The 2021 mid-year population estimates assert that the South African total population is at 60.1 million people (StatsSA, 2021). The South-African population is usually classified using the population groups that people use to describe themselves in the country’s census, and that have a historical basis in the ‘racial’ classification system of the Apartheid regime: Black African, Coloured, White, Indian/Asian, and Unspecified. The table below provides the breakdown of the population structure, as per these estimates:

Table 1: Mid-year estimates for South Africa by population group and sex for 2021[1]

Source: (StatsSA, 2021). Mid-year population estimates (table 5), p.9. 

The majority of the population falls within the 25-59 year old age range (44%), followed by 0-14 year olds (29%), 15-24 year olds (18%) and 60 years and over (8%) (United Nations, 2017).

[1] The total population estimates have been updated for 2021 but the data presented in the remaining tables remain for 2018 as the overall proportions and trends have not changed.

References:

StatsSA. (2021). Mid-year population estimates 2021. In Statistics South Africa: Release date 19 July 2021 (Issue Statistical release P0302). Available from: http://www.statssa.gov.za/publications/P0302/P03022021.pdf

United Nations. (2017). World Population Prospects The 2017 Revision Key Findings and Advance Tables. World Population Prospects The 2017, 1–46. Available from: https://population.un.org/wpp/publications/files/wpp2017_keyfindings.pdf

South Africa’s surface area covers 1 219 602km² and hosts a wide variety of physical features such as bushveld, grasslands, forests, deserts, mountain peaks, coastal wetlands, and beaches (Countryeconomy.com, 2018; South African Government, 2018b). The country comprises of 9 provinces with a population density that varies widely across more urban versus more rural spaces. See table below for the population density for each province (according to the 2011 National Census, see https://en.wikipedia.org/wiki/List_of_South_African_provinces_by_population_density):

Table 2: Population Density across provinces

Source: National Census 2011 at  https://en.wikipedia.org/wiki/List_of_South_African_provinces_by_population_density

* Total population for 2011 (57.7 million in 2018).

References:

Countryeconomy.com. (2018). Countries data: Demographic and economy South Africa. Countryeconomy.Com. https://countryeconomy.com/countries/south-africa

South African Government. (2018b). Geography and climate. Republic of South Africa. Available from: https://www.gov.za/about-sa/geography-and-climate

South Africa has 11 official languages:

• English
• Afrikaans
• Zulu
• Xhosa
• Southern Sotho
• Northern Sotho
• Tswana
• Venda
• Tsonga
• Swati
• Ndebele

The South African census makes use of the following population groups: Black, White, Coloured, Asian, and Other/unspecified.

According to projections, the overall South African growth rate has increased between 2002 and 2018, with a growth rate of 1.04% for 2002-2003 and 1.55% for 2017-2018 (StatsSA, 2018d).

Table 3: Estimated growth rates, 2017-2018

Source: Adapted from (StatsSA, 2018d) Mid-year population estimates (appendix 4), p.22.

By the year 2050 the South African population is expected to increase to 73 million people (Ritchie & Roser, 2019; United Nations, 2017), with older persons 65 years and over predicted to increase to 10.5% of the population (i.e., from 5.7% in 2015) (Kohler & Behrman, 2015).

References:

Kohler, H., & Behrman, J. (2015). South Africa Perspectives Population.

Ritchie, H., & Roser, M. (2019). Age Structure. Our World in Data. https://doi.org/10.1016/b0-08-043076-7/01822-2

StatsSA. (2018d). Quarterly Labour Force Survey. Available from: https://www.statssa.gov.za/?p=11882

United Nations. (2017). World Population Prospects The 2017 Revision Key Findings and Advance Tables. World Population Prospects The 2017, 1–46. Available from: https://population.un.org/wpp/publications/files/wpp2017_keyfindings.pdf

Persons aged 60 years and over comprised about 8.5% (i.e., approximately 4.9 million people) of the population and has an estimated growth rate from 1.21% (2002-2003) to 3.21% (2017-2018) (StatsSA, 2018d).

Life expectancy

Life expectancy for men is 61.1 years and 67.3 years for females (StatsSA, 2018d). Persons 65 and older comprised 5.6% of the South African population, of which 0.95% are between 75 and 79 years and 0.97% are 80 years and over (StatsSA, 2018d).

Total dependency ratio

South Africa has a total dependency ratio of 52.5% (i.e., defined as persons aged 0-14 and 65 and older who are non-working, compared to the number of persons if working age), of which the dependency ratios for persons aged 0-14 is 44.8% and 65 years and over is at 7.7% (Index Mundi, 2018). More than half of the country’s population is economically dependent, outnumbering, as well relying on a minority that is employed and supporting the non-working.

Old-age dependency ratio

Comparing persons of non-working age to the number of those of working age, the South African dependency ratio for older persons are estimated at 7.7% (Index Mundi, 2018).

Life expectancy at birth by gender

Largely due to the impact of HIV/AIDS, life expectancy decreased between 2002 and 2006. However, the expansion of health programmes and an increase in the availability of anti-retroviral treatment has partly increased life expectancy since 2007 (StatsSA, 2018d). For the year 2018, life expectancy at birth is estimated at 61.1 years for men in South Africa and 67.3 years for women (StatsSA, 2018d).

Life expectancy at birth

South Africa’s life expectancy at birth is estimated for 2015-2020 as being 63.7 years (United Nations, 2017). The country has also seen a decrease in the infant mortality rate from 53.2 deaths per 1000 live births in 2002 to 36.4 in 2018 (StatsSA, 2018d). The mortality rate for children under 5 years has also decreased for the same period from 80.1 to 45.0 child deaths per 1000 live births (StatsSA, 2018d).

Median age of the population

The median age for the South African population in 2017 is 27.1 years of age, for which 26.9 years are male and 27.3 female (Index Mundi, 2018).

Total fertility rate

Fertility rate calculations from the year 1975 to 2100 estimate an overall decrease in children born to South African women.

For the year 2017, the total fertility rate for South Africa is 2.29 children born per woman (Index Mundi, 2018). Fertility varied by province for 2016-2021, with the Eastern Cape (2.89) and Limpopo province (2.86) ranking highest for live births per woman in South Africa.

Furthermore, South Africa is experiencing a decline in fertility rates, a trend that contradicts predictions for Sub-Saharan Africa (Kohler & Behrman, 2015).

References:

Index Mundi. (2018). South Africa Demographics Profile 2018. South Africa Demographics Profile 2018. Available from:  https://www.indexmundi.com/south_africa/demographics_profile.html

Kohler, H., & Behrman, J. (2015). South Africa Perspectives Population.

StatsSA. (2018d). Quarterly Labour Force Survey. Available from: https://www.statssa.gov.za/?p=11882

United Nations. (2017). World Population Prospects The 2017 Revision Key Findings and Advance Tables. World Population Prospects The 2017, 1–46. Available from: https://population.un.org/wpp/publications/files/wpp2017_keyfindings.pdf

Estimated migration from 2016-2021 is presented below (StatsSA, 2018d):

Table 4: Estimated provincial streams 2016–2021

Source: Adapted from: (StatsSA, 2018d). Mid-year population estimates (table 9), p.15.

The Gauteng and Western Cape provinces receive the highest number of people in-migrating, and this is most likely due to these two provinces being the economic hubs of the country. Thus, people migrate to these provinces for employment (migrating out of provinces with less economic opportunity such as the Eastern Cape, Limpopo, and KwaZulu-Natal). Gauteng is the smallest province (in area) and yet the highest populated in the country (see population density under Part 1) explaining the high in- and out-flow of people migrating in the country (StatsSA, 2018d).

The migration outside of South Africa for each of the 9 provinces are tabled below:

Table 5: Migration outside of South Africa by province

Source: Adapted from: (StatsSA, 2018d). Mid-year population estimates (table 9), p.15.

