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Sep 23
Today is International Day of Sign Languages, and these researchers are lobbying for equal access to health services for the Deaf in South Africa

By: Lunga Memela (Communications Engagement Lead)

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In South Africa (SA), up to 80% of healthcare consultations are conducted across language barriers. Access to quality healthcare is enshrined in our Constitution, and more recently promised by National Health Insurance. However, for persons born deaf who rely on South African Sign Language (SASL) for communication, this access is thwarted by language barriers. Barriers include providers who cannot communicate in the patient's language, and an absence of SASL interpreter services. The consequences are a particular disadvantage for deaf healthcare users, who experience multiple axes of discrimination both in health care and in broader society, limiting their capacity to manage miscommunication in health care.

This is according to a review co-authored by health experts Leslie London, Virginia Zweigenthal and Marion Heap (published posthumously) from the Division of Public Health Medicine at the University of Cape Town's School of Public Health and Family Medicine, and the Cape Town-based organisation Equal Health for the Deaf. Appearing as the 19th chapter in the 2020 edition of the South African Health Review (SAHR) – a flagship publication of the Health Systems Trust – their review, Ensuring equal access to health services for the Deaf in South Africa, recommends that the provision of adequate interpretation services should be complemented by programmes that boost agency of the deaf in challenging the historical but persisting discrimination they experience.

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The United Nations identifies the International Day of Sign Languages on 23 September as a unique opportunity to support and protect the linguistic identity and cultural diversity of all deaf people and other sign language users. The 2021 theme, declared by the World Federation of the Deaf (WFD), is "We Sign For Human Rights," highlighting how each of us – deaf and hearing people around the world – can work together, hand-in-hand to promote the recognition of our right to use sign languages in all areas of life.

The International Week of Deaf People (IWDP) is an initiative of the WFD and was first launched in 1958 in Rome, Italy. It is celebrated annually by the global Deaf Community during the last full week of September, to commemorate the same month the first World Congress of the WFD was held. The IWDP is celebrated through various activities by deaf communities all around the world. WFD signs about it in this video.

In March 2021, the World Health Organization (WHO) estimated that 1 in 4 people are projected to have hearing problems by 2050. WHO published a World Report on Hearing, which aims to provide evidence-based guidance to drive actions for integration of quality ear and hearing care services into national health plans of Member States, as part of their work towards universal health coverage. "According to the World Federation of the Deaf, there are more than 70 million deaf people worldwide. More than 80% of them live in developing countries. Collectively, they use more than 300 different sign languages," says WHO.

In the conclusion of their SAHR chapter London, Zweigenthal and Heap state "[t]he words below, from a participant in Tshegofatso Senne's study, capture both the challenges of a health system seeking to be responsive to [d]eaf patients, and the agency needed by the [d]eaf to make their constitutional rights real":

You need to know that you have your rights and you must fight for them. I have the right to go to the police station or to the clinic. Tell them you're [d]eaf and you have a problem and that you need SASL. I have the right to be treated as a normal person .... We have a right to be recognised in South Africa as a whole. If people know about accessibility and understand this, then we just need to make SASL an official language. There's no other way to solve it.

Access the full chapter here: Chapter 19: Ensuring equal access to health services for the Deaf in South Africa, or to see other contributions to the 2020 edition of the SAHR: Access to health care for persons with disability in South Africa, click here.



Sep 22
Resilient SA SURE teams ensure patients’ continuity of HIV treatment and care

By: Joslyn Walker (Programme Manager: Health Systems Strengthening)

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Facilities were damaged during the July 2021 public unrest.

Widespread public unrest across KwaZulu-Natal Province during July 2021 blocked access to health services through closure of roads and facilities, and disrupted medical, food and fuel supply chains. Hundreds of medicine collection pick-up points and pharmaceutical warehouses were either temporarily closed or looted and destroyed.

Following the first national COVID-19 lockdown in 2020, the SA SURE project's implementation of a proactive, client-centred approach in eThekwini District had brought 2 354 of 3 236 identified patients back into care during the six weeks from 28 May to 12 June. This 93% retrieval demonstrated the benefits of this approach, so these activities were replicated in response to the July 2021 service disruptions, but scaled up across all four supported districts.

