WHO Country Cooperation Strategy 2016-2020: South Africa

WHO/AFRO Library Cataloguing – in – Publication Data WHO Country Cooperation Strategy 2016-2020 South Africa 1. 2. 3. 4. 5. 6. National Health Programs – organization and administration Health Priorities – organization and administration Health plan implementation Health Planning Technical Assistance International Cooperation South Africa

World Health Organization, Regional Office for Africa ISBN: 978-929023350-3 NLM Classification: WA 540 HU5 © WHO Regional Office for Africa, December 2016 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro.who. int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions expected, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use. Country Cooperation Strategy Republic of South Africa 2016–2020

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TABLE OF CONTENTS ABBREVIATIONS ............................................... ......................................... IV FOREWORD . . . . . ............................................................................................ VII EXECUTIVE SUMMARY ........................................................................ VIII 1. Introduction . . . ......................................................................................... 1 2. Health and Development Situation ....................................................... 4 2.1 Main health achievements and challenges ............................................ 4 2.2 Development cooperation, partnerships and contributions of the country to the global health agenda .................................................... 16

3. Review of WHO’s cooperation over the past CCS cycle .................. 20 4. Strategic Agenda for WHO Cooperation in South Africa: 2016-2020 ....................................................................... 27 4.1 Strategic Priority 1: Strengthen national efforts to attain universal health coverage (UHC) ...................................................................... 27 4.2 Strategic Priority 2: Contribute towards reduction of the disease burden for communicable diseases, especially HIV, TB, STIs, hepatitis and vaccine-preventable diseases ........................................ 29 4.3 Strategic Priority 3: Support the prevention and control of noncommunicable diseases, mental health disorders, violence and injuries . ....................................................................................... 31 4.4 Strategic Priority 4: Support South Africa in meeting its global health obligations while contributing to international health and development ...................................................................................... 33 II Country Cooperation Strategy Republic of South Africa 2016–2020

5. Implications for the WHO Secretariat ................................................. 36 5.1 Ensuring smart technical focus .......................................................... 36

5.2 Mobilizing resources for implementation ............................................. 37 5.3 Focusing on WHO core functions ....................................................... 37 5.4 Harnessing WHO resources at all three levels of the Secretariat .......... 38 5.5 Strengthening and expanding relationships with partners ................... 38

5.6 Improving communications ................................................................. 39 5.7 Strengthening the support functions of the country office ..................... 39

6. Evaluation of the CCS .......................................................................... 40 Annex 1: Key indicators........................................................................... 41 Annex 2. Linkages between CCS focus areas, national priorities, GPW, SDGs, and the UNDAF ................................................................... 42

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ABBREVIATIONS AEFI AFCON AFRO AFP AIDS ART ARVs BRICS bOPV CCS CDC CVI DCST DIRCO DQS DRS DR-TB DTI EDPLN EML EPI EU FCTC FAO GCP GFATM GIZ GoSA GPW GVAP GXP HED HIV HIV-DR HPV IV

adverse events following immunization Africa Cup of Nations WHO Regional Office for Africa acute flaccid paralysis acquired immune deficiency syndrome antiretroviral treatment antiretroviral drugs Brazil, Russia, India, China and South Africa bivalent oral polio vaccine country cooperation strategy Centres for Disease Control Centre for Vaccines and Immunology District Clinic Specialist Teams Department of International Relations and Cooperation data quality self-assessment drug resistance survey drug-resistant tuberculosis Department of Trade and Industry Emerging and Dangerous Pathogens Laboratory Network Essential Medicines List Expanded Program on Immunization European Union Framework Convention on Tobacco Control Food and Agricultural Organization good clinical practice Global Fund to Fight AIDS, Tuberculosis and Malaria German International Cooperation Government of South Africa General Program of Work Global Vaccine Action Plan GeneXpert heavy episodic drinking human immunodeficiency virus HIV drug resistance human papillomavirus

Country Cooperation Strategy Republic of South Africa 2016–2020

HRH HTC ICDMM ICESCR ICH IDSR IHR IOM IPT ISHP IST IVD LSDI MAG MCC MCV MDGs MDR-TB MNORT MRC NCC NCDs NDoH NDP NHC NHI NHIF NHLS NICD NIMART NNT NPEC NRA NSDAs NSP NTDs

Human Resources for Health HIV testing and counselling Integrated Chronic Disease Management Model International Covenant on Economic, Social and Cultural Rights International Conference on Harmonization Integrated Diseases Surveillance and Response Strategy International Health Regulations International Organization for Migration Isoniazid preventive therapy Integrated School Health Program Inter-Country Support Team immunization and vaccine development Lubombo Spatial Development Initiative Malaria Advisory Group Medicines Control Council measles-containing vaccine Millennium Development Goals multidrug-resistant tuberculosis Multi-sectoral National Outbreak Response Team Medical Research Council National Certification Committee (for Polio) noncommunicable disease conditions National Department of Health National Development Plan National Health Council National Health Insurance National Health Insurance Fund National Health Laboratory Services National Institute of Communicable diseases nurse-initiated management of antiretroviral treatment neonatal tetanus National Polio Expert Committee National Regulatory Authority Negotiated Service Delivery Agreements National Strategic Plan neglected tropical diseases Country Cooperation Strategy Republic of South Africa 2016–2020

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NVP OECD OHSC PCV PEPFAR PHC PICT PLHIV PMTCT R&D RAF RED SADC SAHPRA SAMEC SANAC SAVIC SDG SOP STIs TB tOPV UHC UN UNCT UNDP UNFPA UNICEF UNSCF USAID VCT WCC WHA WHO-CC WHO XDR-TB

nevirapine Organisation for Economic Co-operation and Development Office of Health Standards Compliance pneumococcal conjugate vaccine United States President’s Emergency Plan for AIDS Relief primary health care provider-initiated counselling and testing people living with HIV prevention of mother-to-child transmission of HIV research and development Road Accident Fund Reach Every District Southern African Development Community South African Health Products Regulatory Authority South African Malaria Elimination Committee South African National AIDS and TB Council South African Vaccine and Immunization Centre Sustainable Development Goals standard operating procedure sexual transmitted infections tuberculosis trivalent oral polio vaccine universal health coverage United Nations United Nations Country Team United Nation Development Program United Nations Population Fund United Nations International Children’s Emergency Fund United Nations Strategic Cooperation Framework United States Agency for International Development voluntary testing and counselling WHO Collaborating Centre World Health Assembly World Health Organization Collaborating Centre World Health Organization Extensively drug-resistant tuberculosis

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Country Cooperation Strategy Republic of South Africa 2016–2020

FOREWORD This WHO third generation Country Cooperation Strategy (CCS) responds to the reform agenda adopted by the World Health Assembly to strengthen WHO capacity at country level and to make its work more responsive to host country needs. It also takes guidance from the WHO 12th General Programme of Work, the Sustainable Development Goals, the National Development Plan and the National Health Strategic Plan 2015-2020. It takes into consideration the roles to be played by different partners including non-state actors in providing support to health development in the country. This third-generation CCS draws on lessons from the implementation of the first and second generation CCSs and the Country Focus Strategy. Universal Health Coverage is the foundation of all other health and health related SDG targets. This is priority number one in the national health development agenda. Consequently, this is a central theme in this CCS. The CCS was developed in consultation with key health stakeholders in the country and highlights the expectations on the work of the WHO. In line with the renewed Country Focus Strategy, the CCS is to be used to guide WHO’s work in the country, guide the development of the WHO Country Biennial Workplans, and as a resources mobilisation tool. It is also intended to be used to inform partners of the WHO Program as well as shape the health dimension of the UNDAF and other health partnership platforms in the country. The CCS defines four Strategic Priorities, and twelve strategic approaches. All the levels of WHO will support South Africa around this strategic agenda. WHO will contribute to the South Africa’s health agenda through focusing on these strategic priorities.

Dr Matshidiso Rebecca Moeti Regional Director Country Cooperation Strategy Republic of South Africa 2016–2020

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EXECUTIVE SUMMARY The WHO South Africa Country Cooperation Strategy was jointly developed by the National Department of Health; stakeholders such as civil society, development partners, and other UN agencies; and the WHO Country Office. Its objective is to determine how WHO as a Secretariat (i.e. the Country Office, Regional Office and Headquarters in Geneva) can jointly contribute to the attainment of national health development goals in South Africa. In that regard, this strategy aligns WHO work on the five-year Strategic Plan 2014/15 – 2018/19 of the National Department of Health, and the National Development Plan 2030: Our future - Make it Work, which presents the longterm vision for the country, including the objective of “Health Care for All.” Four strategic priorities have been set for WHO Cooperation in South Africa. These are based on the country’s disease epidemiology; the WHO 12th General Program of Work; National Health Strategy; international commitments including the Sustainable Development Goals; and the comparative advantage of WHO and its contribution relative to the activities and priorities of other multilateral and bilateral agencies. The first strategic priority is support to the implementation of National Health Insurance (NHI) to achieve universal health coverage (UHC). South Africa has enshrined the right to health care in its Constitution. It has also published a white paper on achieving universal health coverage through National Health Insurance (NHI) by ensuring universal access to services regardless of ability to pay. The first strategic priority is to support the implementation of South Africa’s National Health Insurance scheme, which is the roadmap to achieving universal health coverage (UHC) and protection from risks. This will be done through support to national work streams established for the phased implementation of the National Health Insurance (NHI) scheme; optimal distribution and effective utilization of the health workforce; and strengthening of the national regulatory authority to ensure quality medical products.

