Nutrition and Health, Nurture, Care and Support and Safety, protection and stimulation. Some of the key activities would be:

• Well baby & child care, quality and links
• Development of First 1000 Days initiative social media campaign with information and links for referrals
• Review standard minimum content for ante natal care education that includes addressing issues of substance abuse
• Expansion of First 1000 day dashboard [WCG] departments through review process
• Explore and identify areas for research and innovation [Catch and Match & Social Impact Bond]
• Intersectoral engagement to encourage departments to promote breastfeeding
• The well-being of the mother during and after pregnancy is also a major concern. Key messages with related actions by parents or main carers and service providers will be determined, using a transversal and multi-sectoral approach. The campaign will also promote the important role of men as caring, engaged fathers, supportive partners and carers.

Progress for these intiatives will be tracked via the maternal, child and women’s health indicators as set out in the APP.