Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-17

Objectives

The 2013–17 Strategic Plan for the Prevention and Control of Non-communicable Diseases seeks to achieve “a long and healthy life for all” by reducing the morbidity, mortality and wider social and economic burden of non-communicable diseases in South Africa.[1][2]It frames non-communicable diseases as a national development priority requiring whole-of-government and whole-of-society action, rather than a health-sector concern alone.[3][4]

The strategy addresses cardiovascular diseases, diabetes, chronic respiratory conditions and cancer, alongside mental disorders and neurological, oral, eye, kidney and musculoskeletal conditions.[1][5]It prioritises prevention of tobacco use, harmful alcohol use, unhealthy diets and insufficient physical activity, while recognising the influence of poverty, urbanisation and other social, economic and environmental determinants.[6][7][8]

• Prevent non-communicable diseases and promote health and wellness at population, community and individual levels through primordial prevention, primary prevention, early diagnosis and cost-effective comprehensive management.[9][7]
• Reduce premature non-communicable disease mortality among people under 60 by at least 25% by 2020.[10][11]
• Reduce tobacco use, per-capita alcohol consumption, salt intake, raised blood pressure, overweight and obesity, while increasing physical activity and expanding cervical-cancer prevention.[12][11]
• Improve control of hypertension, diabetes and asthma in sentinel sites, and increase screening and treatment for mental disorders.[12][11]
• Strengthen health-system control and reform through integrated, patient-centred, lifelong chronic care, including prevention, treatment, rehabilitation and palliative care.[2][13]
• Monitor non-communicable diseases and their major risk factors, establish baselines for the summit targets, and conduct innovative research to guide policy and service improvement.[9][14]

Key preventive action includes strengthening tobacco and alcohol controls; improving food environments through salt and trans-fat regulation, healthier food access and nutrition measures; and creating opportunities for physical activity.[15][8][16]The strategy also promotes screening, early detection, timely treatment, secondary prevention, adherence and self-management for people at risk of, or living with, chronic disease.[1][17]

Its strategic orientation combines social, biomedical and behavioural interventions, with an emphasis on service equity, equitable funding, skilled health workers and appropriate technology.[6][18][19]The plan identifies cost-effective and evidence-based ‘best buy’ interventions as priorities, particularly where resources are constrained.[15][7][20]

Implementation

Implementation is based on an integrated, phased and multisectoral model led by the National Department of Health in collaboration with provincial health departments, non-communicable disease co-ordinators and health-service managers.[18]It links prevention and health promotion with primary health-care re-engineering, National Health Insurance, integrated chronic disease management, workforce development and stronger information systems.[21][19]

• Establish an intersectoral structure, with clear terms of reference, to plan, coordinate and monitor the national response to non-communicable diseases.[3][22]
• Develop sectoral action plans and integrate them into a joint prevention strategy aligned with the Department of Health Health Promotion Policy.[22]
• Engage government departments, local government, civil society, non-governmental organisations, users and survivors, professional bodies, academics, the media, communities and non-conflicted private-sector actors.[1][13][23]
• Implement prevention measures across sectors including Agriculture, Trade and Industry, Finance, Education, Sport and Recreation, Transport, Human Settlements and Social Development.[7][8]
• Integrate non-communicable disease prevention, screening and treatment into clinics, school health services, HIV counselling and testing, community outreach and other government service points.[24][17][10]
• Strengthen referral and back-referral links between community services, primary care, district services, secondary and tertiary hospitals, specialised hospitals and palliative-care providers.[2][17][25]

Primary health care is the principal delivery platform.[19][13]The Integrated Chronic Disease Management model is to be implemented incrementally across districts to combine communicable and non-communicable chronic care around universal coverage, equity, health promotion, community participation, intersectoral collaboration and appropriate technology.[19]The plan provides for testing the integrated chronic-care model in three sub-districts, assessing feasibility, expanding to at least 10 districts if appropriate, and progressing towards national implementation of long-term care.[26]

Community-based delivery includes primary health-care outreach teams in every ward, with community health workers and health promoters supporting healthier lifestyles, identifying people at high risk for referral, providing adherence counselling and assisting families with lifestyle modification.[27]Patients should receive self-management support through education, support groups, treatment reminders, nutrition support, family and peer involvement, and advice on diet, physical activity, tobacco and alcohol.[17][27]

Clinical implementation should use risk-based screening, overall cardiovascular-risk assessment, evidence-based guidelines, the Essential Drug List and access to appropriate medicines, equipment, diagnostics and medical supplies.[17][27]More complex treatment should be initiated at secondary or tertiary level, while rehabilitation and palliative care should be available across the continuum of care.[17][25]

Monitoring arrangements include comprehensive surveillance of risk-factor exposure, illness, cause-specific mortality, health-system capacity, access and intervention quality.[28]Routine monitoring should draw on the District Health Information System, Statistics South Africa data, surveys, cancer and chronic-disease registers, and research platforms.[28][20][14]Deficiencies identified through monitoring should trigger corrective action plans, while in-depth evaluations should investigate cases where implementation is satisfactory but outcomes do not improve.[28][20]