References:

StatsSA. (2018d). Quarterly Labour Force Survey. Available from: https://www.statssa.gov.za/?p=11882

The World Health Organisation estimates that for the year 2016, NCDs account for 51% of all deaths in South Africa (WHO, 2018). Communicable, maternal, perinatal, and nutritional conditions account for 40% of mortality, followed by cardiovascular diseases (19%), cancers (10%), injuries (9%), diabetes (7%), and chronic respiratory diseases (4%) (WHO, 2018). For the same year men were more at risk for premature deaths from NCDs – 32% compared to 21% of their female counterparts (WHO, 2018).

Data from 2015 ranked cerebral-vascular disease fourth on the top ten causes of years of life lost (YLLs) (Groenewald et al., 2017).

References:

Groenewald, P., Bradshaw, D., Day, C., & Laubscher, R. (2017). 14 Burden of disease. October 2012, 206–226. Available from: https://www.hst.org.za/publications/District%20Health%20Barometers/14%20(Section%20A)%20Burden%20of%20Disease.pdf

WHO. (2018). Non-communicable diseases (NCD) Country Profiles:South Africa. Available from: https://apps.who.int/iris/handle/10665/274512

In 2018 an estimated 7.52 million people were living with HIV in South Africa, with 18.99% of adults between the ages of 15 and 49 being infected, and 22.32% of women (StatsSA, 2018d).

In 2015, HIV/AIDS (1 365 000) and TB (849 000) were identified as the country’s two leading causes of YLLs to premature mortality (Groenewald et al., 2017). The table below ranks the top ten causes of YLLs, including both communicable and non-communicable diseases or conditions:

Table 5: Top ten causes of years of life lost (YLLs) for South Africa, 2015

Source: Adapted from Groenewald et al., (2017), p.214

South Africa has seen an increase in the burden of HIV/AIDS and TB and other communicable diseases, perinatal, maternal and nutritional conditions (i.e., comm/mat/peri/nutr) from 37.8% in 1997 to 62.1% in 2006 (Groenewald et al., 2017). However, for 2015 there has been a decline (45.4%) in HIV/AIDS, TB and Comm/mat/peri/nutr and this is attributed largely to an increase in the burden of non-communicable diseases (i.e., from 29% in 2006 to 40% in 2015). Despite these gains, the increase of cases of multiple drug resistant, TB (MDR-TB) has placed strain on the health system to cope, with rates for TB alone increasing from 3.2% total DALYs in 2010 to 3.7% in 2015 (EMERALD, 2017).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

Groenewald, P., Bradshaw, D., Day, C., & Laubscher, R. (2017). 14 Burden of disease. October 2012, 206–226. Availabe from: https://www.hst.org.za/publications/District%20Health%20Barometers/14%20(Section%20A)%20Burden%20of%20Disease.pdf

StatsSA. (2018d). Quarterly Labour Force Survey. Available from: https://www.statssa.gov.za/?p=11882

South Africa’s injury burden, particularly homicide, is reportedly 6 times higher than the global average (Jabar & Matzopoulos, 2017). Interpersonal violence ranked 8^th on the top ten causes of premature death in South Africa in 2015, followed by road injuries and accidental gunshots (Groenewald et al., 2017). Injury related deaths moderately increased from 11% in 2006 to 14.6% in 2015 (Groenewald et al., 2017).

References:

Groenewald, P., Bradshaw, D., Day, C., & Laubscher, R. (2017). 14 Burden of disease. October 2012, 206–226. Availabe from: https://www.hst.org.za/publications/District%20Health%20Barometers/14%20(Section%20A)%20Burden%20of%20Disease.pdf

Jabar, A., & Matzopoulos, R. (2017). Violence and injury observatories Reducing the burden of injury in high-risk communities. SA Crime Quarterly, 59(59), 47–57. https://doi.org/10.17159/2413-3108/2017/v0n59a1547

The South African GDP per capita (PPP, purchasing power parity) is recorded as US$12 294.88 in 2017. GDP decreased by 0.7% in the second quarter of 2018, with the largest negative contributors being agriculture (-0.8, i.e., decreasing by 29.2%), transport (-0.4, i.e., decreasing by 4.9%), and trade (-0.3, i.e., 1.9%) (StatsSA, 2018a). Positive contributions primarily came from the mining (0.4, i.e., increasing 4.9%) and finance, real estate and business service industries (1.9%) (StatsSA, 2018a). The third quarter in 2018 saw the Real GDP (measured by production) increasing by 2.2% for which the largest contributors to growth were the manufacturing (7.5%, contributing 0.9 of percentage point to GDP), finance (2.3%, 0.5 percentage point), and transport and trade industries (5.7%, 0.5 percentage point) (StatsSA, 2018b). These figures have been significantly affected by the COVID-19 pandemic and associated lockdowns with a reduction in productivity and increase in unemployment by 2021.

The World Bank categorises South Africa as an Upper-middle-income country (The World Bank, 2018a).  South Africa is one of the most unequal countries in the world and this categorisation by the World Bank is not what most of the South Africans experience in terms of their living conditions.

References:

StatsSA. (2018a). Gross Domestic Product: Second Quarter. In Statistics South Africa: Release date 04 September 2018. https://doi.org/10.1080/00128775.1994.11648537

StatsSA. (2018b). Gross domestic product: Third quarter. Available from: https://www.statssa.gov.za/publications/P0441/P04413rdQuarter2018.pdf

The World Bank. (2018a). Overcoming Poverty and Inequality in South Africa:An Assessment of Drivers, Constraints and Opportunities. Available from: https://documents.worldbank.org/en/publication/documents-reports/documentdetail/530481521735906534/overcoming-poverty-and-inequality-in-south-africa-an-assessment-of-drivers-constraints-and-opportunities

The table below summarises the main productive sectors of the South African economy, compiled from data source (StatsSA, 2018b):

Table 6: Composition of the economy (main productive sectors)

References:

StatsSA. (2018b). Gross domestic product: Third quarter. Available from: https://www.statssa.gov.za/publications/P0441/P04413rdQuarter2018.pdf

Historically the South African Government debt has steadily increased from January 2016 (US$40 265 Million), peaking at US$81 061 Million by January 2018. Government Debt for 2018 has now decreased from US$70 549 Million in the second quarter of 2018, to US$67 998 Million (third quarter) (Trading Economics, 2019). Household debt grew by 4.6% on average in 2018 and amounts to R165 billion (SARB, 2019).

References:

SARB. (2019). Quarterly bulletin: March 2019 (no.291). Available from: https://www.resbank.co.za/en/home/publications/publication-detail-pages/quarterly-bulletins/quarterly-bulletin-publications/2019/9148

Trading Economics. (2019). South Africa Government Debt to GDP. Trading Economics, 1–8. Available from: https://tradingeconomics.com/south-africa/government-debt

South Africa faces a ‘triple challenge’ of high poverty, inequality, and unemployment and it has been identified as one of the world’s most unequal countries in the world (The World Bank, 2018a). The Living Conditions Survey (2014/15) found that the country’s Gini coefficient increased at the end of Apartheid (i.e., 0.61 in 1996) to 0.63 in 2015 as one of the highest in the world[1] (The World Bank, 2018a).