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The second strategic priority is to prevent and reduce the disease burden of HIV, hepatitis, STIs and tuberculosis (TB), with a view to increasing life expectancy gains. South Africa has made impressive achievements in expanding access to care and treatment for HIV and TB, and is moving towards malaria elimination. The second strategic priority focuses on the communicable disease burden, with a view to supporting the national target of accelerating life expectancy gains. This will be done through focused work programs targeting communicable disease conditions, including strengthening HIV treatment and care; preventing and controlling hepatitis and STIs; improving the prevention and treatment of TB and multidrug-resistant TB; and promoting access to existing and new immunization products. The third strategic priority is to promote longer healthier lives by supporting the prevention and control of noncommunicable diseases, injuries and accidents, and mental health. Smoking, harmful use of alcohol, high consumption of salt and sugar, and lack of exercise are major contributors to the growing noncommunicable disease burden. The third strategic priority is to promote policies for healthy communities and environments, which help people to make the appropriate behavioural choices and receive quality care that promotes longer healthier lives. This will be done through activities aimed at achieving global targets and honouring national commitments on noncommunicable disease (NCD) prevention and control; supporting the fulfilment of commitments under the WHO Framework Convention on Tobacco Control (FCTC); reducing the harmful use of alcohol; advancing the obesity strategy to promote healthy diets and exercise; and addressing pertinent mental health issues. The fourth strategic priority is to help South Africa meet its global health obligations while contributing to international health and development. Being on the front line of several major epidemics, South Africa’s responses to its domestic health challenges are watched regionally and globally. Regional reference laboratories, clinical and academic institutions, and WHO-CCs in South Africa serve critical roles that must be recognized and supported Country Cooperation Strategy Republic of South Africa 2016–2020

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to serve national, regional, and global health interests. The fourth strategic priority emphasizes WHO’s mandate and role in working with the South African government to honour its global health obligations while contributing to international health and development. This will be done by accelerating programmes to reduce South Africa’s share of the global burden of disease, and by identifying and documenting innovations and models for replication elsewhere. WHO will also support malaria and measles elimination, outbreak and emergency response systems, and polio eradication under the Polio Eradication and Endgame Strategic Plan, 2013-2018. WHO will specifically work with national authorities to develop the RMNCH strategic plan aimed at improving the quality of health services for women and children, with a view to meeting SDG targets. WHO in South Africa will also endeavour to expand its health partnerships in all technical areas and use this CCS to inform the development of the new United Nations Strategic Cooperation Framework. Such partnerships are critical to achieving the Sustainable Development Goals including crosssectoral collaborations, promoting gender and human rights, and reducing inequities. As part of the UN Country Team, WHO will fully participate in UN consultations on localization and implementation of the SDGs, anticipated to take place during the lifecycle of the CCS. The successful implementation of the strategic priorities outlined in this strategy will build on the achievements of the previous Country Cooperation Strategy and on the Government’s strong collaboration and good relationship with its counterparts and other major partners and stakeholders. The WHO Country Office, guided by the provisions of WHO Reform and the African Region Transformation Agenda, will provide focused technical support to selected areas as reflected in the strategic priorities. This will require strengthening the supporting functions of the country office, mobilizing resources, shifting resources to new areas of work, as well as strengthening teamwork and building partnerships with other stakeholders.

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1. INTRODUCTION The World Health Organization (WHO) Country Cooperation Strategy (CCS) is a medium term strategic vision to guide WHO work in and with a country. It is aimed at supporting a country’s national development plan, national health policy, and national health strategy. It is the strategic basis of the bottom-up process for developing the WHO Programme Budget (PB) and the Biennial Country Workplan. The CCS is also the main instrument for harmonizing WHOs cooperation in countries with that of other United Nations (UN) Agencies and development partners. The first Country Cooperation Strategy for South Africa was developed for 2008-2012. An extension strategy was approved for 2013-2014 to align the Country Cooperation Strategy with national health planning cycles and priorities. This 3rd generation CCS is expected to cover the period 2016 -2020. WHO activities, throughout the world, are guided by the current 12th General Program of Work (GPW)1 approved by the World Health Assembly for 20142019. It gives consideration to current changes taking place in the world, including social and economic developments, burden of disease, and the growing number of stakeholders involved in global health. WHO work is also guided by the SDGs approved in 2015 by the United Nations General Assembly. The CCS has to respond to SDG 3 and other health-related targets in 14 other SDGs. The CCS also informs and reinforces the health dimension of the United Nations Development Assistance Framework (UNDAF) which, in South Africa, is referred to as the Strategic Cooperation Framework. This CCS is guided by the National Development Plan 2030: Our future – Make it Work,2 which presents the long-term development vision of the country. One of the Plan’s 15 objectives is “Health Care for All”, which is the

1 WHO. Twelfth General Programme of Work: Not merely the absence of disease. http://www.who.int/about/resources_planning/twelfth-gpw/en/ 2 The National Development Plan http://www.npconline.co.za/pebble.asp?relid=757 Country Cooperation Strategy Republic of South Africa 2016–2020

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long-term health vision as stated in the five-year Strategic Plan 2014/20152018/20193 of the National Department of Health. The eight goals of the National Health Strategic Plan 2014/2015-2018/2019 are: prevent disease, reduce the disease burden and promote health; make progress towards universal health coverage; re-engineer primary health care; improve health facility planning; improve financial management; develop an efficient health management information system; improving quality of care; and improve human resources for health. In December 2015, the government published a white paper on the implementation of National Health Insurance (NHI) to achieve universal health coverage (UHC), focusing on the dual objectives of strengthening quality in public facilities, and reducing the cost of private health care. National Health Insurance (NHI) is the central mechanism through which South Africa seeks to achieve universal health coverage, under the principles of solidarity and equity in access. Under NHI, six work streams were established to undertake preparatory work for implementation of the scheme. These work streams focus on the establishment of the NHI Fund, benefits package, purchaser-provider split, role of private medical schemes, finalizing the NHI policy paper, and strengthening the district health system. WHO collaborates with many research institutions and universities in South Africa. There are 13 WHO collaborating centres covering different health programmatic areas such as communicable diseases, noncommunicable diseases, health systems and family health, among others. They carry out work in various technical fields, sometimes on behalf of the Organization. WHO is implementing reforms to enhance its effectiveness and accountability. The reforms focus on programmes which include: priority setting; the changing role of the Organization in global health governance; and internal governance and managerial issues within the Organization.4 The WHO African Region Transformation Agenda5 is a vision for change which lays

3 National Department of Health. Strategic Plan. www.health.gov.za/index.php/2014-03.../ strategic.../229-2015str?...strategic-plan... 4 WHO. WHO Reform http://www.who.int/about/who_reform/WHO_Reform_map_2015 pdf?ua=1 5 WHO Regional Office for Africa. The Transformation Agenda of the WHO Secretariat in the African Region. http://www.afro.who.int/en/rdo/transformation-agenda.html

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out a programme for accelerating WHO Reform within the Region. It seeks to foster the pro-results values of excellence, team work, accountability, integrity, equity, innovation and openness. It proposes smart technical focus on regional priorities and commitments, and it emphasizes strategic operations to ensure more efficient and effective resource management. The CCS formulation process was led by the WHO Representative, and the Director General and her team at the South Africa National Department of Health. The writing and technical analysis was done by WHO staff in the Country Office, with the technical input of the WHO technical staff in the Inter-country Support Team, the WHO Regional Office for Africa, and WHO Headquarters. The CCS was developed and finalized through a consultative process. Partners and stakeholders were invited to participate in the prioritysetting survey, and they made useful recommendations for WHO’s program of work. They also participated in subsequent consultative processes as part of an inclusive dialogue. This strategy will be monitored annually against office annual reports, and the results of the biennial work plan. The reviews will be documented and recommendations made to improve implementation.

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2. HEALTH AND DEVELOPMENT SITUATION The health and development situation is presented under the subheadings ‘Main achievements and challenges’ and ‘Development cooperation, partnerships and contributions of the country to the global health agenda’.

2.1 Main health achievements and challenges 2.1.1 Political, social and macro-economic context South Africa is a constitutional democracy with a three-tier system composed of: the government, parliament and an independent judiciary.6 The executive branch of government is led by the President at the national level, the premier at the provincial level, and the mayor at the municipality level. These officials are designated through an electoral process. The national, provincial and local levels of government have legislative and executive authority in their respective spheres, and are distinctive, interdependent and interrelated. For example, there is devolution of authority in the health sector such that each sphere is semiautonomous. This necessitates extensive consultations and relevant regulations for policy decisions made at the national level to be implemented in the provinces and municipalities. According to Statistics South Africa, the country had an estimated population of 54 million people residing in nine provinces in 2014. The annual population growth rate increased from 1.28% in 2002/2003 to 1.65% in 2014–2015.7 South Africa’s population is relatively young, with about 30% aged 15 years or younger. However, some 8.4% (or 4.5 million) of the population is aged 60 years or more. South Africa is one of the three upper middle-income countries in the African Region. In 2014, its gross domestic product (GDP) was US$ 350.1 billion with a GDP per capita of US$ 6,483.8 South Africa is 6 South Africa Year Book: Structure and functions of the South African Government. http://www.gov.za/about-government/government-system/structure-and-functions-south -African-government 7 Statistics South Africa: Statistical Release P0302; Mid-year population estimates 2015. https://www.statssa.gov.za/publications/P0302/P03022015.pdf 8 South Africa Data Portal. South Africa GDP per capita. http://southafrica.opendataforafrica. org/oxlkluf/south-africa-gdp-per-capita

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one of the BRICS countries (Brazil, Russia, India, China and South Africa) and is an active member of SADC and the African Union. South Africa and France currently co-chair the UN “High Level Commission on Health, Employment and Economic Growth”.9 High levels of migration into the country and between the provinces have created problems such as rising unemployment, ethnic conflict and competition for essential services such as health, water, electricity and waste disposal. As regards natural hazards, South Africa faces episodic natural disasters like droughts, tornados, earth tremors and abnormally heavy rains, which particularly affect certain vulnerable population groups, particularly those in informal settlements as well as farmers.