Partnering with the Department of Health (DoH), SA SURE teams established emergency processes to assess the number of patients whose HIV treatment had been interrupted during and in the aftermath of the unrest, and took remedial action to return them to care.

In the weeks following resumption of services, the cohorts of patients who had missed their clinic appointments in the 10 days of unrest were identified and traced for continuation of treatment and viral load testing. These patients were contacted and returned to the facility for treatment, or a community drop-off point was agreed for medicine delivery to ensure their sustained care. In addition, patients who were already in the cohort of 'early missed appointments' (1−28 days) or 'late missed appointments' (29−90 days) were closely monitored and included in the tracing efforts to ensure that tracing teams did not focus solely on the emergency response.

The collaborative efforts of the SA SURE and DoH tracing teams with pharmacy staff and community caregivers ensured that of the 52 154 patients at risk of being lost to follow-up and treatment failure through missed appointments, 48 315 were retrieved within a period of four weeks.

Diligent record-keeping and data capture are essential to enable efficient monitoring of Missed Appointment Lists, which in turn facilitates successful tracing of identified patients to support their return to care. The process entails establishing a baseline of missed appointments and then daily reporting against the baseline.

Dedicated patient tracking and tracing, along with intensified HIV case management, constitute a good-practice strategy for stabilising patients' clinical care following social crises, and for improved performance in routine continuity of care towards achievement and maintenance of viral suppression.

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Via a GoTo meeting, the Zululand SA SURE team celebrated being the first district to achieve 100% return of patients to care.

We salute our district teams for their unfailing efforts − despite increased caseloads and amid the challenges of the COVID-19 pandemic − to address the needs of people living with HIV who are affected by health service disruption. Their innovations and hard work contribute to minimising the length of treatment interruptions, which helps to prevent HIV drug resistance, onward transmission of the virus, illness and death.


Sep 16
HST tackles soaring numbers of teenage substance abuse in KZN’s uMgungundlovu District

By: Lunga Memela (Communications Engagement Lead)

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The increasing rate of teenage substance abuse in KwaZulu-Natal's (KZN's) uMgungundlovu District, Pietermaritzburg, is being tackled head-on by the Adolescent and Youth Friendly Services (AYFS) Programme which is supported by the Health Systems Trust's (HST's) Unfinished Business (UB) for Paediatric and Adolescent HIV Project in three districts of the province.

According to HST's Psychosocial Advisor, Phelelani Mbatha, the UB project in uMgungundlovu has been hard at work together with the Department of Health (DoH) partners and other community youth structures to address the issue of teenage drinking and drug-taking, which often leads to other social ills, including preventable teenage pregnancy, rising school dropout rates, as well as the spread of HIV and other sexually transmitted infections (STIs) – preventing youngsters from ever realising their full potential.

YOLO was the key message shared into school-going and unemployed youth who recently attended an event targeted at promoting good physical and mental health and condemning the use and abuse of alcohol and drugs, not only underage drinking, but also highlighting the dangers that come with consuming alcohol, drug use, and bad decision-making. The event was held at a local school and invited primary and high school learners to understand that "You Only Live Once (YOLO)" and, therefore, the decisions that you make today will impact the outcome of the rest of your life. "Take good care of yourself and the ones you love," Mbatha said.

The learners and local youth present were introduced to children and youth-friendly services available at DoH facilities. "As parents or healthcare workers, it feels good, even great, when our children need us. However, we have to remind ourselves that our long-term goal is to raise independent kids. We don't want them to be emotionally distant or independent from their family, but simply capable and confident of their own abilities," said Mbatha.

Mbatha said that it's not enough that we ask children to do things and expect them to obey. "We actually need to teach them why things happen the way they do. Learning cause-and-effect is a very important developmental milestone. After something goes one way or the other, it is wise to ask them what they think about it; to get them involved in how things work."

The provision of AYFS serves as a reminder to the youth to make and own their life choices. This includes their right to say NO to any involvement in social ills such as substance abuse, crime and early sexual interaction. "The programme helps young people to make positive changes in their communities. The intention is for us to create a movement of responsible young people who are able to contribute positively not only to their lives, but also to their household, to their communities, to their villages, to their schools. So, we remind young people that they have one life and they have one chance at it and how we can work together with them to make it a better chance of living," Mbatha explained.