South Africa sees a polarisation of its employment market and is divided into two extreme job types: on the one end of the spectrum there is a small number of people with high earning jobs which once obtained, they are unlikely to give up and the other extreme where the majority of the population work at low earning jobs – the latter being more fluid and witnessing exits from employment (The World Bank, 2018a). The National Minimum Wage (NMW) was set at ZAR3500 per month across all sectors from May 2018 (with domestic and agriculture minimums set at 75 and 90% respectively (The World Bank, 2018a). Race and gender statistical trends remain biased where African and female workers on average earn significantly less than male and white workers (The World Bank, 2018a). Despite a notable decline in the observed gender inequality after 2011 (The World Bank, 2018a), the average gender pay gap in South Africa is reported at 28.6% in the Global Wage Report for the year 2018/19 (i.e., where women earn an average of 28.6% less than men for the same job). Women are generally earning less in South Africa leading to female-headed households being 10% more likely to become impoverished (and 2% less likely to escape it) than households headed by their male-counterparts (The World Bank, 2018a). Women still comprise less than 50% of positions of influence, for example 32% of Supreme Court of Appeal judges, 31% of advocates, 30% of ambassadors and 24% of Heads of State-owned enterprises (StatsSA, 2018c). Less than a third (32%) of managers in South Africa are women, and tend to dominate the domestic worker, clerical and technician occupations (men dominating the rest) (StatsSA, 2018c). By 2017, senior level management (decision-making level) are over-represented by men who dominate in both the public (60.7%) and private (68.5%) sectors (SAHRC, 2017a). Top level management in both public and private sectors also continue to be overrepresented by men, where women comprise 32.6% of top positions in government and 21.6% in the private sector (Department of Labour, 2017).

The majority of South Africans live in poverty (76%), of which nearly half are considered chronically poor and living at the upper-bound national poverty line of ZAR 992 per person per month (The World Bank, 2018a). Middle class earners constitute 20% of the working population between 2008 and 2015 and are a comparably smaller proportion than in other countries (The World Bank, 2018a). South Africa has also seen an increase in its poverty rate from 36 to 40% between 2011 and 2015 (The World Bank, 2018a). Poverty has also ‘deepened’ during this period as well and shows a 2.4 point increase (i.e., 16.4 to 18.8%) when calculated at the US$1.9 a day poverty line. Female-headed households, black South Africans, the less educated, the unemployed and bigger families experience higher levels of poverty (The World Bank, 2018a).

Rural areas in South Africa have the highest concentration of poverty (60.3% in 2006 and 59.7% in 2015), for which the Eastern Cape, KwaZulu-Natal, and Limpopo are the three poorest provinces in the country (2006-2015) (The World Bank, 2018a).

[1] Gini coefficient: Numbers range from 0 to 1; the higher the number/closer to 1, the greater the degree of income inequality

References:

Department of Labour. (2017). Commission for Employment Equity Annual Report 2017-2018. Availabe from: https://www.abp.org.za/wp-content/uploads/2018/07/Commission-for-Employment-Equity-18th-Annual-Report.pdf

SAHRC. (2017a). RESEARCH BRIEF ON GENDER AND EQUALITY IN SOUTH AFRICA 2013 to 2017. Available from: https://www.sahrc.org.za/home/21/files/RESEARCH%20BRIEF%20ON%20GENDER%20AND%20EQUALITY%20IN%20SOUTH%20AFRICA%202013%20to%202017.pdf

StatsSA. (2018c). How do women fare in the South African labour market? Statistics South Africa. http://www.statssa.gov.za/?p=11375

The World Bank. (2018a). Overcoming Poverty and Inequality in South Africa:An Assessment of Drivers, Constraints and Opportunities. Available from: https://documents.worldbank.org/en/publication/documents-reports/documentdetail/530481521735906534/overcoming-poverty-and-inequality-in-south-africa-an-assessment-of-drivers-constraints-and-opportunities

The country is currently experiencing an electricity crisis with the implementation of ‘load-shedding’ (i.e., blackouts) since 2008 as ESKOM (i.e., South Africa’s power utility) struggles to meet demand.

The Western Cape Province has also been experiencing its most severe drought since 2015, with water levels beginning to rise in September 2018 (see https://en.wikipedia.org/wiki/Cape_Town_water_crisis). By 2021 this drought had been resolved in the Western Cape but remains critical in some other provinces such as the Eastern Cape.

During the third quarter (July-Sept) of 2018, South Africa’s unemployment rate increased by 0.3 percentage point to 27.5% (StatsSA, 2018d). Compared to the second quarter (2018), employed persons increased by 92 000 (i.e., to 16.4 million), while persons slipping into unemployment increased by 127 000 (i.e., to 6.2 million) for the same period (StatsSA, 2018d). Currently, the national unemployment rate recorded for the first quarter of 2019 stands at 27.6% (StatsSA, 2019b). This trend in increasing unemployment has continued with a significant impact of the COVID-19 pandemic and associated lockdowns.

The latest statistical release indicates a further decrease in employment between the fourth quarter in 2018, with declines recorded in both the formal and informal sectors (StatsSA, 2019b). During the first quarter in 2019, the unemployment rate increased in 6 of the 9 provinces, with Mpumalanga (2.2%), Limpopo and Free State (2.0%), and Eastern Cape (1.3%) recording the largest increases in unemployment (StatsSA, 2019b).

In 2018, the expanded unemployment rate (i.e., including people who have stopped looking for work) increased from 36.7% in the second quarter to 37.2% in the third quarter, with higher rates for women (41.2%) than for men (33.7%) (StatsSA, 2018d, 2018c). This trend continued into the first quarter of 2019 with a recorded expanded unemployment rate of 38% (StatsSA, 2019b).

Regardless of race, men in South Africa are more likely to be in paid employment compared to women, who by the second quarter of 2018 totalled 55.2% of workers involved in non-market activities (StatsSA, 2018c).

Based on these figures, the female South African workforce continues to experience lack of opportunities, systematic inequality, and indirect discrimination (SAHRC, 2017a).

Table 7: South African labour force by age (Jul-Sept 2018)

Source (data): (StatsSA, 2018d), p.23-24.

Table 8: South African labour force by gender (Jul-Sept 2018)

Source (data): (StatsSA, 2018d), p.19-20.

References:

SAHRC. (2017a). RESEARCH BRIEF ON GENDER AND EQUALITY IN SOUTH AFRICA 2013 to 2017. Available from: https://www.sahrc.org.za/home/21/files/RESEARCH%20BRIEF%20ON%20GENDER%20AND%20EQUALITY%20IN%20SOUTH%20AFRICA%202013%20to%202017.pdf

StatsSA. (2017a). Public healthcare: How much per person? Statistics South Africa: Statistical Release. http://www.statssa.gov.za/?p=10548

StatsSA. (2018c). How do women fare in the South African labour market? Statistics South Africa. http://www.statssa.gov.za/?p=11375

StatsSA. (2018d). Quarterly Labour Force Survey. Available from: https://www.statssa.gov.za/?p=11882

StatsSA. (2019b). Quarterly Labour Force Survey: Q1 2019. Available from: https://www.statssa.gov.za/publications/P0211/Presentation_QLFS_Q1_2019.pdf

Reportedly, 85.5% of all new businesses in South Africa start up unregistered and operate in the informal economy (Williams, 2017). The following describes the informal economy in South Africa (Williams, 2017):

1. Approximately 32.7% of non-agricultural workers are employed in the informal economy, of which more than half (54.4%) are in informal jobs in informal enterprises;
2. 39% of employed women and 29% of employed men are working within the informal economy;
3. The informal workforce comprises of 67% informal employees, 25% ‘own account’ workers, 5% employers and 3% unpaid family workers;
4. 26% of employment within metropolitan areas is informal and is distributed across trade (29%), private households (29%), construction (12%), manufacturing (8%) and services (other than private households) (7%).

When compared to other countries (e.g., India where the informal economy comprises 84.3%, Brazil 42.3%, and China 34.4%), the informal economy in South Africa is less pervasive and found in particular industries (Williams, 2017).

During South Africa’s third quarter in 2018, the informal sector increased in employment by 188 000 when compared to the previous quarter (StatsSA, 2018d). These gains were mostly seen by industries of trade (+75 000), finance and other business services (+67 000), and construction (+48 000) (StatsSA, 2018d). Employment losses within the informal economy for the same period were largely found within the community and social services (decreased by 7 000), mining (-2 000), and utilities (-1 000) industries.

Essentially, the increase of economic engagement in the informal sector means that fewer South Africans are contributing to tax – a key source of revenue for South Africa.