2.1.2 Health System The right to health care is enshrined in South Africa’s constitution. In population coverage terms, South Africa’s health system is dominated by the public health sector, while the private health sector mainly caters for the affluent members of society. The National Development Plan 203010 has several health priorities which have guided the National Health Strategic Plan 2015-2020, aimed at achieving a long and healthy life for all South Africans.11 The foundation of the public health system is composed of primary care facilities, which are mainly clinics and community health centres that are the first line of access to formal healthcare services. The ward-based PHC outreach teams form a link between community-based services and those offered by primary care facilities. The next tier of the public health care system in South Africa is the district hospital to which patients are referred from primary care facilities, when necessary. The final tier is tertiary hospitals, also known as provincial and central hospitals. Patients are free to

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World Health Organization: Health workforce. High-Level Commission on Health Employment and Economic Growth. http://www.who.int/hrh/com-heeg/en/

10 South Africa. The National Development Plan http://www.npconline.co.za/pebble. sp?relid=757 11 National Department of Health. Strategic Plan. www.health.gov.za/index.php/2014-03.../ trategic.../229-2015str?...strategic-plan... Country Cooperation Strategy Republic of South Africa 2016–2020

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choose their providers in the public sector and they often access the closest facility. This inadvertently forces central or tertiary hospitals to provide all types of health services, including primary care. Private provision of care mainly involves private hospitals and highly specialized services to which access is limited by affordability. Hence, they are mainly used by people who have voluntary health insurance coverage. Many uninsured patients consult general practitioners and make out-of-pocket payments for these services. Private sector health professionals are generally funded through private health insurance. In terms of health financing, 43% of health expenditure is channelled through voluntary health insurance regulated by the Council for Medical Schemes. In the public sector, services are subsidized and provided at no cost in primary care facilities. For the abovementioned reasons, the National Development Plan 203012 seeks to implement a national health insurance system, reduction in the relative cost of private medical care and bolstered by greater human capacity and better systems in the public health sector. It is noteworthy that the distinct nature of the spheres of government entails different mandates for each sphere. The National Department of Health is mainly responsible for formulating policy, generating national norms and standards, proposing legislation and monitoring local and international targets. Although provinces are expected to implement policies and adhere to targets developed at the national level, it is not uncommon for them to initiate the implementation of policies at different time periods and thus affect the national coverage of services and the achievement of the set targets. However, the National Health Council (NHC) and the Technical Advisory Committee to the National Health Council chaired by the Minister of Health and the Director General respectively are the bodies responsible for coordination between the Provinces and the NDoH. The Provincial Members of the Executive Council for Health constitute NHC while the Provincial Heads of Department of Health constitute the Technical Advisory Committee to the NHC.

12 Nations Online Project http://www.nationsonline.org/oneworld/map/za_provinces_map2.htm

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Emergency medical services which provide emergency ambulance services, including emergency care and transportation to hospitals, and the laboratory services are managed through distinct institutions which support the different tiers of health facilities. Figure 1: Map of South Africa showing Provinces and major urban areas13

2.1.3 Social, economic and environmental factors The main drivers of the South African economy include mining, agriculture and fisheries, vehicle manufacturing and assembly, food processing, clothing and textiles, telecommunications, energy, financial and business services, real estate, tourism, transportation, and wholesale and retail trade. In 2014, 13 Statistics South Africa. Millennium Development Goals Country Report 2015 South Africa Data Portal. South Africa GDP per capita. http://southafrica.opendataforafrica. org/oxlkluf/south-africa-gdp-per-capita Country Cooperation Strategy Republic of South Africa 2016–2020

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South Africa had a gross domestic product (GDP) of US$ 350.1 billion and a GDP per capita of US$ 6,483.14 It spends 9% of its GDP on health, amounting to US$ 570 per capita and public spending accounts for 48% of total expenditure. The government devotes 15.5% of its total expenditures to health. Most people (>80%) use public services. Private insurance schemes account for 43% of total health expenditures (THE), but cover only 16% of the population, while international aid accounts for less than 2% of total health expenditures. Informal settlements are widespread, particularly in the surrounding suburban areas. Such settlements tend to have a higher probability of open collection of stagnant waters, are more likely to use open containers for water storage and generally have poor infrastructure, leading to water- and sanitationrelated health hazards. The quality of service delivery systems in informal settlements vary by province. National systems for managing emergencies and outbreaks as well as risk communication strategies are in place.

2.1.4 Health status of the population Statistics South Africa reports that the average fertility rate was 2.3 births per woman in 2013. Life expectancy in South Africa has increased dramatically (9.6 years) over a relatively short period of time, rising on average from 51.6 years in 2005 to 61.2 years in 2014. This increase stems from the introduction of antiretroviral treatment for people living with HIV, and other major health initiatives. Life expectancy for persons without HIV was estimated at 69 years (65.2 for men, 72.7 for women). Based on civil registration data, Statistics South Africa indicates the main causes of death as tuberculosis (8.8% of total deaths), influenza and pneumonia (5.2%), HIV (5.1%), cerebrovascular diseases (4.9%), diabetes mellitus (4.8%), other forms of heart disease (4.6%), and hypertensive diseases (3.7%). South Africa faces a quadruple burden of disease resulting 14 South Africa Data Portal. South Africa GDP per capita. http://southafrica.opendataforafrica org/oxlkluf/south-africa-gdp-per-capita

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from communicable diseases such as HIV/AIDS and TB; maternal and child mortality; NCDs such as hypertension and cardiovascular diseases, diabetes, cancer, mental illnesses and chronic lung diseases like asthma; as well as injury and trauma. Some of the water-borne diseases that pose a high risk to South Africans include gastroenteritis, cholera, viral hepatitis, typhoid fever, bilharziasis and dysentery. Malaria is endemic in small areas within the provinces of Kwazulu-Natal, Limpopo and Mpumalanga.

2.1.5 Health-related MDGs With regard to Millennium Development Goal 4 (MDG4), substantial progress has been made towards achieving the target to reduce child mortality by two-thirds by 2015. Child mortality declined by 25% between 1994 and 2013, falling from 59 to 34 under-five deaths per 1,000 live births, and infant mortality declined by 30% from 54 to 24 infant deaths per 1,000 live births between 1998 and 2013.15 Early neonatal mortality rates remained virtually unchanged between 1998 and 2013, at 8 to 9 per 1000 live births. Hence the country did not meet its MDG 4 target. South Africa reported over 90% coverage of DPT1 containing vaccine (DTaP-IPV//HIB) for the past 3 years (2013-2015) with a dropout rate of 1.1% between DPT1 and DPT3. The dropout rate for the measles-containing vaccine (MCV) is over 10% between the first and second doses. There were three outbreaks of measles (2003/04, 2009/10, and 2015/16), which can be attributed to an accumulation of susceptible people due to low coverage with the first and the second doses of MCV. Another contributing factor is the sporadic vaccine stock-outs due to sub-optimal vaccine stock management skills. This represents a major challenge to achieving the measles elimination target for the WHO African Region in 2020. In 2008, South Africa introduced the rotavirus and pneumococcal conjugate vaccines in its routine immunization schedule. This was a significant step

15 Statistics South Africa. Millennium Development Goals Country Report 2015 Country Cooperation Strategy Republic of South Africa 2016–2020

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towards achieving MDG4. The introduction of these vaccines into the routine childhood immunization schedule substantially reduced childhood morbidity and mortality due to rotavirus, diarrhoea and pneumococcal disease. In April 2014, the National Department of Health implemented a schoolbased human papilloma virus (HPV) vaccination program targeting all girls 9 years and older in grade 4 in public schools. Implementation of the HPV vaccine is a step towards attaining the goal of reducing premature deaths caused by cervical cancer. According to the Civil Registration and Vital Statistics System (CRVS) report published in 2012, the maternal mortality ratio (MMR) was 269 per 100 000 live births in 2010, having reduced from 310 per 100 000 in 2009. The WHO Global Health Observatory data repository estimated the MMR at 138 per 10 000 live births in 2015. The three leading causes of this high MMR are non-pregnancy-related infections, especially HIV and tuberculosis (TB) and pneumonia (34.7%); obstetric haemorrhage (15.8%); and hypertension complications (14.8%). The antenatal care (ANC) utilization rate was over 90% in 2014, although this figure does not reflect the number of ANC visits. In 2015, the percentage of births attended by skilled health personnel was estimated at 94.3%, an indicator that has been consistently high over the years. Based on the SDGs targets, South Africa is expected to reduce its maternal mortality ratio to less than 70 per 100,000 live births by 2030. With regard to MDG 6, South Africa has achieved two of the three HIVrelated targets and has stabilized and reversed HIV prevalence among the population aged 15-24 years from 9.30% in 1994 to 7.10%, relative to the target of 8.70% set for 2015. The condom use target in 2012/3 was estimated at 58.49%, relative to the set target of 75.9 for 2015. The number of people living with HIV (PLWH) increased from an estimated 4.6 million in 2008 to 6.8 million in 2014. Over 3.2 million PLWHs had access to antiretroviral therapy (ART) by December 2015, including approximately 58% of those who met the eligibility criteria of having a CD4 count ≤ 500. HIV drug resistance (HIV-DR) is an emerging phenomenon, although it is still characterized as moderate. According to unpublished available information, transmitted HIV-DR is estimated at 5.3%, pre-treatment HIV-DR among adults ranges

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from 3.7 to 22.5% and acquired resistance at 12-15 months and at 24-36 months is estimated at 7% and 11.3% respectively.16 According to Statistics South Africa, tuberculosis remained the leading cause of death among South Africans in 201317 and among the youth between 2009 and 2014.18 The WHO Global TB Report (2015) estimates the TB incidence rate at 834 cases per 100,000 population. In 2014, there were 306 000 notified cases of all types of TB. The treatment success rate for drugsusceptible TB is 78% for new and relapse cases registered in 2013, which is below the global target of > 85%. In 2014, South Africa accounted for 15% of the global burden of multidrug-resistant TB (MDR-TB) and about 73% of the burden in the African Region. Furthermore, only 62% of confirmed MDR-TB cases were reported to have been initiated to treatment in 2014, with a 49% treatment success rate. Sixty one percent of TB cases are co-infected with HIV. Some 79% of TB patients co-infected with HIV were on ARVs in 2014.19 As regards malaria control, South Africa achieved a 75% decrease in malaria case incidence, between 2000 and 2013. The total number of reported malaria cases substantially dropped from 0.6 per 1000 (64622) in 2000 to just under 0.2 per 1000 (8851) in 2013.