Well-received by the attendees, the event concluded that young people should be exposed to as much health information as possible so that they can make informed decisions. The idea is also to encourage parents not to hold judgmental attitudes about young people's behaviour, but rather to support efforts for the best possible futures affordable at district and community level.

HST's Health Systems Strengthening (HSS) Unit provides technical support through strategic use, analysis and distribution of information about health and related fields to enhance district-based services as well as health system performance. HSS is directed by Ronel Visser and the UB programme is headed by Rakshika Bhana.

Last year's Annual Report confirmed that through the UB programme, the retention-in-care rate improved from an average of 76% to 86% among children and adolescents aged 0−19 years during the reporting period. Viral load suppression in this age group reflected a 10% increase, from 78% to 88%, during the reporting period. For continued support in the face of COVID-19, virtual contact through calls and messaging was adopted to provide mentoring for facilities. For children who could not access services at facility level, efforts were made to provide services in the community through planned household visits.


Sep 10
Promoting women, maternal, newborn and child healthcare on International Gynaecological Health Day

By: Joan Dippenaar (Technical Advisor: Training Unit) 

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Although women globally are still experiencing a lack of the fundamental services they need to 'survive, thrive and transform,' as set out in the Global Strategy for Women's, Children's and Adolescents' Health 2016–2030. Women in South Africa, in particular, are facing challenges in terms of access to quality healthcare.

The COVID-19 pandemic put the progress made in the improvement of maternal health through vigorous surveillance and programme development in South Africa in response to the Sustainable Development Goals (SDGs), at risk.  In April 2020, the National Department of Health published COVID-19 guidelines to guide the care of pregnant women and babies during the pandemic. The socio-economic impact of the COVID-19 pandemic inevitably brought economic challenges (such as rising food costs) and this has impacted negatively on the most vulnerable, including women and children, resulting in increased poverty and health risks particularly during pregnancy and early childhood.

In 2021 the South African Civil Society for Women, Adolescents and Children Health (SACsoWACH) focused on the promotion and support of breastfeeding in a consolidated response to ensure the wellbeing of babies during the COVID-19 pandemic, by providing donor mother's milk from the mother's milk banks to babies. The COVID-19 pandemic and  recent conflicts in SA, as well as migration of women from African countries and from rural areas to cities across provincial borders puts women and children's health and wellbeing  at risk. Discrimination, abuse and violence against women, with a particular high rate of intimate partner violence (IPV)-related deaths of women at the hand of a partner is a matter of great concern in the South African context.

The National Department of Health intends to strengthen and improve the quality of service delivery of Women, Maternal, Newborn and Child healthcare through the development and implementation of focused, standardised evidence-based international aligned policies (2021) that incorporate 'Respectful Maternity Care' (RMC) as framework for the SA healthcare context.

Improving the quality of maternal and newborn care remains a priority in South Africa, although inequality, lack of income and high levels of single mothers depending on grants are factors that influence the progress of women and children to 'survive, thrive and have transformed healthy lives.'


Sep 08
In the frontline for persons with disabilities

By: Lunga Memela (Communications Engagement Lead)

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The experiences of community-based peer supporters for persons with disabilities were explored in two training programmes featured in the latest issue of the South African Health Review (SAHR), a flagship publication of the Health Systems Trust, which was published under the theme: Access to health care for persons with disabilities in South Africa.

Contributing the ninth chapter of the Review's 23rd edition, the authors, Gillian Saloojee, an independent physiotherapist, and Maryke Bezuidenhout from Manguzi Hospital's Rehabilitation Department, describe the development and implementation of peer-supporter training programmes by two non-profit organisations – Malamulele Onward, which has trained and currently funds parents of children with cerebral palsy at 18 sites nationally, and Manguzi-based Siletha Ithemba Kubantu Bethu in northern KwaZulu-Natal, which formed after eight adults with spinal cord injuries were trained as peer supporters.

The authors highlight the importance of peer supporters as they assist caregivers to understand and care for those with disabilities in helpful ways. "They help to transform a sense of hopelessness, isolation and guilt into pride and acceptance, and increased self-confidence provides critical insight into barriers and facilitators, good practices, and successful service-delivery models for disability inclusion and rehabilitation."