References:

StatsSA. (2018d). Quarterly Labour Force Survey. Available from: https://www.statssa.gov.za/?p=11882

Williams, C. C. (2017). THE INFORMAL ECONOMY AS A PATH TO EXPANDING OPPORTUNITIES. https://doi.org/10.2139/ssrn.2804172

Two national departments are responsible for education in South Africa, namely (1) the Department of Basic Education (primary and secondary schooling) (DBE), and (2) Department of Higher Education and Training (DHET) (post-schooling education and training) (South African Government, 2018a). Education in South Africa is compulsory from grade 1 to 9 (age 7 to 15), and optional from grade 10-12 (Expatica, 2018). Public schools are funded by government and are run at provincial level. As a result, educational quality and standards vary between provinces and tend to be higher in bigger cities than in less developed areas (Expatica, 2018).

According to the General Household Survey of 2018, almost half of South African children aged 0-4 years remained home with parents/guardians (49.2%) with 38.4% attending grade R/day-care/educational facility outside of their home (StatsSA, 2019a). Attendance at ECD facilities was most common in major cities, such as Gauteng (49.8%), Free State (48.3%), and the Western Cape (43.7%).

In 2018, 32.2% of children and youth 5 years and older attended an educational institution of some kind, with 87.7% of this age range being in school and 4.5% in higher education institutions (StatsSA, 2019a). There is a noticeable delay in educational attainment whereby 11.4% of school-attending individuals are still attending secondary school by the age of 24, with very few entering tertiary levels of education (StatsSA, 2019a).

Women within this age range (5-24) who were not attending an education institution listed the following as their main reasons: (1) having no money for fees (25.2%), (2) poor academic performance (19%), and (3) family commitments (18.1%). Their male counterparts listed (1) poor academic performance (21.7%), (2) no money for fees (19.7%), and (3) education is useless (14%) as their main reasons (StatsSA, 2016).

According to the General Household Survey of 2015 (StatsSA, 2016), literacy was measured in terms of functional literacy (irrespective of a Grade 7 education) whereby respondents should (with reference to at least one language) indicate whether they have ‘no difficulty’, ‘some difficulty’, ‘a lot of difficulty’ or are ‘unable to’ read newspapers, magazines and books, or write a letter (StatsSA, 2016). Using this measure, literacy for persons over the age of 20 increased from 91.9% in 2010 to 93.7% in 2015 (StatsSA, 2016). The highest adult literacy rates for persons aged 20 and over were evident in the Western Cape Province (97.8%), followed closely by Gauteng (97.7%) and the Free State (94.5%).

More recently, the Organisation for Economic Co-operation and Development (OECD) has released a report on the status of education for partnering countries: “Education at a Glance 2018” (OECD, 2018), summarising the following for South Africa:

• The younger generations (25–34-year-olds) are increasing their representation at higher education levels (i.e., 76% attaining secondary education);
• Only 6% of adults are attaining tertiary level education;
• 16% of children (5-14 years old) are not enrolled in any form of education (South Africa rating lowest across all partner countries);
• For children under 5 years old, few are enrolled in pre-primary education (i.e., any form of Early Childhood Education and Care services) (17%), and less than 40% enrolled in school. School enrolment increases for 6-year-olds (75%) whereas at this age it’s universal at 98% for partner countries;
• Many learners in secondary education are over-age (21%) and 16% in upper secondary general programmes are repeaters (rating highest across partner countries for both over-age and repeaters); and
• Compared to partner OECD countries, South Africa also has the highest rate of persons 20–24-year-olds who are unemployed or not in any form of education or training.

Tertiary education in South Africa is very expensive. Since 2015, a student-led movement termed the “FeesMustFall” led a series of protests across South African universities to stop the increase of student fees and increase state expenditure for universities (see https://en.wikipedia.org/wiki/FeesMustFall). This movement succeeded in 2015 in preventing the increase of fees for 2016. However, protests flared up again in 2016 after it was announced that fees will increase in 2017 but will be capped at 8% (universities would decide by how much they would increase). This movement therefore reflects the limitations South Africans experience in accessing tertiary education.

References:

Expatica. (2018). Education in South Africa. https://www.expatica.com/za/education/children-education/education-in-south-africa-803205/

OECD. (2018). Education at a Glance: Country Note for South Africa. https://doi.org/10.1787/eag-2018-en

StatsSA. (2016). General Household Survey. Available from:  https://www.statssa.gov.za/publications/P0318/P03182015.pdf

StatsSA. (2019a). General Household Survey 2018. Available from: https://www.statssa.gov.za/?p=12180

South African Government. (2018a). Education. South African Government. Available from: https://www.gov.za/about-sa/education

Social protection schemes implemented by the government

South Africa’s welfare system has been described as ‘well-established’, distributing over 17 million social grants on a monthly basis (GroundUp, 2016). Grants are administered by the South African Social Security Agency (SASSA) who is responsible for providing support to those vulnerable to poverty and in need of State support, including older people, persons with disabilities and children (GroundUp, 2016).

As of 1^st October 2018, the amounts payable for social security grants are tabled below (table 9). Annual increases are usually given for these grants.

Table 9: Social security grants paid by the South African government (2018)

By the end of December 2018, the South African government has spent a total of ZAR17,731,402.00 on social grants across all grant types and all nine provinces (SASSA, 2018). The bulk of these funds are distributed as child support grants (i.e., ZAR12,440,728.00), followed by old age (pension) grants (ZAR3,521,733.00) and disability grants (ZAR1,058,263.00).

In the context of widespread poverty and unemployment, access to social grants is important to many economically vulnerable South Africans. The latest General Household Survey shows that for the year 2018, social grants (excluding pension) are the second most common source of income (45.2%) for households, nationally (StatsSA, 2019a). Despite the availability of social grants being critical for the survival of many South Africans, this reality (i.e., widespread poverty and growing dependency of families on State grants) poses an economic threat to the country as it represents a decrease in an economically active population that can contribute to the country’s revenue as taxpayers.

Social protection schemes implemented by international development partners or donors

There was no information found that confirmed whether South Africa receives any social protection schemes from international development partners. Organisations like UNICEF work with the country’s Department of Social Development to guide on how social protection programmes can be implemented. However, the literature reviewed indicates that these schemes are primarily funded and implemented through the country’s public sector (to qualifying members of the public) and private sector (to private members or clients). Moreover, social protection implemented in South Africa is estimated at 58.5% of households covered (World Bank, 2015 as cited in EMERALD, 2017).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

GroundUp. (2016). Everything you need to know about social grants. https://www.groundup.org.za/article/everything-you-need-know-about-social-grants_820/

SASSA. (2018). A Statistical Summary of Social Grants In South Africa.

StatsSA. (2019a). General Household Survey 2018. Available from: https://www.statssa.gov.za/?p=12180

South Africa today

Today, South Africa is a democratic country that is governed by a Constitution and an independent judiciary system (South African Government, 2018c). It has three levels of government (national, provincial, and local), for which each has its own legislative – and executive authority. To date, key political issues in South Africa that negatively influence local and foreign investors include Land reform, State corruption (e.g., state capture inquiry involving now former president Jacob Zuma), widespread unemployment, the economic crisis as well as provincial water and national energy (electricity) crises involving Eskom (country’s power supplier) and a severe drought.

The three tiers of Government are described below (South African Government, 2018c):

1. Executive authority: comprises of a National Cabinet and is constituted by the President, Deputy President and Ministers;
2. Legislative authority: comprises of a National Parliament and is constituted by two bodies, i.e., the National Assembly (350-400 members) and the National Council of Provinces (90 delegates);
3. Judicial authority: judges are appointed by the Judicial Service Commission and the authority itself is made up by the Courts and includes the Constitutional Court, Supreme Court of Appeal, High Courts and Magistrates’ Courts.

The people of South Africa democratically elect a ruling party every five years, whereby general elections elect a new National Assembly and provincial legislatures. The last general elections were held on 8 May 2019.