2.1.6 Social determinants of health According to the national 2015 MDGs Progress Report, some progress was made towards addressing some of the social determinants of health such as poverty and hunger; universal primary education; gender equality and women’s empowerment; and safe drinking water and basic sanitation. For MDG 1 (eradicating extreme poverty and hunger), the improvements made between 1990 and 2015 were not sufficient to meet the MDG targets. Of 16 National Institute for Communicable Diseases (NICD): HIV-1 Drug Resistance in South Africa – unpublished data 17 Statistics South Africa: Causes of death report. http://www.statssa.gov.za/?p=6395. Accessed 9/9/2016 18 Statistics South Africa: Vulnerable Groups Series I: The Social Profile of Youth, 2009–2014. http://www.statssa.gov.za/?p=6395. Accessed 9/9/2016. 19 WHO Global TB Report: 2015: South Africa Profile. www.who.int/tb/publications/global report/en/. Accessed 9/9/2016 Country Cooperation Strategy Republic of South Africa 2016–2020

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the eight poverty-related international indicators (Target 1A), South Africa attained five, including reducing the proportion of the population living on less than US$1.25 per day from 46.2% to 39%. The prevalence of underweight under-five children was reduced to 8.3%, which was still short of the target (4.6%). For MDG 2 (achieving universal primary education), South Africa achieved one of the three targets by reaching a net primary enrolment ratio of 100% for both males and females. Literacy rates increased to 92% and 96% for males and females, respectively, but fell short of the 100% target. Significant progress was made on MDG 3. The targets met include gender parity at the primary, secondary, and tertiary educational level, as well as in literacy and employment. With regard to MDG 7 on safe drinking water, South Africa increased the proportion of people having access to safe drinking water from 23.4 to 88.3 between 1999 and 2015. It also raised the proportion of the population having access to improved sanitation facilities to 75.5% by 2012. The current challenge is to further increase these levels and sustain the resilience of infrastructure.

2.1.7 Universal health coverage Although South Africa is working hard to gradually achieve its UHC goals, fragmentation in pooling, passive purchasing and historical budgets undermine the effectiveness and quality of service delivery in the public sector. High prices have limited access to private providers who consequently cater only for the high-income segment of the population. Voluntary health insurance is prone to risk selection, high prices, limited control over service delivery volumes and the service delivery itself is highly fragmented and uncoordinated. In December 2015, the government published a white paper on the introduction of a national health insurance (NHI) scheme to achieve universal health coverage (UHC), focusing on ensuring progressive realization of the right to health by extending health coverage benefits to the entire population, in 12 Country Cooperation Strategy Republic of South Africa 2016–2020

a resource-constrained environment while benefiting from efficiency gains.20 NHI objectives include ensuring universal coverage for all South Africans; improving the quality of health care services for all users irrespective of socioeconomic status; and promoting equity and social solidarity through pooling of risks and funds. South Africa spends more on voluntary private health insurance (43%) as a share of total health expenditure than any other country in the world, but this serves only 16% of the population. The concentration of highly skilled human resources in the private sector and the resultant high cost of services limit the government’s ability to use private health sector resources to increase public access to health services and thus curb the marked inequality. Hence, the NDoH proposes on improving the quality of health services by ensuring the equitable distribution and efficient utilization of the health workforce and building the capacity to regulate health products, especially medicines.

2.1.8 Noncommunicable diseases Noncommunicable diseases (NCDs) and injuries account for 49% of mortality. Some 40% of NCD deaths among men and 29% among women are premature, affecting people below the age of 60 years. In 2013, over 38,000 South Africans died from cancer-related causes. The 2014 Global Status Report on Noncommunicable Diseases estimated hypertension prevalence in South Africa at 25.2%, and that of diabetes at 12.9%. One in four adults is obese, half are overweight and half are physically inactive. Smoking, harmful use of alcohol (at 27.1 litres per person per year), high consumption of salt and sugar, and lack of exercise are major contributors to the NCD disease burden. Smoking prevalence is among the highest on the continent at 16.2%. Some 26.5% of men smoke while 12.7% of the youth reportedly smoke daily. Alcohol consumption during pregnancy is responsible for high rates of foetal alcohol syndrome in some communities and is strongly correlated with traffic mortality. The Government has instituted a number of initiatives to combat NCDs, such as the introduction of an innovative sugar-sweetened beverages (SSB) consumption tax at roughly 20% of the retail price. 20 National Health Insurance for South Africa: Towards Universal Health Coverage. https://www.health- .org.za/wp-content/uploads/2015/12/National-Health-Insurance-forSouth-Africa-White-Paper.pdf Country Cooperation Strategy Republic of South Africa 2016–2020

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2.1.9 Increasing access to medical products South Africa’s National Drug Policy (NDP), adopted in 1996, is aimed at supporting equitable access to medicines by addressing legislation, selection, pricing, procurement and supply, human resources, traditional medicines and cooperation with regional and international organizations.21 South Africa regularly publishes Standard Treatment Guidelines and Essential Medicines List to ensure affordable and equitable access to medicines.22 These are reviewed regularly to keep pace with changes in health care and to provide access to quality and much-needed health care for all South Africans. Implementation of the national Essential Medicines List and support structures in the form of provincial and facility-based Pharmacy and Therapeutics Committees are meant to improve efficiency in medicine selection. South Africa applies generic substitution policies, and employs rigorous methods including cost-effectiveness analysis in the procurement process for medicines. Access to quality medicines and diagnostics is a critical issue. The Government has the largest HIV treatment programme in the world, reaching 3.4 million of people and expanding. The Medicines Control Council (MCC) will be transformed into the South Africa Health Products Regulatory Authority (SAHPRA), with independent management, budget, and broader regulatory scope that includes medical devices, complementary medicines, and IVDs. This is work in progress and will require the support of WHO. The national regulatory authority works in collaboration with WHO Prequalification of medicines (WHO-PQ), and regional New Partnership of Africa’s Development (NEPAD) initiatives to undertake collaboration on registration of medicines. South Africa has made remarkable achievements in reducing the prices of medicines, especially ARVs, through different mechanisms including voluntary licensing. There are still challenges relating to medicine stock-outs even for vital 21 National Drug policy for South Africa. http://apps.who.int/medicinedocs/documents/ 17744en/s17744en.pdf 22 Standard Treatment Guidelines and Essential Medicines List for South Africa. www.up.ac.za/media/shared/62/ZP_Files/standard-treatment-guidelines.zp66671.pdf

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medicines like ARVs and anti-tuberculosis drugs and the process of managing a huge backlog of medicines for registration needs further improvement. As regards the rational use of medicines, it is noteworthy that South Africa has one of the highest burden of MDR and XDR tuberculosis in the world and that the implementation of early-warning indicators to monitor HIV and TB drug resistance will help in the early detection of resistance and the adoption of timely corrective actions.

2.1.10 International Health Regulations South Africa has experienced natural disasters in the past, including droughts which increase the vulnerability of certain population groups. The national capacity to cope with emergencies was self-assessed as high, using the International Health Regulations (IHR) capacity assessment tool.23 South Africa has a strong laboratory network, provides laboratory services to other countries in the African Region and participates in the Emerging and Dangerous Pathogens Laboratory Network (EDPLN). The level of government investment in public health is high, as is access to basic health services. As regards IHR requirements, a national coordination mechanism exists, IHR updates are conducted, surveillance is being strengthened, and the overall strengthening of core capacity requirements is underway. South Africa has a number of institutions that play a central role in disease prevention and control. The National Institute for Communicable Disease (NICD) under the National Health Laboratory Service, serves as a centre of excellence and a regional WHO reference laboratory. It plays a central role in disease prevention and surveillance in the Region.

2.1.11 Sustainable Development Goals The third Sustainable Development Goal (SDG 3),24 which is the SDG exclusively dedicated to health, has 13 targets which cover most national 23 International Health Regulations (2005) http://www.who.int/topics/international_health_ regulations /en/ 24 United Nations. Sustainable development Goals: 17 Goals to Transform Our World. http:/ www.un.org/sustainabledevelopment/ Country Cooperation Strategy Republic of South Africa 2016–2020

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health concerns. However, there are health related targets in 14 other SDGs. The SDGs address a greater diversity of issues than the MDGs and encourage a systems and multi-sectoral approach in achieving new health targets for 2030. To address most of the new priorities which are interrelated, the CCS will put significant emphasis on UHC and health systems strengthening (HSS) as critical cross-cutting issues within the key priority areas. The National Development Plan (NDP) and the NDoH Strategic Plan are both aligned to the SDGs. CCS implementation will follow a smart technical focus approach, concentrating on the key strategic priorities that collectively address the majority of SDG3 targets. South Africa ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR)25 on 18 January 2015, which entered into force on 12 April 2015. Article 12 recognizes the right of everyone to enjoy the highest attainable standard of physical and mental health.

2.2 Development cooperation, partnerships and  contributions of the country to the global health agenda 2.2.1 Partnerships and development cooperation Based on data from the Development Assistance Committee (DAC) of the Organization for Economic Cooperation and Development, total international aid flows to South Africa increased in nominal terms to 1.1 billion in 2014.26 Over half of total DAC aid flows are dedicated to health.27 The vast majority of aid is from bilateral partners (82%). According to OCED DAC data, the United States Government (USG) is by far the largest health sector donor, contributing US$ 357 million in 2014. USG runs the President’s Emergency Plan for AIDS Relief (PEPFAR), focusing on reducing the HIV disease burden. Other major donors include the Global Fund for HIV, TB, and Malaria; the Bill

25 United Nations Human Rights. International Covenant on Economic, Social and Cultural Rights. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx 26 OECD DAC. http://www.oecd.org/dac/stats/statisticsonresourceflowstodevelopingcountries.htm 27 AID flows OECD/DAC http://www.oecd.org/dac/stats/health-related-aid-data.htm

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& Melinda Gates Foundation; the German Government; and the European Union. Civil society organizations play a critical role in advocating for health and care of vulnerable groups. Although they had initially focused on HIV care and treatment, many have expanded their coverage to TB screening and treatment support, as well as NCDs particularly through prevention of the harmful use of alcohol, health promotion and advocacy. The WHO Regional Office for Africa has memoranda of understanding with both US CDC and USAID, which outline comprehensive areas of cooperation with WHO in the African Region. In South Africa, WHO partners closely with the CDC on HIV treatment, care, support and prevention. This also includes work on early-warning indicators of HIV drug resistance. It also partners with USAID, particularly on tuberculosis prevention and control, including multidrug-resistant TB. It has a global collaboration agreement with the EU on health policy, and South Africa will be included in this agreement from 2016 to 2019, with support provided to assist in the implementation of the National Health Insurance (NHI). The main development partners’ coordination forum is the Health Partners Forum (HPF), which brings together all major health sector partners. It is currently co-chaired by WHO and the European Union, and meets every two months. It also meets twice a year with the Director General of Health in the ODA Planning Forum and annually with the Minister of Health in the ODA Development Forum.