The impact of both programmes has demonstrated their value: Malamulele Onward has assisted caregivers to understand cerebral palsy, and helped them learn how to care for their children in helpful ways and how to transform a sense of hopelessness, isolation and guilt into pride, acceptance and increased self-confidence. Clients with newly acquired spinal cord injuries experienced easier inclusion and integration back into family and community settings. Their ongoing telephonic contact with their peer supporters prevented unnecessary out-of-pocket expenses and creates an early warning system for avoidable secondary complications, the study found.

The lived experience of a spinal cord injury or of caring for a child with a complex disability combined with in-depth training and ongoing mentoring gives peer supporters credibility, and their advice and information are more likely to be believed and acted upon. "What takes therapists years to achieve with clients in terms of behaviour and lifestyle changes can be achieved by a peer supporter in one session. Peer supporters offer a way of filling the gaps in the current inequity of access to rehabilitation for persons with disabilities," the authors say. "If integrated into traditional rehabilitation services and with a sustainable funding model, improved outcomes are possible for adults and children with disabilities in terms of social inclusion and prevention of secondary complications."

Also lobbying for persons with disabilities in the 13th chapter of the Health Review, authors Kate Sherry, Steve Reid and Madeleine Duncan promote health-system strengthening that matters to rural persons with disabilities, highlighting lessons learnt from the Eastern Cape. They argue that disability, poverty and poor access to healthcare services occur in a mutually reinforcing vicious cycle, stressing that health system strengthening measures are vital in interrupting this cycle.

A group of people with disabilities was followed over two years in the study, providing qualitative longitudinal data on health system engagement, contextualised within the realities of daily life in an impoverished, rural community. Through understanding the healthcare experience from the perspective of people with disabilities, important lessons emerged on how health systems can either exclude or engage this vulnerable population.

The study describes the often-hidden temporal and spatial dimensions of healthcare engagement, which pose serious barriers to people with chronic health conditions and people with disabilities. At the same time, it reveals the pivotal role of individual interaction between the healthcare worker and healthcare seeker, and the ways in which the health system can either constrain or enable this.

While the findings point to large-scale health system changes needed if people with disabilities are to fully realise their right to health care, the findings also suggest the protective role of trust and positive relationships at individual level in strengthening healthcare engagement. The recommendations offer hope not only for people with disabilities, but also for the broader population.

Download the SAHR 2020 full document here.

Download the Chapters at a glance here

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Imagine the world in 2030, fully inclusive of persons with disabilities, probes the United Nations in #Envision2030: 17 goals to transform the world for persons with disabilities.


Sep 01
Optimising delivery of HIV treatment through community-based services begins

​By: Judith King  (Copy and Content Editor: SA SURE)

Despite the proven benefits of well-managed antiretroviral therapy (ART) for people living with HIV (PLHIV), many are not diagnosed as HIV-positive and are not engaged in care.

Decentralising the provision of HIV services from overburdened health facilities to community sites can change this reality. Reducing barriers to acceptable, efficient and more prompt ART initiation and management can support more PLHIV in achieving viral suppression.

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This was validated by Health Systems Trust (HST) during the COVID-19 Level 5 lockdown period in 2020, when SA SURE Project teams took HIV services into communities to ensure continuity of treatment for PLHIV and accelerated decongestion of health facilities.

The DO ART Study

A study on delivery optimisation for antiretroviral therapy (DO ART) was conducted from 2016 to 2019 to provide community-based ART initiation, monitoring and resupply among HIV-positive people in South Africa and Uganda. The results showed that in settings with high and medium HIV prevalence, community-based ART delivery significantly increased viral suppression compared with clinic-based ART services, particularly among men. The results also confirmed the safety and cost-effectiveness of this approach.

The DO ART Demonstration Project

The DO ART Study team recommended that community-based ART (CBA) services for people with detectable viral load should be implemented and evaluated in different contexts.

Funded through a grant from the Bill & Melinda Gates Foundation, HST is building on the findings of the DO ART study to determine within a real-world setting − in eThekwini South and Nongoma Sub-districts − the potential of CBA services for improving the numbers of ART-eligible clients being initiated on treatment and their continuity of care towards viral suppression within six months.