The strategy does not specify a confirmed overall budget, funding allocation, funding source or quantified funding gap.[21][20]It nevertheless prioritises efficient, low-cost and cost-effective interventions, and identifies an estimated annual cost of more than 11 billion Rand for non-communicable disease interventions in South Africa as unrealistic at the time, reinforcing the need to prioritise the best outcomes for each Rand spent.[12]

Monitoring & Evaluation

The strategy establishes a comprehensive monitoring, surveillance, evaluation and research function to inform policy, planning, management and assessment of progress towards the 10 South African Non-Communicable Disease Summit targets.[14]It combines population health surveillance, health-system monitoring, implementation tracking and research to support prevention, early detection, treatment and chronic care.[2][28]

• Establish an integrated surveillance and routine monitoring mechanism across public and private health sectors by March 2014, in collaboration with partners including the Medical Research Council and Human Sciences Research Council.[14]
• Measure baseline information for every summit target, verify data quality and issue progress reports on implementation.[14]
• Monitor exposure to behavioural risk factors, particularly tobacco use, harmful alcohol use, unhealthy diet and physical inactivity; health outcomes including morbidity and cause-specific mortality; and health-system capacity, access and intervention quality.[2][28]
• Track target areas including premature mortality, tobacco and alcohol consumption, salt intake, overweight and obesity, physical activity, raised blood pressure, cervical cancer screening, control of hypertension, diabetes and asthma in sentinel sites, and screening and treatment for mental disorders.[11]
• Use indicators covering the establishment and functionality of the intersectoral structure, availability of monitored sectoral plans, tobacco and alcohol consumption, population salt intake, and overweight and obesity prevalence.[20][22]
• Draw data from the District Health Information System, Statistics South Africa mortality data, rapid mortality surveillance, burden-of-disease studies, the South African National Health and Nutrition Examination Survey, demographic and health surveys, cancer and chronic disease registers, directed surveys and school health monitoring.[28][20][10]
• Collect essential health indicators through the District Health Information System, monitor desired clinical outcomes, and maintain medicine-availability and utilisation records to identify supply and delivery problems.[27]
• Measure service implementation against policies, norms and standards, require corrective action plans where deficiencies are found, and undertake in-depth evaluations where implementation is satisfactory but outcomes fail to improve.[28][20]
• Evaluate specific delivery initiatives through research, including the integrated chronic care model, while monitoring cataract surgery through provincial hospital data, mental-health caseloads through the District Health Information System, and medicine stock-outs, equipment availability and guideline adherence through supervision reports.[26]
• Conduct research on macroeconomic and social determinants, risk-factor exposure, healthy lifestyles, cost-effectiveness, best buys, low-cost screening and intervention approaches, medicines and vaccines.[2]
• Strengthen research capacity through the National Health Research Committee, maintain at least two relevant research projects and produce results from at least three projects.[14]
• Require strategic leadership to give effect to targets and demand results during implementation.[18]

The available material does not specify a single detailed reporting timetable, indicator definitions for all targets, or a standalone formal accountability framework; however, it assigns monitoring and supervision functions to health-system structures and identifies national and multisectoral leadership arrangements.[27][14]

Costing & Financing

Cost-effectiveness is a central principle: the strategy prioritises evidence-based best buys, low-cost approaches and interventions expected to achieve the greatest health gain for each Rand spent.[12][15][20]The source nevertheless provides no confirmed strategy budget, financing framework, funding allocation, funding-gap estimate or detailed resource-mobilisation plan.[12][14]

• Estimate annual expenditure on non-communicable disease interventions in South Africa at more than 11 billion Rand, including approximately 150 million Rand for population-based interventions and 1.125 billion Rand for individual-based measures.[12]
• Prioritise low-cost, highly or moderately impactful and very cost-effective measures addressing tobacco use, harmful alcohol use, unhealthy diet and physical inactivity because the estimated expenditure level was regarded as unrealistic at the time.[12]
• Use fiscal measures, food advertising regulation, food labelling, worksite interventions, mass-media campaigns, school-based interventions and physician counselling as cost-effectiveness options, with listed Rand values ranging from 0.20 to 11.80.[15]
• Recognise affordability barriers to healthy diets: a 2009 rural supermarket study found healthier foods cost 10% to 60% more by weight and 30% to 110% more by food energy than unhealthy foods.[7]
• Consider human papilloma virus vaccination potentially highly cost-effective, subject to vaccine purchase price and affordability.[24]
• Use behaviour-change interventions, cardiovascular-risk assessment and evidence-based preventive drug treatment to reduce resource needs and health-care costs.[17]
• Promote equitable funding, investment in health-system reform, innovation and research, and affordable medicines, devices, vaccines and essential services.[6][23]
• Record nil resource or cost requirements for establishing the intersectoral structure and developing the integrated intersectoral prevention plan.[22]
• Note that hypertension and diabetes account for around 17 million health-centre visits annually, contributing to significant health-care and human-resource demands.[29]
• Recognise that poorly managed incurable conditions can generate costly avoidable admissions for the State and patients, supporting investment in accessible palliative care.[25]

Broader international financing priorities include increased national budget allocations, predictable domestic, bilateral, regional and multilateral resources, innovative financing options, and official development assistance commitments.[30][31]The available material does not quantify domestic allocations, programme funding sources or a funding gap.[30][32]