2.2.2 Collaboration with the UN System at country level In early 2013, the United Nations Country Team (UNCT), comprising 17 United Nations agencies, signed the South Africa-United Nations Strategic Cooperation Framework (UNSCF) for 2013-2017. WHO channels its contribution to the UNSCF through the four areas of cooperation, namely: inclusive growth and decent work; sustainable development; human capabilities; and governance and participation. In line with its mandate, WHO is responsible for health sector coordination and response. UNSCF management and implementation arrangements are structured through the UN Country Team (UNCT), Programme Management Team Country Cooperation Strategy Republic of South Africa 2016–2020

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(PMT), Results Groups (RG) and Operation Management Team (OMT) which have proven to be effective. The UNCT is the executive-level coordination structure and comprises all UN Agency Heads. The Programme Management Team (PMT), composed of programme heads from each UN agency, facilitates, monitors and manages UNSCF execution. Results Groups (RG) represent the four pillars of the UNSCF (inclusive growth and decent work; sustainable development; human capabilities and governance; and participation) through which each agency coordinates its substantive contribution to the UNSCF. The OMT is composed of the most senior operations/administrative managers of all agencies or their designated alternates. The OMT is mandated to accelerate “operating as one” and enhance the harmonization of operational and business processes to support delivery of programmes. UNSCF structures work closely with lead counterpart institutions in government to review individual programmes, including through project steering committees for each project. According to the UNSCF, the DIRCO should have convened annual review meetings on UNSCF progress, in coordination with other partners, to review outcomes of the Strategic Cooperation Framework relative to government priorities and emerging needs. However, these annual review meetings have not been held hitherto. Occasionally meetings are held with the National Treasury and DIRCO to discuss ways of strengthening cooperation.

2.2.3 Country contributions to the global health agenda South Africa has a number of institutions that play a central role in disease prevention and control. The National Institute for Communicable Disease (NICD), under the National Health Laboratory Service (NHLS), serves as a centre of excellence and regional WHO reference laboratory. The NICD plays a central role in disease prevention and surveillance in the African Region. It specifically contributes to strengthening laboratory capacity for various program areas. The NICD hosts the TB, polio and measles regional reference laboratories and contributes to HIV drug resistance early-warning indicators and malaria case management and diagnostics.

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WHO has been coordinating an African Microbiology External Quality Assessment (EQA) programme since 2002, which is technically organized by the NICD. EQAs are essential to increase the confidence in laboratory results that are used for surveillance purposes of Integrated Disease Surveillance and Response (IDSR) priority diseases and Vaccine-Preventable Diseases. South Africa is committed to the regional and global elimination of specific diseases including measles by 2020, maternal and neonatal tetanus (MNT) by 2015, and polio eradication. In 2006, South Africa presented its polio-free documentation to the Africa Regional Certification Committee (ARCC) and it was accepted. The country has maintained its polio-free status (last polio case reported in 1989) and makes steady efforts to remain polio free and to support the global polio eradication initiative. In 2002, South Africa achieved the MNT elimination target of less than one neonatal tetanus case per 1000 live births in every district and has maintained this level. There are 13 WHO Collaborating Centres in South Africa. WHO collaborates with these universities and academic institutions to support evidence-based decision-making processes. This includes collaborating with universities and research institutions on a broad range of communicable diseases as well as noncommunicable conditions and risk factors. Having been a member and chair of the WHO Executive Board (EB), South Africa has played a crucial role in the decisions and the health agenda of the Organization. It is a very active member in the World Health Assembly and Regional Committee for Africa and has also played a critical role in discussions of the African Group in Geneva. This group has been instrumental in presenting the African position during the WHA and complements the coordination role of the WHO Regional Office for Africa among Member States. South Africa spearheaded the use of DDT for indoor residual spraying which has helped to reduce malaria cases, not only in South Africa but also in many other African countries.

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3. REVIEW OF WHO’S COOPERATION OVER THE PAST CCS CYCLE The second generation CCS for South Africa (2008 - 2013) was informed by the WHO global and regional strategic documents. It also took into account the country’s level of development and disease burden profile. The CCS was developed through a participatory process and the following five strategic priorities were identified for that period: Strategic Priority 1: Strengthen health policies and systems to minimize inequities in access for the poor and vulnerable; Strategic priority 2: Reduce neonatal, infant, child and maternal morbidity and mortality and promote responsible and healthy sexual and reproductive health behaviour; Strategic Priority 3: Combat HIV/AIDS, tuberculosis and malaria; Strategic Priority 4: Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, accidents, violence and injuries; Strategic Priority 5: Strengthen the surveillance system to promote prevention of communicable and noncommunicable diseases and their impact on the health of the poor and vulnerable In an effort to align WHO’s work with national health planning cycles and priorities, a CCS was developed for 2013-2014, prior to the implementation of a new five-year strategic plan. Again, this bridging CCS was developed through a consultative process taking into consideration WHO’s General Program of Work for 2014 -2020, WHO’s global and regional resolutions and the existing policies of the Government of South Africa. The following four strategic priorities were identified during this period: Strategic Priority 1: Promote universal health coverage (UHC) and financial risk protection for all South Africans by supporting health systems strengthening; 20 Country Cooperation Strategy Republic of South Africa 2016–2020

Strategic Priority 2: Prevent and reduce the disease burden for HIV, TB, and malaria to achieve further gains in life expectancy; Strategic Priority 3: Promote longer healthier lives through prevention and control of noncommunicable diseases, injuries and accidents; and Strategic Priority 4: Support South Africa’s contribution to and leadership in the achievement of global and regional health goals. In the absence of a new CCS during 2015, WHO continued to operate on the basis of the bridging CCS developed for 2013-2014. Below is a summary of the notable achievements made during the 20082016 period. Strengthen health policies and systems to reduce inequities in access for the poor and vulnerable, thus promoting UHC WHO provided technical support in the development of key policy documents which include Nursing Strategy for South Africa (2008); Human Resources for Health Strategy (2012/13-2016/17); PHC strategy (2008); National Curriculum for Clinical Associates (Mid-Level Worker); and the National Pharmacovigilance Plan. Furthermore, WHO provided support in the implementation of WHO global strategic guidelines in nursing and midwifery to improve the quality of PHC service delivery and provided capacity-building support on quality standards to assess medical devices and diagnostics. WHO provided capacity-building on transfer of technology for the production of influenza vaccines to BIOVAC, South Africa. It also commissioned international reviews of country experiences in preventing and managing obstetric litigation and promoting patient safety initiatives to reduce litigation. It has also served as a member of the Ministerial Advisory Committee for National Health Insurance (NHI). WHO supported the data collection process for National Health Accounts and continues to support the Competition Commission’s Health Market Inquiry (HMI) by sharing international experience in price regulation of healthcare services. It has also supported the development of the Implementation Guideline of Health Workforce

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Normative Guides and Standards for Fixed Primary Care facilities,28 as well as initiation of the process of transitioning from the Medical Control Council to a more comprehensive South Africa Health Products Regulatory Authority (SAHPRA). This support is ongoing till the full establishment of SAHPRA. Reduce neonatal, infant, child and maternal morbidity and mortality and promote responsible and healthy sexual and reproductive health behaviour WHO facilitated the interpretation and incorporation of WHO global evidencebased practices on achieving MDG targets for MDG 4 and 5, for utilization in plans, policy and strategy documents (2008-2012). It also supported the development of the Millennium Development Goals Countdown Report for South Africa in 2013, highlighting specific numbers of deaths to be averted in order for South Africa to achieve the MDGs by 2015. WHO provided technical support in the conduct of the mid-term review of the ‘Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition in South Africa 2012 – 2016’ and also supported phase 1 of the development of the MNCWH Investment Case for South Africa. WHO supported the global case studies of youth services models (20112012) and provided research tools and guidance documents for the national gender audit, and research on the national status of adolescent pregnancy (2010). It also supported the development of routine checklists in cervical cancer screening, and development of standardized integrated training materials for contraception (2012). WHO provided technical support in the launch of the National Integrated School Health Program. In immunization, WHO supported the Reach Every District strategy and Effective Vaccine Management training, as well as the phased introduction and monitoring of pneumococcal and rotavirus vaccines.

28 National Department of Health. Implementation Guideline of Health Workforce Normative Guides and Standards for Fixed Primary Health Care Facilities 2015-2019. www.gov.za/ sites/www.gov.za/files/39244_gon902s.pd

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Prevent and reduce the disease burden for HIV, TB, and malaria to achieve further gains in life expectancy WHO provided technical support in the development of the National Strategic Plan (NSP) for HIV/TB and STIs 2012-2016, supported the development and the revision of many HIV and TB programme Guidelines including ART, MMC, VCT, Infection Control, IPT, and SOP for TB data management HIV and TB Guidelines on ART, MMC, VCT, drug-susceptible TB and DR-TB, Infection Control, IPT, and SOP for TB data management. WHO contributed to the development of the malaria elimination strategy covering malaria treatment, quality assurance, and surveillance, as well as the development of the training curriculum for nurse-initiated management of ART (NIMART). WHO provided technical support to cross-border malaria initiatives with Botswana, Zimbabwe, Swaziland, and Mozambique, and to prevent and control malaria with demonstrable success under the Lubombo Spatial Development Initiative (LSDI) that targets Swaziland, South Africa and Mozambique. In an effort to address neglected tropical diseases, WHO also participated in schistosomiasis control programme reviews between 2010 and 2011. In addition to the above, WHO provided support in establishing a national system for HIV drug resistance monitoring and a pregnancy register, which collects data on exposed and unexposed healthy pregnancies and their outcomes, to help establish safety of new drugs or identify potentially problematic consequences. Technical support was also provided in order to generate evidence through systematic review of TB among high risk groups, drug-resistant TB surveys and community TB engagement. WHO also provided normative guidance in the development of the TB component of the Global Fund Round 10 proposal. Furthermore, WHO is an active member of many committees and technical advisory groups, including the Malaria Advisory Group (MAG), Global Fund Country Coordinating Mechanism (CCM) and TB and DR-TB prevalence surveys. WHO also provided the technical lead in the national review of the 2013 joint national HIV, TB and PMTCT programmes, and of the malaria programme. Technical support was also provided during the reporting period on strengthening the HIV, TB and malaria programme surveillance systems, including, compilation of global reports.