Programme Manager Joslyn Walker explains: "This entails providing comprehensive screening services, ART initiation, and ongoing community-based management of patients on ART – embedded as part of routine services offered through the SA SURE Project's current HIV programmatic work in KwaZulu-Natal. By the end of the project's 12-month duration, we hope to demonstrate a 30% improvement in viral load suppression after six months among participant patients in the two districts receiving the CBA services, compared to those receiving the clinic-based standard of care."

The project will also involve developing an understanding of the experiences and preferences among male and female participants receiving CBA services to inform appropriate service delivery. The perspectives of clinical and field-based project staff on opportunities and challenges of implementing CBA will be documented, and the financial and safety implications of implementing the CBA model will be described.

"This work will assist in establishing a body of knowledge around CBA implementation and its potential to expand the overall capacity of the health system," says Walker. "Our project findings will influence policy and practice by informing provincial and national roll-out through the Department of Health."

The DO ART Project management team

With Ronel Visser (Director of Health Systems Strengthening) as Principal Investigator, the HST contingent comprises Ntombizodwa Mbelle (Director of Health Systems Research), Joslyn Walker (HSS Programme Manager), Gugulethu Sokhela (DO ART Project Manager), Sphindile Magwaza (eThekwini Project Manager), Makhosazana Khosa (Zululand Project Manager), Dr Livhuwani (Lima) Mashamba (Monitoring and Evaluation Deputy Manager), and Felicity Basson (HIV Testing Services Co-ordinator: KZN). Technical guidance is provided by the Human Sciences Research Council's Philip Joseph (Chief Operating Officer), Thulani Ngubane (Implementation and Safety Officer), and Professor Alistair van Heerden (Director) – all from the HSRC's Centre for Community-based Research.

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From left: Ronel Visser, Zo Mbelle, and Joslyn Walker

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Gugu Sokhela

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From left: Lima Mashamba, Felicity Basson, Makhosazane Khosa, and Sphindile Magwaza

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From left: Thulani Ngubane, Alistair van Heerden, and Philip Joseph

Protocol revision and SOP development

The DO ART Project team has developed data-flow processes to create a standard operating procedure (SOP), and data-flow and data-collection tools have been shared and aligned with the standard Department of Health process steps so as to minimise duplication and maximise efficiency. A 'library' of SOPs aligned with the DO ART protocol was created for training purposes and approval by Zululand and eThekwini District DoH structures.

M&E Framework development

The Monitoring and Evaluation Framework has been designed and the data flow finalised. The DoH data will be collected in paper-based format, and project-specific qualitative and quantitative data will be collected electronically using digital tablets.

The clinical workplan was integrated in a Gantt chart and individual workplans are being designed with performance indicators for rigorous monitoring.

The project's mobile clinics will be registered as Tier.Net organisational units by the KZN DoH.

Implementation and reporting

Operational Managers and Sub-district Managers have been engaged in the development of strategies for integrated reporting. These will be finalised to synergise and streamline clinic-based activities, DoH mobile services, and DO ART community-based services. Staff will be assigned to individual buses and other vehicles, and route mapping and identification of service points will be conducted with facility-based teams and DoH management.

Recruitment and training

The posts for Nurse Clinicians, Driver Mobilisers and Lay Counsellors were filled in June, and recruitment of Data Capturers, Campaign Agents and Community Educator-Engagers is under way.

Various categories of project staff received three days of training on the DO ART Project protocol during July 2021. The interactive format of this hybrid virtual and in-person programme entailed role-play, group feedback, and building on existing clinical knowledge to enhance narratives for project participant recruitment and treatment.

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Attendees at the virtual dual-district DO ART training sessions hosted from Durban, July 2021

The training covered the background and contextual issues of the originating DO ART study, and then focused on the data-collection processes and clinical interventions required for implementation, as well as participant eligibility criteria, marketing strategies, recruitment approaches, and plans for community engagement.

Additional training on HIV self-screening and index contact testing will be provided. In-service training and monitoring will be conducted to fine-tune processes for recruitment, enrolment, and implementation of performance management.

