On 18 September, Prof Salome Maswime, Associate Professor, Obstetrician and Gynaecologist and Head of Global Surgery at the University of Cape Town (UCT), presented a talk on SDG indicators for health outcomes in South Africa. The seminar, this time hosted collaboratively by the African Centre for Cities with the Department of Medicine of the Faculty of Health Sciences of UCT was attended by researchers, academics and the City of Cape Town.

The seminar kicked off with welcoming words by Prof Graham Fieggen, Head of Surgery at the Faculty of Health Sciences of UCT who expressed a keen interest in the SDGs. Prof Maswime then started by highlighting the broader vision behind SDG 3 on good health and well being as the aim to achieve the highest attainable standard of health for all people in all countries. Inequality represents an important factor in determining health outcomes. In low-income countries the most common factors affecting health and mortality rates are avoidable diseases and conditions that could be treated with access to essential health services, whereas in high income countries better access to health means that people live longer lives.

Prof Maswime went on to provide an overview of the nine different outcome-oriented targets and four means of implementation-oriented targets of the health SDG and their respective indicators as well as the data available in South Africa to monitor them. South Africa still performs poorly when it comes to maternal and children under five mortality rates, while it is getting better at treating communicable diseases such as HIV. For a number of indicators, such as the indicator  to monitor the prevention and treatment of substance abuse there is no data available nationally. She also pointed to the existence of multiple and at times conflicting data sources on health and the inherent dangers in monitoring that relies on estimates, predictions and complex computational approaches. Overall, South Africa performs relatively poor against SDG targets on the global SDG Index compared to countries such as Singapore, Iceland and Sweden, although it performs much better than countries such as Somalia, Central African Republic and Afghanistan.

Prof Maswime then proceeded to present three different case studies to illustrate her findings. A study on a decade of stillbirth rates in women living with HIV in South Africa between 2008 – 2017 as part of the national Perinatal Problem Identification Programme has produced important insight into the causes of stillbirths and neonatal deaths. It showed that 26% of stillbirths were delivered by women living with HIV and that the number of stillbirths was highest (47,6%) amongst women not on any Antiretroviral Therapy (ART). However, as a result of national policy, HIV testing rates and ART use has improved dramatically over the past ten years.

The second case study focused on maternal mortality as a result of bleeding during and after caesarean sections in South Africa. A health systems audit of 18 different hospitals across the wider Johannesburg area showed that regional and district hospitals had the highest number of maternal deaths due to shortages in staff, facilities and essential drugs, which were skewed in favor of academic hospitals. Moreover, in regional and district hospitals lower levels of care were not sufficiently prepared to manage or refer severe complications and healthcare workers failed to diagnose and treat severe haemorrhage, while women survived in multi-disciplinary settings with functional health systems. However, in recent years awareness raising and involvement of national stakeholders have contributed to reduced numbers of deaths, across all levels of service delivery

The third case study focused on the link between health and infrastructure by looking at the role of roads in facilitating the movement of people, goods and services on the one hand, while increasing the circulation and risk of infection of communicable diseases on the other. Demographic and Health Surveys from Ethiopia, Cameroon, Malawi, Kenya and Zimbabwe combined with geographical coordinates of the proximity of people’s residential areas to paved roads shows that those living closer to roads are at greater risk of HIV infection. HIV awareness and treatment campaigns should therefore target people living on main transport corridors, while the role of transport should be evaluated in social welfare analysis.

Overall, the case studies show the importance of national policies in improving health outcomes, the role of clinical environment and poor clinical decisions and health systems in contributing to avoidable deaths, while illustrating how infrastructural development can affect healthcare. The link and trade offs between infrastructure and health also become apparent in the case of dams which are increasing in number in Africa, therefore improving people’s access to water but at the same time increasing their chances of getting malaria.

Prof Maswime concluded by outlining the importance of social determinants of health, such as education, employment, food security, water security and sanitation, equity and equality and infrastructure. Amongst the barriers to health are pollution, which is probably amongst the most important causes of premature deaths of children, as well as lack of skilled and specialized human resources, critical care facilities as well as poor infrastructure. Geographical location and access to health care is therefore just as important as the conditions of health care facilities themselves. This means that none of the SDG 3 targets can be achieved without achieving other SDGs such as those on water and sanitation, infrastructure and inequality, while health system strengthening in turn will contribute to achieving other SDGs. So far, progress has been made but that there is still a long way to go to reach the health targets in South Africa. However, national programmes led by multiple stake-holders are often successful in contributing to improving health outcomes.

In the discussion that followed the presentation those present commended the focus on the complexity of health, which is often left out in high level discourses on the SDGs. The SDGs cannot be achieved without taking the extent to which they are interlinked into account. Health thinking specifically tends to be very specialized, without a recognition of the interlinkages to other sectors. Infrastructure in turn is dominated by engineers, who don’t think of the health effects of their work. This illustrates the importance of bringing different stakeholders together and the importance of multi-sectoral policy interventions. A representative from the City of Cape Town indicated that the City is already trying to work more transversally by having different departments working together on single policies but urged health experts to give input on city policies, such as the city water strategy which was open for public comment this year.

At the same time, those present highlighted the importance of being cognizant of the complexity of health systems at the community level and the differences and interactions between different areas, even within the same city. Effective monitoring efforts rely on disaggregated data that gives us insight into these local complexities, but such data is often not collected or available, even to government institutions themselves.

Researchers have been trying to make use of data opportunities as they arise, for instance by merging data from enumeration surveys conducted by the Provincial Department of Human Settlements with health indicators to understand patterns. At UCT, the newly created Global Surgery consortium consists of 4 departments which stand at the interface of public health and surgical disciplines from a public health perspective, improving access to care. Training people in this interdisciplinary way will have longer benefits to public health on the longer term.

The presentation and recording of the seminar is available upon request.

• The next SDG seminar is scheduled to take place at ACC on Wednesday 23 October with Ms. Namhla Mniki-Mangaliso of African Monitor presenting a civil society view on the SDGs.