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Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, accidents, violence and injuries WHO provided technical support in the development of various strategies relating to health promotion, including the Integrated Health Promotion Strategy, National Guidelines on Promoting Healthy Lifestyles and the Health Promoting Schools Initiative. In addition other NCD policies, strategies and legislative instruments were supported including the Integrated School Health Programme Strategy, the National Tobacco Products Control Act and the Mental Health policy framework development. Furthermore, WHO participated in the launch of the Decade of Action for Road Safety in South Africa. In collaboration with the NDoH, WHO also convened joint workshops on chronic diseases and geriatrics. During this reporting period, WHO served as a member of many task teams including the National Health Promotion Task Team, National Tobacco Products Control Task Team and many committees of the 2010 FIFA World Cup Tournament. Furthermore, WHO also participated in the National Summit on Prevention and Control of Noncommunicable Diseases, the National Mental Health Summit in 2012, and the meeting on the Global Mental Health Action Plan 2013-2020. Support South Africa’s contribution and leadership to achieving global and regional health goals WHO is a member of the Multi-Sectoral National Outbreak Response Team (MNORT). It has supported national preparedness for the Ebola virus disease (EVD) and the annual assessment of core country capacities to implement the IHR. In support of the Polio Eradication and Endgame Strategic Plan, WHO has served as the secretariat for the polio committees, namely: the National Polio Expert Committee (NPEC), National Polio Certification Committee (NCC), and the National Task Force (NTF) on laboratory containment. WHO has coordinated and supported the compilation of the country annual update report on polio eradication, convened a national Polio Stakeholders Symposium and supported the switch from trivalent oral polio vaccine (tOPV) to bivalent oral polio vaccine (bOPV). It has also provided

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ongoing technical support to the polio and measles reference laboratories at the NICD which provide their testing services to South Africa and other countries in the Region. Strengthen surveillance systems to promote prevention of communicable and noncommunicable diseases and their impact on the health of the poor and vulnerable WHO provided technical support to enhance national preparedness to receive and deploy pandemic influenza A (H1N1) vaccines, including a WHO donation of 3.5 million doses. Technical support was also provided to update the yellow fever policy, meningococcal disease treatment guidelines, influenza treatment guidelines, influenza vaccination policy and E-Health policy. WHO conducted an assessment of core country capacities to implement the IHR, and advocated for the implementation of an IDSR strategy for timely response to outbreaks and other events of public health concern. WHO provided outbreak response coordination and field support to cholera and Rift Valley fever control activities, including information and data management, as well as training of provincial CDC staff in outbreak investigation. Over the period under review, WHO supported the national focal point (NFP) in the management of information on outbreaks and public health events, including verification of public health events within and outside South Africa. WHO trained port health staff in ship sanitation inspection and conducted training on food safety norms and standards to ensure food safety at the 2010 FIFA World Cup and the 2013 Africa Cup of Nations (AFCON). WHO also provided technical support in strengthening immunization data quality surveillance (DQS), and ongoing technical support on AFP, measles, NNT and AEFI surveillance to all the provinces.

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Constraints The major constraints in the implementation of set strategic priorities include: • Inadequate financial resources: Due to the global economic recession, there were reduced budget allocations to WHO country offices. Moreover, being a middle-income country, South Africa has a very small donor base. Consequently, the WCO has very limited capacity to raise resources locally. Limited human resources: Despite the high NDoH demand for support needs, the WCO has remained small and has limited capacity to address growing country requests. There is frequent organization-wide mobilization of the required technical expertise when it is unavailable at the country office level. Difference in planning cycles: The difference in the planning cycles of the South African government and WHO occasionally impacts on the depth of planning that takes place between WHO and NDoH. Bypassing the WCO: Some requests from the NDoH were sent directly to the WHO Headquarters, bypassing the WCO, thus creating coordination problems in WHO support.

•

•

•

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4. STRATEGIC AGENDA FOR WHO COOPERATION IN SOUTH AFRICA: 2016-2020 WHO in South Africa grounds its programme of work on the national disease burden; the WHO 12th General Program of Work (GPW); the National Development Plan; National Health Strategy priorities and targets; and international goals and commitments such as the Sustainable Development Goals. Its work will also be guided by WHO Reform and, more specifically, the Transformation Agenda of the World Health Organization Secretariat in the African Region. WHO will ensure that its business is guided by proresults values, smart technical focus, responsive strategic operations and effective communication and partnerships as described in the Transformation Agenda. WHO must also consider its comparative advantage relative to the contributions made by other agencies to health and social development. Based on the criteria above, four strategic priorities for WHO Cooperation with South Africa for 2016-2020 have been proposed. The table in Annex 2 presents each strategic priority and its linkages with national priorities, the GPW, the SDG targets, and the UNDAF key areas of work.

4.1 Strategic Priority 1: Strengthen national efforts to attain      universal health coverage (UHC) The first strategic priority is to strengthen national efforts to attain universal health coverage (UHC). South Africa has prepared a white paper on achieving UHC through National Health Insurance (NHI) while ensuring universal access to services regardless of ability of pay.29 WHO will support the phased institutionalization of National Health Insurance; support initiatives to promote equitable distribution and utilization of the health workforce; and strengthen the national medicines regulatory authority to ensure the supply of quality medical products.

29 NDOH. National Health Insurance for South Africa: Towards Universal Health Coverage. Oct 2015 Country Cooperation Strategy Republic of South Africa 2016–2020

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(a) Support the phased institutionalization of NHI and specifically promote the National Health Insurance Fund, benefits package design, and strategic purchasing in the health sector The NDoH has established six work streams to support NHI implementation. WHO will support these work streams to ensure the establishment of the NHI fund, development and costing of the benefits package, establishment of the purchaser-provider split, identification of the role of private medical schemes, finalization of the NHI White Paper and development of other policy documents, and strengthening of the district health system for service delivery and contracting. This support is expected to create a strong financing system and strategy to generate resources, pool funds, purchase services, deliver good quality services and ensure good value and performance.30 In the same vein, WHO will continue to support initiatives to address high prices and volumes in the private health care sector, through continued work on health service pricing comparisons, international experiences in price regulation, and the economic benefits of well-designed health care reforms. WHO will also support the institutionalization of national health accounts to monitor public and private expenditures in health and build evidence required for making policy adjustments in health financing. (b) Support the optimal distribution and effective utilization of the health workforce Human resources are critical to ensuring that health services are of good quality and safe. The WHO Workload Indicators of Staffing Needs (WISN) tool will be used to develop evidence-based staffing norms to ensure an appropriate skills mix and equitable distribution between and within district and specialized health facilities. This has already been done for the primary care level. The third phase will focus on provincial and central hospitals. WHO will also support a related activity, namely the development of the 2016-2021 National Human Resources Strategic Plan. It will also contribute to health workforce capacity-building for global health priorities such as epidemics and other emergencies including antimicrobial resistance (AMR). WHO will 30 WHO Health Financing Action Plan http://www.who.int/health_financing/Health_Systems_ Financing_Plan_Action.pdf;

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establish partnerships for HRH development to ensure that all stakeholders support the National HRH Strategy. (c) Strengthen the national regulatory authority (NRA) to ensure access to safe quality medical products and food Access to quality medical products is a major component of universal health coverage. WHO will support the establishment of the South African Health Products Regulatory Authority (SAHPRA), as a functional entity with a broad scope, to promote quality, safe, and efficacious medical products, diagnostics and medical devices in South Africa and the continent. Since it will be a newly-established entity, systems will be required for overall quality management, information technology, human resources and capacitybuilding. WHO will provide specialized technical support for monitoring blood products and biologicals, as well as regulatory oversight of active pharmaceutical ingredients, medical devices and IVDs, and complementary and traditional medical products. This will include pharmacovigilance and safety monitoring. Significant efforts will be made to encourage participation in collaborative initiatives to share information that can be used in regulatory processes in other countries of the Region.

4.2 Strategic Priority 2: Contribute towards reduction of the disease burden for communicable diseases, especially HIV, TB, STIs, hepatitis and vaccine-preventable diseases The second strategic priority focuses on reducing the very high communicable disease burden. The goal is to enhance national strategies to accelerate improvements in life expectancy. This will be done by focusing programmes of work on communicable disease conditions, including strengthening HIV prevention, treatment and care; conducting STI prevention and management; and improving the prevention and treatment of TB, MDR/XDR-TB and vaccine-preventable diseases.