This article refers to a demonstration project funded by the Bill & Melinda Gates Foundation. The findings and conclusions contained herein are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation.


Aug 13
HST promotes return to care for CCMDD patients following civil unrest in KZN and Gauteng

By: Lunga Memela (Communications Engagement Lead)

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Economists have been hard at work, crunching numbers to establish the value of looted goods as well as the cumulative cost of the overall damage caused by the recent civil unrest that broke out in South Africa's KwaZulu-Natal (KZN) and Gauteng (GP) provinces early in July.

It did not help that these incidents – which include arson – took place during the country's ongoing third wave of COVID-19. This meant that the looting and vandalising of pharmacies and other health facilities, together with the obstruction of national and domestic roads, would hinder not only adherence to health protocols such as practising social distancing and the wearing of face masks, but also impact the nationwide COVID-19 vaccination drive and limit direct access and adequate delivery of healthcare services and treatment to patients who need them most, especially those on chronic medication.

The National Department of Health (NDoH) confirmed that approximately 300 000 patients were impacted as a result of their chronic medication pick up points (PUPs) being closed due to the civil unrest across the country. The NDoH-led CCMDD (Central Chronic Medication Dispensing and Distribution) Programme – also known as Dablapmeds – put out a call that is supported nationally by the Heath Systems Trust (HST) to encourage patients to 'return to care' following the civil unrest. CCMDD enables patients with chronic conditions such as diabetes, high blood pressure, HIV/AIDS, asthma and epilepsy to collect their medication at convenient locations in their communities.

CCMDD's Provincial Co-ordinator for KZN, Roma Ramphal, encourages those with chronic conditions to request a CCMDD registration at any public health facility. For patients who were once a part of the programme and have been deactivated because of travelling to other districts or provinces, the programme requires the patient to return and convenient alternative PUPs will be offered.

Ramphal said the protest action has impacted those who were due for viral load blood tests, those patients due for a CCMDD clinical review as well as those patients who were due to collect at PUPs  during the week of the unrest. "KZN has lost pick up points that will need time to rebuild. In the interim, there are contingency plans for patients on CCMDD that have been affected."

Ramphal emphasised that patients should check their SMSs and ensure that their contact details are captured correctly upon registration. Communication via SMS has been sent to affected patients whose parcels have been rerouted close to their original pick up point. Ramphal stressed that patients should never miss a day of chronic medicines and can return to the health facility for medicines at any time and choose a new pick up point.

Patients enrolled on the CCMDD programme may contact the Pharmacy Direct Toll Free call centre on 0800 21 23 50 (KZN only) if they require information on whether the PUPs are operating following the civil unrest or where their parcels have been rerouted to.

Some additional advice to encourage patients to take charge of their health and wellness:

  • Visit your nearest public health facility for a full health screening.
  • Ensure you are maintaining COVID-19 protocols when accessing healthcare facilities and pick up points.
  • As a CCMDD patient, you can call the Pharmacy Direct Call Centre to update your cellphone number.
  • Should you have missed your viral load blood test – ensure it is completed. Demand it at your next visit!
  • Visit the CCMDD webpage and Get Checked. Go Collect. Facebook page for regular updates.
  • Content will be updated on the website so that we can more easily create direction.


In line with its vision for improved health equity in a healthier Africa, HST remains committed to making the United Nations Sustainable Development Goal 3 – which is to ensure healthy lives and promote well-being for all at all ages – a reality.  



 



Aug 04
Protecting breastfeeding - A shared responsibility

By: Joan Dippenaar (Technical Advisor: Health Systems Training Institute and Specialist Midwife)

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The exclusive breastfeeding (EBF) target for South Africa is that 50% of women should breastfeed the baby exclusively for 6 months by 2025 regardless of their HIV status. In 2016, South Africa reported that 67.3% of infants were initiated onto breastfeeding within 1 hour of birth with an increase of exclusively breastfeeding from 10 –31.6%, the lowest rates on the African continent. The global target is 75%.

In view of the call for shared responsibility the importance of all stakeholders to be involved is recognised. Breastfeeding is a full-time activity and the mother needs support, time and care.