References:

South African Government. (2018c). Structure and functions of the South African Government | South African Government. Available from: https://www.gov.za/about-government/government-system/structure-and-functions-south-african-government

History of South Africa

Historically a Dutch and British colony and a half-way stop in the Spice trading route to India, the discovery of diamonds (1867) and gold (1886) intensified immigration and subsequent oppression of the original inhabitants (CIA, 2019). Despite the preceding war between the Afrikaners (Dutch descendants) and the British (1899-1902), they jointly ruled South Africa from 1910 (independence from British colonial rule) and became a republic for favouring whites only and leading to the institutionalisation of Apartheid by 1948 under the leadership of the National Party – i.e.,  the separate development of people as classified by race in favour of the white minority, and the underdevelopment of the other than white majority (CIA, 2019). The country’s first democratic, multi-racial elections signalled the end of this oppressive regime led by the opposition (the African National Congress) and appointing Nelson Mandela as the country’s first black president in 1994.

References:

CIA. (2019). The World Factbook: South Africa. Central Intelligence Agency. Available from:  https://www.cia.gov/the-world-factbook/countries/south-africa/

National elections occur every 5 years, with the last one held on the 8^th May 2019, re-electing the same ruling party (i.e., the African National Congress) with no radical changes to be expected. South African citizens aged 18 years and over elect a ruling party for the Provincial as well as for a National Government.

South Africa ranks 71^st (out of 180 participating countries) on the Corruption Perceptions Index for 2017, with a score of 43/100[1] (Transparency International, 2017).

[1] This score reflects a country’s perceived level of public sector corruption whereby a score of 0 is ‘highly corrupt’ and 100 is ‘very clean’ (Transparency International, 2017).

References:

Transparency International. (2017). Transparency International – South Africa. https://www.transparency.org/country/ZAF#

The World Bank describes South Africa’s political transition to a democratic country as ‘one of the most remarkable political feats of the past century” (The World Bank, 2018b). According to the Political Stability Index that collects data from The World Bank for 195 countries, South Africa ranked 122^nd for the year 2017 with a score of -0.27 (-2.5 weak and +2.5 strong) (TheGlobalEconomy.com, 2018a). For the period 1996 to 2017, South Africa’s political stability scored an average of -0.14 points (min.-0.54 in 1998 and max. 0.22 in 2007) (TheGlobalEconomy.com, 2018b).

References:

The World Bank. (2018b). The World Bank in South Africa. Available from: http://www.worldbank.org/en/country/southafrica/overview

TheGlobalEconomy.com. (2018a). Political stability: Country rankings. Available from: https://www.theglobaleconomy.com/rankings/wb_political_stability/

TheGlobalEconomy.com. (2018b). South Africa: Political stability. Available from: https://www.theglobaleconomy.com/South-Africa/wb_political_stability/

About 82 of every 100 South Africans (i.e., 45 million) are largely dependent on public healthcare  (StatsSA, 2017a), which provides healthcare to 84% of the population (Mahlathi & Dlamini, 2015). This sector is governed by the National Department of Health which is responsible for the development of policies and overall coordination (Mahlathi & Dlamini, 2015). Provincial departments are responsible for providing primary, secondary and tertiary care services through public clinics and hospitals (Mahlathi & Dlamini, 2015).

References:

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

StatsSA. (2017a). Public healthcare: How much per person? Statistics South Africa: Statistical Release. http://www.statssa.gov.za/?p=10548

Access to private medical care is largely contingent on whether South Africans have access to medical insurance, for which only 17 of 100 persons (i.e., 12.7 million) are able to make use of these services (StatsSA, 2016, 2017a), providing services to only 16% of the population (Mahlathi & Dlamini, 2015). The sector consists of services provided by general practitioners, medical specialists, and private hospitals, and tend to be located in more urban areas (Mahlathi & Dlamini, 2015). This sector is largely under-regulated and has limited accountability at various levels (Competition Commission SA, 2018). In the absence of value-based purchasing, shortfalls include ineffective constraints on rising healthcare rates and insurance cover, while consumers are generally uninformed and disempowered (Competition Commission SA, 2018). The sector is furthermore characterised by a lack of integrated care models, with an enduring preference for solo practices and fee-for-services (FFS) billing that incentivises practitioners to provide more services than needed, especially in an unregulated pricing environment (Competition Commission SA, 2018).

Private healthcare in South Africa is extremely expensive and unaffordable for most of the population. Medical practitioners drive health care expenditures in the sector in two ways: (1) through their own activities (i.e., diagnosis and treatment); and (2) through referral for further investigation, treatment and hospitalisation (Competition Commission SA, 2018). The Competition Commission of South Africa found that despite rulings that doctors may not negotiate collectively, there are specialist groupings that operate collectively to resist joining service provider networks and introduce/adapt codes to inflate prices – without noticeable improvement in the quality of care offered. General practitioners form Independent Practice Associations (IPAs) that promote inclusion in preferred provider networks. These networks include quality assessments that are not publicly available, with no evidence of consequences for practitioners who do not meet standards (Competition Commission SA, 2018). Specialists join related (specialist) societies and associations, protecting their interests. Regulation within this sector is inadequate to inform and empower (and protect) the healthcare user.

References:

Competition Commission SA. (2018). Health market injuiry. Available from:  http://www.compcom.co.za/wp-content/uploads/2018/07/Executive-Summary.pdf

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

StatsSA. (2016). General Household Survey. Available from:  https://www.statssa.gov.za/publications/P0318/P03182015.pdf

StatsSA. (2017a). Public healthcare: How much per person? Statistics South Africa: Statistical Release. http://www.statssa.gov.za/?p=10548

Rationed by waiting lists and queuing systems, public healthcare services are accessed via a District Health system, as the preferred government mechanism for primary care service provision for the majority of South Africans (Mahlathi & Dlamini, 2015). Services are accessed through public clinics, public hospitals, community health centres/clinics and ambulance services, and governed by the use of Norms and Standards.

The PHC sector has around 3500 clinics and health centres across the country that is accessible within 5km to more than 90% of people living in South Africa (McKenzie et al., 2017).

Private healthcare services are accessed by those who have medical insurance, or those who pay the private rates and fees attached to these private and specialist services, via private practices and hospitals.

References:

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

McKenzie, A., Schneider, H., Schaay, N., Scott, V., & Sanders, D. (2017). Primary Health Care Systems (Primasys). In World Health Organization and Alliance for Health Policy and Systems Research. Available from: https://apps.who.int/iris/bitstream/handle/10665/341145/WHO-HIS-HSR-17.38-eng.pdf?sequence=1

Patients receiving care from the public sector access services via a primary health care facility (e.g., community clinics, day-hospitals) and they can access secondary and tertiary care via referral (via the general practitioner or district surgeon). Similarly, within the private sector, specialist services at secondary and tertiary levels are accessed via referral from a local practicing general practitioner. This is enforced by medical insurance service providers, where patients will only be covered/insured for secondary and tertiary services with supporting referral documentation from the PHC authority (e.g., general practitioner), and with prior authorisation for in-hospital treatment and care.

The South African healthcare sector is characterised by inequality in terms of access to care services and resources (human, financial and technologies) between provinces, with more facilities and services concentrated in more urban areas (Competition Commission SA, 2018; Department Planning Monitoring and Evaluation, 2017; Mahlathi & Dlamini, 2015), despite the majority of the population (64.7%) living in provinces that are largely characterised as more rural (Mahlathi & Dlamini, 2015). Most patients access health care via the Public District Health System where healthcare is free, however overburdened by catering for the service needs of 84% of the population (Mahlathi & Dlamini, 2015), and further characterised by:

• Poor management and governance;
• Shortages of key health care professionals, and skewed between the public and private sector;
• Weak service delivery platform with poor quality of care and delivery of healthcare services;
• Lack or inconsistent supply of medical products and health technologies;
• Fragmented and unequal healthcare financing; and
• Poor information management (Department Planning Monitoring and Evaluation, 2017).