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(a) Strengthen the capacity to scale up prevention, treatment and management of HIV, STIs and hepatitis, including measures to promote adherence and prevent drug resistance WHO supports the development of the National Strategic Plan for HIV and TB, helping to define the game-changers among the most cost-effective prevention, treatment and care interventions. It will support joint efforts aimed at reaching global treatment and care targets for HIV and hepatitis. It will also assist in strengthening quality of care to improve clinical outcomes, focusing on, inter alia: adherence to treatment; HIV drug resistance monitoring mainly through Early Warning Indicators (EWIs); and pharmacovilance. WHO will support the development, review and implementation of strategies, plans and HIV technical guidelines based on latest evidence. Particular attention will be given to PrEP, Test and Treat All, HIV testing guidance, and voluntary medical male circumcision (VMMC). WHO will provide advice on the collection of critical strategic information about hepatitis for decisionmaking, and will support the review of hepatitis technical guidance and national strategic plans as required. It will also support the update of STI national strategic plans and technical guidance in response to the new global guidelines including on antimicrobial resistance. (b) Strengthen the prevention and treatment of TB, including M/XDR-TB, to reduce incidence, prevalence, and case fatality rates WHO will support implementation of the END TB Strategy by strengthening the TB surveillance system, establishing baselines for the top 10 END TB indicators and, monitoring progress towards national and global TB targets. To ascertain the TB burden in South Africa, WHO will provide technical support for the implementation of the first South Africa TB prevalence survey. It will also work with national authorities to implement the recommendations of the National DR-TB Review (2015) and the National DR-TB Survey (2016). Furthermore, it may provide technical support for the introduction of new drugs and new tools for quality programmatic management of DR-TB. In all, emphasis will be placed on the proper and judicious use of all tools available for TB prevention, treatment and control. Furthermore, WHO will facilitate the mainstreaming of TB social protection into the National TB Response as a key enabler for improving treatment outcomes. It will support the piloting 30 Country Cooperation Strategy Republic of South Africa 2016–2020

of decentralized management and nurse-initiated MDR-TB treatment and promote the effective involvement of NGOs at community level in extending the reach of the health system. (c) Promote access to existing and new immunization products to reduce vaccinepreventable diseases Immunization remains a critical activity for improving child, adolescent and adult health. WHO will support national plans and policies to improve access to and utilization of existing and new immunization products. This will be done through the development and implementation of national comprehensive multi-year plans. WHO will support the development or review of the National Vaccinator’s Manual, National Cold Chain Manual and the National Surveillance Guideline, and also support their proper utilization in the field. It will also support the Reach Every Community strategy to increase immunization coverage and reduce the dropout rate between antigens. WHO will support the planning and implementation of integrated measles and polio supplementary immunization activities and the introduction of new vaccines such as the rubella-containing vaccine, hepatitis B birth dose and others. It will also support efforts to address immunization data quality.

4.3 Strategic Priority 3: Support the prevention and control    of noncommunicable diseases, mental health disorders, violence and injuries Working jointly with partners, WHO will focus on promoting health, as well as preventing and controlling noncommunicable diseases, mental health disorders, malnutrition, violence and injuries, and disabilities by addressing their risk factors and determinants. (a) Support the development and implementation of policies, strategies and regulations to combat tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity, violence and injuries, and other risk factors WHO will support the establishment of a multi-sectoral coordinating body for health promotion to implement programmes that tackle tobacco use and harmful use of alcohol, violence and injuries, and other health risk factors. It will Country Cooperation Strategy Republic of South Africa 2016–2020

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also support implementation of the National Obesity Policy and development of cost-effective evidence-based policies to promote healthy diets. WHO will also advocate and participate in the development and implementation of regulations for the reduction and control of salt content in processed foods; comprehensive bans on advertising and promotion of tobacco products, alcohol and unhealthy foods; development and implementation of related fiscal policies; and effective nutritional labels and consumer information. It will also support capacity-building on health promotion, increased knowledge and awareness on the importance of regular physical activity, other health promotion activities, and the development of environments that enable physical activity. (b) Support improved management of the four main noncommunicable diseases (NCDs), namely cardiovascular diseases, cancers, diabetes and chronic respiratory diseases, in order to decrease morbidity and mortality WHO will work closely with the government to support multi-sectoral collaboration and institutional arrangements required for the implementation of evidence-based policies to achieve global and regional goals that have been integrated into South Africa’s National NCD Strategic Plan. Specific to the health sector is the capacity to properly manage common NCDs especially at the primary care level. This will require support for the development and application of guidelines for clinical management of the four main NCDs namely: cardiovascular diseases, the most prevalent cancers, diabetes, and chronic respiratory diseases; as well as the development of an integrated and intersectoral plan for coordinated response to prevent NCDs. (c) Guide and support the preparation and implementation of multi-sectoral, population-wide programmes to promote mental health and prevent mental and behavioural disorders WHO will support the government in implementing the national mental health strategic plan, including PHC integration, and in conducting and completing a quality rights-based mental health project that seeks to improve care for patients suffering from mental health disorders.

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4.4 Strategic Priority 4: Support South Africa in meeting its global health obligations while contributing to  international health and development South Africa is signatory to various international global health agreements and also has world standard health institutions such as the 13 WHO Collaborating Centres it hosts and which support other countries in many technical fields. These institutions contribute to the eradication and elimination of diseases, thus providing a global public health good, with vast economic and social benefits. (a) Support the implementation of International Health Regulations (2005) The International Health Regulations (IHR) impose an obligation on countries to prevent, protect against, control and respond to the international spread of disease to ensure global public health security.31 WHO will support the building of core capacities for all health emergencies. This will include review of the disease surveillance and response capacity, right down to the district and community levels, including the capacity for data management and analysis, as well as a reporting platform for generating timely emergency health information products. Through the Joint External Evaluation process, WHO will systematically identify core capacities that need strengthening and address weaknesses. WHO will help to establish a comprehensive incident management system for coordinated action for all graded emergencies, and support the development of business continuity plans, SOPs, and regular simulations for emergencies. South Africa has many strong domestic institutions which play important roles in global health. These include regional reference laboratories, as well as clinical and academic institutions. Thirteen of these are recognized as WHO Collaborating Centres and will play critical roles that serve national, 31 WHO. International Health Regulations (2005) http://www.who.int/topics/international_ health_regulations/en/ and the Implementation of International Health Regulations in the WHO Africa Region http://www.afro.who.int/en/downloads/cat_view/1501-english/861-regional-committee/2065sixty-second-session-of-the-who-regional-committee-for-africa/2066-english/2074resolutions.html?limit=15&limitstart=0&order=hits&dir=DESC Country Cooperation Strategy Republic of South Africa 2016–2020

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regional, and global health interests. WHO will utilize the rich technical capacity of these institutions to contribute to health improvement in the Region and globally. The BRICS Ministerial Forum presents an opportunity to share experiences and establish collaboration. (b) Support progress towards disease elimination and eradication In line with the global and regional elimination and eradication goals and targets, WHO will support measles elimination efforts in the Region by strengthening routine and supplementary immunization activities, conducting suspected measles case surveillance and supporting the WHO measles reference laboratory at the NICD. Polio eradication will also be supported through routine and supplementary immunization activities and AFP surveillance. WHO will support maintenance of the maternal and neonatal tetanus elimination status attained in 2002. Should a decision be reached for NICD to become a poliovirus-essential facility (PEF), WHO will provide the technical support required. It will also contribute to cross-border malaria elimination activities involving Mozambique, Swaziland, South Africa and Zimbabwe. (c) Support maternal and neonatal mortality reduction in order to meet SDGs and other international commitments The health of women and children remains an unfinished agenda from the MDG era. WHO will support the development and implementation of an integrated Reproductive Maternal Neonatal Child and Adolescent Health Plan in line with the Global Strategy on Women and Children’s Health. WHO will undertake capacity-building, resource mobilization, and adaptation of guidelines with respect to the plan. It will work with national authorities to implement innovative quality improvement strategies such as basic antenatal care that promotes the identification of risk factors, early diagnosis of pregnancy complications, appropriate management and health education. Support will be provided to enhance the quality of care administered to pregnant women to ensure normal deliveries as far as possible and reduce 34 Country Cooperation Strategy Republic of South Africa 2016–2020

the high incidence of caesarean sections. Contribution will be made towards improving neonatal care in line with WHO guidelines. WHO will work closely with the four WCCs that specialize in reproductive health, nursing education and development, and quality assurance of health services to improve quality of care.

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5. IMPLICATIONS FOR THE WHO SECRETARIAT Implementation of the strategic priorities set forth in this strategy will build on the achievements of previous country cooperation strategies, existing strong collaboration and good relationships with government counterparts and other major partners and stakeholders. Successful implementation will depend on shifts in technical approach and focus, in strengthening and expanding relationships with partners, and in improving the efficiency and effectiveness of WHO response. Specifically, the implications for WHO include maintaining focused technical programmes as outlined in this strategy; implementing WHO core functions; efficiently utilizing technical resources at all levels of WHO; strengthening partnerships; improving communications; and strengthening the administrative and financial functions of the country office. All the above is covered in the WHO African Region Transformation Agenda, which should provide the required platform for making changes in how we operate at country level.

5.1 Ensuring smart technical focus The priorities were defined as part of a consultative process involving WHO, the Government of South Africa, and key partners. It builds on WHO’s core capacities, emphasize WHO global and regional resolutions, and considers the contribution of other partners and stakeholders. While new priorities may arise, it is critical to focus on and see through the priorities outlined. In response to the policy environment, the implementation of this strategy requires maintaining a focused program of work. HIV and TB are the biggest public health challenges facing the country. The Government has made it a priority to use National Health Insurance (NHI) as a platform for executing major reforms conducive to universal health coverage. Operating through the health and other sectors, national authorities have embarked on ground-breaking multi-sectoral work to promote health and prevent the carnage caused by noncommunicable diseases. It is equally important to work with the many highly specialized institutions such as universities and laboratories, many of which are WHO collaborating centres, to address 36 Country Cooperation Strategy Republic of South Africa 2016–2020

global health issues. Strong technical focus on these issues will enable WHO to contribute to health and development in South Africa and beyond.

5.2 Mobilizing resources for implementation Implementing this strategy will require shifts in human and financial resources in accordance with technical priorities, and the mobilization of additional resources for areas that are currently under-resourced but feature among the priorities of the Department of Health. Implementation of the strategic priorities will be enhanced by maintaining the alignment of programmes across the Organization and mobilizing resources locally. Given the country’s high middle-income status, the possible sources of funding would be industry, the private sector, and other international NGOs and foundations which have a special interest in certain subject areas.

5.3 Focusing on WHO core functions Given the limited human and financial resources, the Secretariat needs to shift away from low-impact activities and small-scale funding, and move towards technical advisory support for activities that will have a measurable and sustainable impact. This requires better utilization of scarce resources; the provision of high quality technical advice that will impact policies and programmes; and long-term systemic government investment in the health sector. The Secretariat should not replace the government but rather work towards systematic capacity-building through counterpart relationships and continuous transfer of skills and knowledge. WHO staff will need to concentrate on its comparative advantage relative to many stakeholders in the health sector, add value to ongoing efforts, and fully carry out its six core functions, namely: 1. Providing leadership and engaging in partnerships for joint action; 2. Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; 3. Setting norms and standards and promoting and monitoring their implementation; Country Cooperation Strategy Republic of South Africa 2016–2020

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4. Articulating ethical and evidence-based policy options; 5. Providing technical support, catalysing change, and building sustainable institutional capacity; and 6. Monitoring the health situation and assessing health trends. Considering the technical areas of focus and WHO core functions, a review of skills will be conducted in the country office, through a functional review, to determine the appropriate skill mix required to implement this CCS.