A review of exclusive breastfeeding research articles 1980–2018 showed why progress is slow in South Africa. From the review of 72 articles they found that several provinces were poorly represented in research, and that the influence of families, community and workplace were not looked at.  They also thought that the rapid implementation of the breastfeeding global agenda in an unsupportive environment may have caused what they term 'unintended damage.'

So what does the context and supported environment for the SA context look like?  Several aspects are briefly highlighted

Socio economic challenges

The Child Health Gauge 2020 focused on food security for children's health in South Africa that does not meet the minimum criteria for acceptable food. The critical period is the need of the baby in the first 1000 days with a focus on the mother's nutrition in pregnancy and lactation and low exclusive breastfeeding rates of children after birth leading to stunting, malnutrition and death. Support is needed to ensure the mother is well-nourished to be able to breastfeed.

Family structure and household income is a major stress as seen by the high rate of single mothers who are often dependent on the family because more than 50% of babies born do not have the biological father's name on the birth certificate. The father of the baby may sometimes also be the primary support to the mother and baby. Men who are part of the family may be unemployed or working far from home. This is critical factor requiring attention in terms of enhancing support to mother and baby.

Patient factors

HIV infections: Young women account for 25% of new HIV infections. Mothers living with HIV (20% pregnancies) should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer but pregnant women living with HIV were less likely to express an intent to breastfeed (71% vs 99%). During the first 6 months postpartum, mothers living with HIV were also less likely to exclusively breastfeed compared to HIV-negative mothers. The factors affecting the EBF of HIV-positive mothers in an Eastern Cape study included employment, low levels of education, and alcohol consumption. School and work commitments were also reasons for discontinuation of EBF (some mothers were teenaged).

Psychological challenges. Research has shown that prolonged breastfeeding has more to do with psychological factors, (such as an optimistic outlook, feeling comfortable with breastfeeding, having faith in breastmilk as a food, expectations of breastfeeding, planned duration of breastfeeding and level of anxiety) than socio economic factors. The psychological condition of women in pregnancy as a stress factor in life is not recognised, considering the young women if single may also work or study.

Staff factors

Competency challenges. One of the main complaints of lactating women is conflicting advice they receive during breastfeeding. To effectively support breastfeeding as the biological norm and respect women's decisions staff should be certified as competent. A competency framework for breastfeeding support in Dublin serves as an example of a standardised approach. It addresses; 1) Awareness level competencies 2) Generalist Competencies and 3). Specialist Competencies. A standardised programme for each level of healthcare worker should certify competency, to ensure safe and effective practice to the community.

Health system factors

Standards of care and scheduled support challenges

Breastfeeding support offered to women with healthy term infants must be structured to increase the duration and exclusivity of breastfeeding. Support may be offered either by professional or lay/peer supporters, or a combination of both.

Characteristics of effective support include:

  • Standardised care by trained competent personnel during antenatal or postnatal care,
  • ongoing scheduled visits so that women can predict when support will be available
  • care should be tailored to the setting and the needs of the population group.
  • strategies that rely mainly on face‐to‐face support are more likely to succeed with women practising exclusive breastfeeding.

Ante and postnatal education and support challenges

The Cochrane review (2016) found lack of evidence that ante natal education makes a difference in Exclusive BreastFeeding (EBF). How best can women be supported then? Breastfeeding problems arise when the baby is born and the mother begins breastfeeding. So, postnatal support is critical. Currently health system practices to support women after birth is ineffective.  Information is given through the MomConnect platform but women also need an experienced face-to- face clinician to assist with some of the problems. Having a source of support in the community will be effective.

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A shared responsibility

When calling on a community to support breastfeeding the next step should engage with the community towards an action plan that can be implemented and measured. Based on the research report that the families, communities and workplaces has an influence, this source can be utilised through the pregnant women and the community involvement in a structured respectful manner for an action plan is to be contextual, finding workable solutions for the community.  Actions should be data driven, and inclusive of all stakeholders for a sustainable outcome.