The legacy of Apartheid perpetuates the racial disparities and inequitable access to care, despite active redresses of the past. Ninety percent (90%) of South Africans are said to live within 7 kilometres from a public healthcare facility, and about two-thirds live within 2 kilometres (Fusheini & Eyles, 2016). However, for most South Africans the cost in time and money to travel to the nearest healthcare facility poses a significant barrier (Fusheini & Eyles, 2016). With regards to population groups, it is estimated that 15% of black South Africans live more than 5km away from the nearest healthcare facility, as compared to 7% coloureds and 4% whites (Mclaren et al., 2013). Poorer South Africans live furthest from facilities and are characterised by poorer health, with a tendency for men to utilise health care facilities less than women (Mclaren et al., 2013).

Barriers in accessing care within the private sector relates to the escalating costs of care, despite having medical insurance. Medical scheme coverage rates often have to be supplemented by out-of-pocket payments, decreasing the range and depth of services accessed (Competition Commission SA, 2018). There are 8 million South Africans that are currently covered by a medical aid scheme (Abraham et al., 2012). More so, 21.3% of households in the metropolitan areas have some form of medical health insurance, compared to only 5.4% of households in more rural areas (DOH, 2011). Access to private health care services in rural areas is limited.

References:

Abraham, M., Dreyer, K., Giuricich, M., & Ramjee, S. (2012). Healthcare Expenditure in the Last year of Life: The Experience of South African Medical Schemes. (Issue 5). Available from: https://www.actuarialsociety.org.za/convention/convention2012registration/assets/pdf/papers/Kathryn%20Dreyer,%20Shivani%20Ramjee%20-%20HEALTHCARE%20EXPENDITURE%20IN%20THE%20LAST%20YEAR.pdf

Competition Commission SA. (2018). Health market injuiry. Available from:  http://www.compcom.co.za/wp-content/uploads/2018/07/Executive-Summary.pdf

Department Planning Monitoring and Evaluation. (2017). Socio-Economic Impact Assessment System (SEIAS) Final Impact Assessment (Phase 2): White Paper on National Health Insurance (Issue May).

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Fusheini, A., & Eyles, J. (2016). Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision. BMC Health Services Research, 16(1), 1–11. https://doi.org/10.1186/s12913-016-1797-4

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

Mclaren, Z., Ardington, C., & Leibbrandt, M. (2013). Distance as a barrier to health care access in South Africa.

The public sector is financed through general taxation and equals 48.37% of the total health expenditure being funded by the State (StatsSA, 2012), serving 84% of the population (Mahlathi & Dlamini, 2015). The private sector is funded by voluntary medical aid membership (66%) and out-of-pocket payments (29.7%) (EMERALD, 2017) and comprises about 51.63% of the country’s total health expenditure (StatsSA, 2012), serving only 16% of the population (Mahlathi & Dlamini, 2015). Approximately 8.5% of GDP is spent on health, whereby 4.1% is spent by the public sector on 84% of the population and 4.4% spent by the private sector on 16% of the population (Fusheini & Eyles, 2016).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

Fusheini, A., & Eyles, J. (2016). Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision. BMC Health Services Research, 16(1), 1–11. https://doi.org/10.1186/s12913-016-1797-4

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

StatsSA. (2012). South Africa Health expenditure: Total vs Private – South Africa Data Portal. South Africa Data Portal. Available from: http://southafrica.opendataforafrica.org/rtwhibg/south-africa-health-expenditure-total-vs-private

As mentioned above, about 16% of the South African population is able to afford health insurance (Mahlathi & Dlamini, 2015), for which most part is concentrated in more urban areas (Competition Commission SA, 2018; StatsSA, 2016).

References:

Competition Commission SA. (2018). Health market injuiry. Available from:  http://www.compcom.co.za/wp-content/uploads/2018/07/Executive-Summary.pdf

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

StatsSA. (2016). General Household Survey. Available from:  https://www.statssa.gov.za/publications/P0318/P03182015.pdf

South Africa is moving towards providing universal health coverage through the development of a National Health Insurance (NHI) as a means of addressing the inequalities and the highly fragmented health system of the past (Barron & Padarath, 2017). The NHI’s objective is to provide all South Africans (as well as legal residents) quality healthcare regardless of whether they’re employed and able to contribute monetarily to the fund (DOH, 2019). South Africans will access healthcare via a defined package of comprehensive healthcare services (DOH, 2019), and they will be funded largely via general taxation and monthly employee contributions (said to be lower than existing medical aid contributions) for higher-income earners. Employees will still retain the right to belong to their own medical aid schemes; however, they will not have the option to opt out of NHI contributions (DOH, 2017). Employers will support the fund-contribution process in two ways, (1) by ensuring their employees’ contributions are collected and submitted; and (2) by matching their employee’s contribution to the NHI (DOH, 2017). The White paper on the National Health Insurance published in December 2015 proposed an implementation process that will span across 14 years (2012-2026) (Barron & Padarath, 2017).

References:

Barron, P., & Padarath, A. (2017). South African Health Review 2017. In Health Systems Trust. Available from: https://www.hst.org.za/publications/Pages/HST-South-African-Health-Review-2017.aspx

DOH. (2017). Understanding National Health Insurance. Department of Health.

DOH. (2019). National Health Insurance – NHI. Department of Health. http://www.health.gov.za/index.php/nhi

South Africa’s National Treasury is responsible for managing budget preparation processes, the equitable distribution of the country’s revenue raised and in so doing, the allocation and utilisation of public financial resources (National Treasury, 2019).

References:

National Treasury. (2019). Department: National Treasury. National Government of SA. Available from: https://nationalgovernment.co.za/units/view/27/department-national-treasury

The country’s national and provincial budget process runs from April to March on an annual basis. The table below describes the budget process for South Africa (adapted from source, Public Education Office, 2015):

Table 10: National and provincial budget process

References:

Public Education Office. (2015). How the Budget works for us. www.parliament.gov.za

National departments set their budget priorities annually, where Provincial departments make decisions on how the budget will be spent in the province to achieve these priorities (see section on budget process).

When Departments reprioritise budgets to allocate to the establishment of a new service, need or requirement, the allocation process often requires that the funds are taken away from somewhere else (instead of additional funding becoming available) (EMERALD, 2017). Where major programme changes are required, Departments will engage Treasury, Cabinet, and then Parliament (according to set budget cycle deadlines) for the reprioritisation of funds, plans and allocations (see section on budget process, as well as (EMERALD, 2017) p.36, and 02.02.04.04).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

Budget allocations across programme areas continue to be based on historical budgeting processes (i.e., funding cycles continue to allocate funds to programmes funded the previous cycle/historically) (EMERALD, 2017). Unless a budget bid is tabled to lodge an investment case, budget allocations will follow historical trends (EMERALD, 2017).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

As discussed previously, 16% of the South African population purchases private health care insurance (Mahlathi & Dlamini, 2015). Health insurance in South Africa is however constrained in terms of dementia-care needs as there is currently no formal long-term care insurance scheme available in the country (Joubert, 2005).

References:

Joubert, J. D. (2005). A Profile of Informal Carers in South Africa. Available from: https://repository.up.ac.za/bitstream/handle/2263/30044/00dissertation.pdf;sequence=1

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

The private healthcare market is characterised by (i) an unregulated pricing environment; (ii) healthcare expenditure that is driven by medical practitioners (i.e., via their own practice or via referral for further investigation); and as a result, (iii) a supply-induced demand that reflects a lack of competition in the market of medical scheme administrators (Competition Commission SA, 2018). Health consumers are largely disempowered with no method to assess the value of services that schemes procure on their behalf, and hence no leverage to hold managed care organisations to account (Competition Commission SA, 2018). Due to the lack of regulations in this area, consumers are also unable to choose a medical aid scheme and cover plan based on value-for-money. Consumers often trade affordability with a reduction in the range of benefits covered by scheme plans offered, where schemes compete ‘cosmetically’ on products that are available on cost-ranges, instead of value-for-money (Competition Commission SA, 2018).