5.4 Harnessing WHO resources at all three levels of the Secretariat Technical professionals are the principal resource of the WHO. The effective implementation of the four strategic priorities requires harnessing technical support at all levels of the WHO Secretariat. Similarly, roles and functions at all levels of the Secretariat have been identified for the five major technical categories of work in the WHO Program Budget. The implementation of each of the core functions requires participation and mutual support at all levels of the Secretariat, including the staff at the South African Country Office (CO), the Regional Office for Africa (AFRO), the Inter-Country Support Team (IST), and Headquarters (HQ) in Geneva. The country office will need to systematically strengthen and expand on the WHO technical support networks across the Organization to fully access the global network of technical support at all levels of WHO.

5.5 Strengthening and expanding relationships with partners The program of work requires multi-sectoral actions, linkages and technical relationships with a range of government departments, partners and stakeholders. WHO will support effective multi-sectoral and multidisciplinary collaborations, and promote engagement across relevant government entities, non-governmental organizations, civil society, and the private sector and facilitate their involvement in collaborative work. Partnerships with other UN agencies and south–south cooperation opportunities will be strengthened.

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Although South Africa faces its own major development challenges, it is important to share and widely disseminate the models and innovations underway. The Secretariat must consider the impact of its work in South Africa on regional and global health, by ensuring greater documentation and dissemination of its work and broader engagement in regional and global forums to ensure that South Africa shares its experiences with the regional and global health community.

5.6 Improving communications The WHO South Africa country office responds to media and information queries about global events. Stronger capacities need to be built to enable the office to respond more effectively to such demands. Furthermore, the country office needs to better communicate to the public, its partners, and the media on WHO initiatives to improve health and welfare. The office will strengthen its communication functions, develop information products for dissemination online and to the media, revamp and regularly update its website, and generally improve documentation and dissemination of WHO activities and products.

5.7 Strengthening the support functions of the country office Under WHO reform, there is renewed emphasis on efficiencies in management and administration. Efforts will be made to further strengthen administrative and financial support for the country office, streamline administration, strengthen financial management and procurement, improve human resources management and performance, and strengthen other essential office functions to enhance efficiency and efficacy. Specifically, the office will continually improve on internal controls in order to maintain its satisfactory audit status; fully comply with all areas of administration and finance; ensure that all staff are aware of and comply with their basic staff responsibilities; and reinforce zero-tolerance for fraud and corruption. At the same time, the office will seek to streamline administration, identify bottlenecks and increase its efficiency.

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6. EVALUATION OF THE CCS The CCS is a tool that informs the biennial planning exercise and both are a part of a continuum that includes the results chain of the General Program of Work, and global and regional strategies and resolutions. Hence, this strategy will be evaluated annually against office annual reports, and biennium work plan results. Furthermore, the CCS mid-term assessment will be conducted. Such evaluations will be documented and recommendations made to improve implementation.

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Annex 1: Key indicators Key indicators: South Africa WHO region Child health Diphtheria tetanus toxoid and pertussis (DTP3) immunization 70 coverage among 1-year-olds (%) (2014) Demographic and socioeconomic statistics Poverty headcount ratio at $1.25 a day (PPP) (% of population) (2009) 13.8 Gender inequality index rank (2014) Human development index rank (2014) Health financing Total expenditure on health as a percentage of gross domestic product 8.9 (2013) Private expenditure on health as a percentage of total expenditure on 51.6 health (2013) General government expenditure on health as a percentage of total 15.5 government expenditure (2015) Health systems Physicians density (per 1000 population) (2013) Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2015) 11.0 [7.6-15.2] Under-five mortality rate (probability of dying by age 5 per 1000 live 40.5 [30.5-53.3] births) (2015) Maternal mortality ratio (per 100 000 live births) (2015) Public health and environment Population using improved drinking-water sources (%) (2015) 93.2 (Total) 81.4 (Rural) 99.6 (Urban) Population using improved sanitation facilities (%) (2015) 66.4 (Total) 69.6 (Urban) 60.5 (Rural) Sustainable development goals Life expectancy at birth (years) (2013) 64 (Female) 57 (Male) 60 (Both sexes) Births attended by skilled health personnel (%) (2008) World Health Statistics Literacy rate among adults aged >= 15 years (%) (2007-2012) 93 94.3 138 [ 124 - 154] 0.776 Nursing and midwifery personnel density (per 1000 population) (2013) 5.114 116 116 Africa

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42 NDP Priorities 2030 12th GPW outcomes 2014/2019 SDG targets 2030 UNDAF Outcomes 2015 Financing universal healthcare coverage Policies, financing and human resources are in place to increase access to people-centred, integrated health services Achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Accelerated progress towards sustainable achievement of health MDGs Improve human resources in the health sector. Review management positions and appointments and strengthen accountability mechanisms Policies, financing and human resources are in place to increase access to people-centred, integrated health services Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the DoHa Declaration on TRIPS Agreement and Public Health, which affirms the right of developing countries to use the full provisions in the TRIPS Agreement regarding flexibilities to protect public health, and in particular, provide access to medicines for all Strengthen the health system Improved access to, and rational use of safe, efficacious and quality medicines and health technologies

Annex 2. Linkages between CCS focus areas, national priorities, GPW, SDGs, and the UNDAF

CCS Focus Areas 2016-2020

NDoH Strategic Goals

Strategic Priority 1: Strengthening national effort towards the attainment of universal Health Coverage (UHC)

1.1 Support the phased institutionalization of the NHI and specifically advance the National Health Insurance Fund, benefits package design, and purchasing

Make progress towards universal health coverage through the development of the National Health Insurance scheme and improve the readiness of health facilities for its implementation

1.2 Support the optimal distribution and effective utilization of the health workforce

Improve human resources for health by ensuring appropriate appointments, adequate training and accountability measures

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1.3 Strengthen the national regulatory authority (NRA) to ensure access to safe quality medical products and food

Strengthen the health system

Annex 2. Linkages between CCS focus areas, national priorities, GPW, SDGs, and the UNDAF NDP Priorities 2030 12th GPW outcomes 2014/2019 SDG targets 2030 UNDAF Outcomes 2015

CCS strategic focus areas 2015-2019

NDoH Strategic Goals

Strategic Priority 2: Contribute towards reduction of the burden of communicable diseases, especially HIV, TB, STIs, hepatitis and vaccine-preventable diseases Prevent and reduce the disease burden and promote health Increased access to key interventions for people living with HIV By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases Accelerated progress towards sustainable achievement of health MDGs

2.1 Strengthen capacity for scaling-up prevention, treatment and care for HIV, STIs and Hepatitis, including measures to promote adherence and prevent drug resistance Prevent and reduce the disease burden and promote health Increased number of successfully treated tuberculosis patients By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases End preventable deaths of newborns and under-five children, with all countries aiming to reduce neonatal mortality to at least 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births, by 2030

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

2.2 Strengthen the prevention and treatment of TB, including M/XDR-TB to reduce the incidence, prevalence, and case fatality rates Prevent and reduce the disease burden and promote health Increased vaccination coverage for hard-toreach populations and communities

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

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2.3 Promoting access to existing and new immunization products to reduce vaccinepreventable diseases

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

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44 NDP Priorities 2030 12th GPW outcomes 2014/2019 SDG targets 2030 UNDAF Outcomes 2015 Prevent and reduce the disease burden and promote health Increased access to interventions to prevent and manage noncommunicable diseases and their risk factors By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being Reduction of tobacco prevalence among the youth, particularly females Prevent and reduce the disease burden and promote health Increased access to interventions to prevent and manage noncommunicable diseases and their risk factors Prevent and reduce the disease burden and promote health Increased access to services for mental health and substance use disorders By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

Annex 2. Linkages between CCS focus areas, national priorities, GPW, SDGs, and the UNDAF

CCS strategic focus areas 2015-2019

NDoH Strategic Goals

Strategic Priority 3: Support the prevention and control of noncommunicable diseases, mental health disorders, violence and injuries

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3.1 Support the development and implementation of policies, strategies and regulations to combat tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity, violence and injuries, and other risk factors

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

3.2 Support improved management of the four main noncommunicable diseases (NCDs), namely cardiovascular diseases, cancers, diabetes and chronic respiratory diseases, in order to reduce morbidity and mortality

Prevent disease and reduce its burden and promote health through a multi-stakeholder National Health Commission

3.3 Guide and support the preparation and implementation of multisectoral, populationwide programmes to promote mental health and prevent mental and behavioural disorders

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

Annex 2. Linkages between CCS focus areas, national priorities, GPW, SDGs, and the UNDAF NDP Priorities 2030 12th GPW outcomes 2014/2019 SDG targets 2030 UNDAF Outcomes 2015

CCS strategic focus areas 2015-2019

NDoH strategic goals

Strategic Objective 4. Support South Africa in meeting its global health obligations while contributing to international health and development Prevent and reduce the disease burden and promote health All countries have the minimum core capacities required by the International Health Regulations (2005) for allhazard alert and response No cases of paralysis due to wild or type 2 vaccinerelated poliovirus globally Strengthen the capacity of all countries, in particular developing countries, for early-warning, risk reduction and management of national and global health risks Strengthened national institutions and systems to support South Africa’s contributions to a better Africa and a better world

4.1 Support the implementation of International Health Regulations (2005)

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission Prevent and reduce the disease burden and promote health

4.2 Support progress towards disease elimination and eradication Prevent and reduce the disease burden and promote health Increased access to interventions that improve women’s health

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

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4.3 Support the reduction of maternal and neonatal mortality in order to meet the SDGs and other international commitments

Prevent disease, reduce its burden and promote health through a multi-stakeholder National Health Commission

Reduce the global maternal mortality ratio to less than 70 per 100 000 live births, by 2030

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