In the Philippines the institution of structural support came in the form of a Republic No 10028 Act, also known as the "Expanded Breastfeeding Promotion Act of 2009." It stipulates the conditions for supporting breastfeeding as "an environment where basic physical, emotional, and psychological needs of mothers and infants" are fulfilled through the practice of rooming-in and breastfeeding, protecting the working women, management of all phases of pregnancy, birth and postnatal care lactation and clean and available lactation stations in public and private places, wet nursing, milk banks, education with inclusion of breastfeeding in all curricula, as well as certification compliance and sanctions for non-compliance.  Structure and control could be strategies that assist with meeting the set targets on time.

See the Cochrane site for Breastfeeding round up information.

Ryan-Vig S. 2019 Breastfeeding: a roundup of Cochrane. Evidently Cochrane. Evidence for Maternity Care.https://www.evidentlycochrane.net/breastfeeding-a-round-up-of-cochrane-evidence/ 

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Jul 28
Hepatitis Can't Wait

By: Lunga Memela (Communication Engagement Lead)

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The theme for this year's World Hepatitis Day is Hepatitis Can't Wait.

Why can't it wait? "With a person dying every 30 seconds from a hepatitis related illness – even in the current COVID-19 crisis – the world cannot wait to act on viral hepatitis," says the World Hepatitis Alliance. "Viral hepatitis B [HBV] and C [HCV] cause 1.4 million deaths per year – more than HIV/AIDS and malaria – and a number comparable to tuberculosis. Together, these viruses cause two in every three liver cancer deaths across the world," according to the Alliance. 

Hepatitis can be described as an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. "These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread," says the World Health Organization (WHO). "In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis, cancer and viral hepatitis-related deaths."

In June 2021, WHO released its first-ever global guidance for country validation of HBV and HCV elimination. This was in response to WHO's 2016 Global Health Sector Strategy on viral hepatitis, which provided the initial roadmap for the elimination of viral hepatitis as a public health problem by 2030, "a 90% reduction in incidence and a 65% reduction in mortality by 2030, compared with a 2015 baseline."

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World Hepatitis Day 2021 will mark the 11th official global commemoration. Take the pledge to raise awareness on hepatitis, get tested and support those infected. 

Jul 23
World Drowning Prevention Day 2021

By: Willemien Jansen (Copy and Content Editor)

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The first global World Drowning Prevention Day will be held on 25 July. This day was created to raise awareness of the profound impact that drowning can have on families and communities. The World Health Organization (WHO) states that an estimated 23 000 people drown every year, and that drowning is among the top ten leading causes of death for children and youth aged 1–24 years. According to the National Sea Rescue Institute (NSRI), there are approximately 1 500 fatal drownings in South Africa each year, of which 350 are children. Drowning is also the leading cause of child mortality, with about a third of fatal drownings being children under 14.

The good news is that drowning is preventable. Anyone can drown: No one should – that is the theme for this year's global commemoration, the day being declared through the April 2021 UN General Assembly Resolution A/RES/75/273 "Global drowning prevention."

The NSRI has been teaching water safety at schools across the country for the past 15 years. The UN and partners suggest implementing the following safety measures:

  • installing barriers controlling access to water;
  • providing safe places away from water such as crèches for pre-school children with capable childcare;
  • teaching swimming, water safety and safe rescue skills;
  • training bystanders in safe rescue and resuscitation;
  • setting and enforcing safe boating, shipping and ferry regulations; and
  • improving flood risk management.


There are many easy tricks that adults can use and teach their children to keep them safe and prevent drowning. Head coach of Eagar Aquatics and FINA (world aquatic governing body) panelist, Douggie Eagar makes the following suggestions for water safety:

  • Keep swimming pools at school and home secure, ideally with fences but otherwise with nets. This is the easiest and most important thing adults can do to prevent children from drowning.
  • Don't leave buckets or baths full of water unsupervised. It takes very little water for a small child to drown.
  • Kids should get used to water at a very early age. Wet a child's face and put it in the water, teach kids to blow bubbles whenever their faces are under water, and make them used to floating and weightlessness in the bath.
  • Parents can take their babies for floating lessons, but must remember that this is not foolproof. Over time little ones forget what they've learned, and floating might not be possible for a little one falling into water wearing a heavy diaper and layers of clothes. The best age to start swimming lessons is 2 years.
  • Avoid flowing water and muddy pools or dams. It is easy to underestimate strong currents or the depth of a dam when you can't see to the bottom.

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