References:

Competition Commission SA. (2018). Health market injuiry. Available from:  http://www.compcom.co.za/wp-content/uploads/2018/07/Executive-Summary.pdf

Out-of-pocket payments comprise approximately 29.7% of private healthcare expenses (WHO, 2011c as in (EMERALD, 2017).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

No, people sending money back to SA towards family sustaining themselves does not play an important role in financing health care.

Yes, South Africa receives funds, skills, expertise, as well as technical support from organisations outside the country. For example, Pfizer (one of the world’s leading bio-pharmaceutical companies) funds independent, non-profit organisations in South Africa to support local programmes that improve patient outcomes. This company forms part of a consortium of 20 other private healthcare companies that has partnered with the South African government’s National Department of Health to support the implementation of priority healthcare programmes (see https://www.pfizer.co.za/Communities).

South Africa is one of five top ranking countries in Africa regarding density of physicians and nurses per 1000 population. However, the country still experiences staff shortages especially in rural areas (Rispel & Padarath, 2018).

The urban-bias in skilled health professionals leaves 44% of the country’s rural population with 19% of the country’s physicians and 12% of its nurses (Rawat, 2012).

Available sources describe South Africa’s health workforce are as follows (DOH, 2011):

Table 11: Total public and private clinical professions in South Africa, 2010

Table 12: Practitioners in public sector for uninsured population

Source: (Docrat, Besada, Cleary, Daviaud & Lund, 2019).

Other sources such as published research articles in South Africa note the following for other medical categories below:

• Psychiatrists 0.1 per 100 000 people (Kalula & Petros, 2011);
• Less than 5 specialists in old-age psychiatry (Kalula & Petros, 2011);
• In 2010, 8 geriatricians were registered for a population of 4 million people of 60 years and older (Lloyd-Sherlock, 2019a).

There was no information found on the number of neurologists registered in South Africa as specialist categories are composite under the category “medical specialists” in the Department of Health and categorised broadly under “medical practitioner” with the Health Professions Council of South Africa (HPCSA).

Gerontology was removed by the South African Nursing Council (SANC) from its specialist training curriculum (Lloyd-Sherlock, 2019a), and despite being urged by the South African Human Rights Commission (SAHRC) to reconsider (SAHRC, 2015), it has not been restored to nursing curriculums.

Officials estimate that approximately 64.7% of the South African population live in rural areas (Mahlathi & Dlamini, 2015) and are served by 12% of doctors and 19% of nurses practicing in the country (DOH, 2011). There are 2.12 medical practitioners per 1000 population that comprise of 0.92 general practitioners and 0.83 specialists (per 1000) in the private sector (Competition Commission SA, 2018). It is estimated that 79% of physicians (Rawat, 2012) and 41.4% of nurses work in the private sector (DOH, 2011). Medical practitioners (i.e., general practitioners) in South Africa are found mostly in the private sector (3.76/10 000 population) compared to the public sector (3.66/10 000 population), with more noticeable imbalances in the Western Cape and Gauteng provinces with 7.64 and 7.32 per 10 0000 population found in the private sector, respectively (DOH, 2011).

References:

Competition Commission SA. (2018). Health market injuiry. Available from:  http://www.compcom.co.za/wp-content/uploads/2018/07/Executive-Summary.pdf

Docrat, S., Besada, D., Cleary, S., Daviaud, E. & Lund, C. (2019). Mental Health system costs, resources and constraints in South Africa: a national survey. Health Policy and Planning, 34, 706-719. https://doi.org/10.1093/heapol/czz085

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805

Rispel, L. ., & Padarath, A. (2018). South African Health Review 2018. Available from: http://www.hst.org.za/publications/South African Health Reviews/SAHR 2018.pdf

SAHRC. (2015). Investigative Hearing Report: Investigating hearing into systemic complaints relating to the treatment of Older Persons. Available from: http://www.sahrc.org.za/construction-site/home/21/files/SAHRC Investigative hearing report.pdf

High staff turnover rates, especially in the public sector, have been a major challenge, for which rates as high as 80% have been reported in some provinces (Rawat, 2012). Attrition rates of health care professionals that do not enter the workforce are estimated at 25% per annum and include both new graduates that struggle to find posts (lack of absorption) and those who migrate to countries with more favourable working environments (DOH, 2011). An added 6% attrition rate is expected due to retirement, change in profession and death (DOH, 2011). Factors fuelling workforce attrition include lack of available posts in the public sector, poor working conditions and lack of personal safety and security, low morale in overburdened health system, and increased risk of contracting TB (DOH, 2011; Rawat, 2012). Factors attracting South African health workforce to countries abroad includes higher remuneration, better resources and working environments, career opportunities, post-basic education, political stability, travel opportunities, and aid work (DOH, 2011).

References:

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805

Migration of health workers has been a major concern in South Africa for many years (Mahlathi & Dlamini, 2015; Rawat, 2012). There is no systematic means of monitoring and collecting data to monitor the movement of professionals within and out of the country – 2 processes that have contributed to a high turnover of specifically South African nurses (Mahlathi & Dlamini, 2015). A third of doctors (i.e., 8921) registered with the country’s regulating body, the Health Professions Council of South Africa (HPCSA), were abroad in 2006 as well as 6844 nurses, and 7642 other health professionals (DOH, 2011).

References:

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805

Yes.  South Africa provides old-age pensions to individuals who are financially needy (WHO, 2017).  All older persons are entitled to free primary healthcare, while access to hospital care is only free for those who do not have the means to pay for these services – including long term care services such as residential care services. Long-term care in South Africa reflects the legacy of Apartheid whereby availability and access to residential care services (usually in the more affluent, urban areas) cater primarily for the older white population, while promoting family care for black South Africans and positioning care for the older persons as primarily a family responsibility (Lloyd-Sherlock, 2019a).

Long-term care services in South Africa are characterised with much variation in services available between the public and private sector. The South African government funds public long-term care for older persons, for which the majority of care is through residential facilities (WHO, 2017). Public services cater only for a small portion of the older population and are largely confined to urban areas (WHO, 2017). Persons who seek residential care, need to undergo a rigorous assessment process in which only those eligible will be admitted (i.e., frail and destitute). Demand for these services is beyond what the public sector can cater for and long waiting lists are significant barriers for eligible individuals accessing long-term care (WHO, 2017). Private care limits access to services for those who can afford it, and as a typical feature of the private sector in South Africa, it is expensive and inaccessible to most South Africans. Another barrier refers to the lack of training among nurses at primary healthcare level that undermines an integrated health and social care system for older persons, especially in rural areas (Lloyd-Sherlock, 2019a).

All registered facilities can apply for subsidies for individual residents, with eligibility restricted to the frail and destitute (South African Government, 2019). Reductions in subsidy amounts paid out by the Department of Social Development have in itself become a barrier to care as they have led facilities to fail to provide services for the poor and frail individuals (who are eligible), while opting to admit more wealthier persons (who are able and can pay themselves) (Lloyd-Sherlock, 2019a). Currently DSD subsidies cover 51.9% of costs of care for frail care, with non-profit organisations left to cover the remaining costs amounting to R3800 per person (TAFTA, 2019b).

Furthermore, historical racial discriminatory practices and cultural preferences in admissions restrict racial transformation and the care of all population groups at facilities. An audit of residential care homes in 2010 revealed that: (1) Only 4% of residents across 405 homes were black; (2) 10 homes physically separated residents between white and black with clear evidence that residents were not receiving the same standard quality of care; (3) in some instances family members threatened to remove older persons should homes be integrated; and (4) that there were evidence of very little sensitivity and knowledge displayed of different religions and cultural practices (e.g., language and food preferences) (Department of Social Development, 2010; Lloyd-Sherlock, 2019a; WHO, 2017).

References:

Department of Social Development. (2010). Audit of Residential Facilities. April, 1–87. Available from: https://social.un.org/ageing-working-group/documents/FINAL%20REPORT%20DSD%20Audit%20of%20Residential%20Facilities%20April2010.pdf

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

South African Government. (2019). Old age pension. 1–7. http://www.services.gov.za/services/content/Home/ServicesForPeople/Socialbenefits/oldagegrant/en_ZA#Cost

TAFTA. (2019b). The Care “Gap.” https://www.gov.za/services/retirement-and-old-age/admission-older-persons-residential-facilities

WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care on healthy ageing. Available from: https://www.who.int/publications/i/item/9789241513388

There are an estimated 1150 residential care homes for older persons in South Africa, of which 415 are officially registered with the Department of Social Development (as mandated by the Older Person’s Act) (Mahomedy, 2017). Residential care is largely run by Non-profit organisations (NGOs) and Faith-based organisations (FBOs), and only 8 of these registered facilities are managed directly and fully subsidised by the State (Lloyd-Sherlock, 2019a; Mahomedy, 2017). All registered facilities can apply for subsidies for individual residents, and will only qualify for this financial support if the older person is frail and destitute, in need of full-time care, 60 years and older, and is a South African resident (South African Government, 2019). If the resident dies or leaves, that subsidy is lost. Reductions in the subsidy received from the Department of Social Development have led to facilities failing to provide services to poor, frail persons (who are eligible), while admitting more wealthier persons (who pay themselves) (Lloyd-Sherlock, 2019a).

There are about 4.6 million persons aged 60 years and older in South Africa. However, no data were found on the proportion of this population that is taken care of within the public long-term care system.

References:

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Mahomedy, Y. (2017). Residential Facilities for Older Persons. Who Owns Whom: African Business Information.

South African Government. (2019). Old age pension. 1–7. Available from: https://www.gov.za/services/social-benefits-retirement-and-old-age/old-age-pension

In addition to public LTCFs, there are over 1000 private long-term care facilities for older persons across South Africa (Mahomedy, 2017). These range from residential homes, retirement villages, frail care facilities, nursing homes, and step-down facilities. Private facilities offer a range of long-term care services, for example, assisted living, frail care, convalescence, as well as old age care (nursing/retirement homes) where they can buy or rent accommodation and are responsible for the full cost of their stay.

There are about 4.6 million persons aged 60 years and older in South Africa, however no data were found on the proportion of this population that makes up the private long-term care system.

References:

Mahomedy, Y. (2017). Residential Facilities for Older Persons. Who Owns Whom: African Business Information.

The South African government funds public long-term care for older persons, for which the majority of care is through residential facilities (WHO, 2017). All registered facilities can apply for subsidies for individual residents, with eligibility restricted to the frail and destitute (South African Government, 2019).

References:

South African Government. (2019). Old age pension. 1–7. Available from: https://www.gov.za/services/social-benefits-retirement-and-old-age/old-age-pension

WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care. Available from: https://www.who.int/publications/i/item/9789241513388

South Africa’s National Treasury is responsible for managing budget preparation processes, the equitable distribution of the country’s revenue raised and in so doing, the allocation and utilisation of public financial resources (National Treasury, 2019).

References:

National Treasury. (2019). Department: National Treasury. National Government of SA. Available from: https://nationalgovernment.co.za/units/view/27/department-national-treasury

See budget process under 02.02.04.03.

National departments set their budget priorities for funding annually, where Provincial departments make decisions on how the budget will be spent in the province to achieve these priorities.

See 03.02.01.04 above. When Departments reprioritise budgets to allocate to the establishment of a new service, need or requirement, the allocation process often requires that the funds are taken away from somewhere else (instead of additional funding becoming available) (EMERALD, 2017). Where major programme changes are required, Departments will engage Treasury, Cabinet and then Parliament (according to set budget cycle deadlines) for the reprioritisation of funds, plans, and allocations (see section on budget process, as well as (EMERALD, 2017) p.36).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

Budget allocations across programme areas continue to be based on historical budgeting processes (i.e., funding cycles continue to allocate funds to programmes funded the previous cycle/historically) (EMERALD, 2017). Unless a budget bid is tabled to lodge an investment case, budget allocations will follow historical trends (EMERALD, 2017).

References:

EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.

Historically, long-term care have been run by NGOs, charities and faith-based organisations (FBO’s), financed via the State (for those who are eligible) or privately (i.e., out of pocket payments) (Lloyd-Sherlock, 2019a). Medical aid schemes in South Africa cover medical events; however, long-term care such as frail care services are rarely supported (Du Preez, 2015). However, depending on the insurance product purchased, despite not covering long-term care accommodation and care in facilities, medical insurance covers any chronic medication or aids required while being frail or incapacitated (Du Preez, 2015).

References:

Du Preez, L. (2015). Frail care: What you should know. Personal Finance. Available from: https://geratecza.com/2018/07/30/frail-care-what-you-should-know-laura-du-preez/

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Medical insurance schemes in general do not support long-term care in South Africa; however, there are a few restricted products that are available to a select minority that, with a strong motivation to access this benefit, can access partial (50%) insurance for frail care (see Du Preez, 2015 for more detail).

References:

Du Preez, L. (2015). Frail care: What you should know. Personal Finance. Available from: https://geratecza.com/2018/07/30/frail-care-what-you-should-know-laura-du-preez/

There are no data found on the OOP payments for specifically LTC. However, analysis of OOP payments by medical aid schemes in South Africa (in general) revealed that for the 2013 financial year, 8.8 million people covered by a medical aid scheme spent R12.2 billion, of which 12% was on managed care, 25% on medicine, 33% on specialists, and 11% on support health professionals (Council for Medical Schemes, 2015).

References:

Council for Medical Schemes. (2015). Out of pocket payments by medical scheme members: research and monitoring (Issue February). Available from:  http://www.medicalschemes.com/files/Research Briefs/RBOPPStudy2013.pdf

No, remittances are not relevant for long-term care financing in South Africa.

There is currently a shift from emphasising the funding of State care homes, to more community-based care (e.g., provisions for caring through the home care cash benefit) (Lloyd-Sherlock, 2019b). However, this shift is slow as currently the bulk of long-term care is still focused on the funding of residential care facilities.

References:

Lloyd-Sherlock, P. (2019b). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

The main provision of long-term care (LTC) in South Africa is unpaid family care that ‘almost always’ entails the labour of female relatives (Lloyd-Sherlock, 2019a). Others include the State and dependent older persons themselves. Although there are no data to demonstrate the specific size of each of these, research suggests that there are indications that unpaid carers and older persons themselves are largely responsible for the long-term care of older persons in South Africa (Lloyd-Sherlock, 2019a).

References:

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Nurses make up the bulk of the formal LTC workforce at formal residential facilities but do not undergo specialist training to work with older persons, as well as persons living with dementia. Gerontology was removed by the South African Nursing Council (SANC) from its specialist training curriculum (Lloyd-Sherlock, 2019a), and despite being urged by the South African Human Rights Commission (SAHRC) to reconsider this, (SAHRC, 2015) it has not been restored to nursing curricula. Generally, organised LTC workers lack adequate training, have unfavourable workloads, and are unhappy with their remuneration and investment in their professional development (WHO, 2017). 

References:

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

SAHRC. (2015). Investigative Hearing Report: Investigating hearing into systemic complaints relating to the treatment of Older Persons. Available from: http://www.sahrc.org.za/construction-site/home/21/files/SAHRC Investigative hearing report.pdf

WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care. Available from: https://www.who.int/publications/i/item/9789241513388

Nurses are regulated by the South African Nursing Council (SANC); however, the bulk of caregiving for persons living with dementia are believed to rest on an informal, unregulated caring system. Recommendations to the Older Persons’ Act amendment bill have called for the registration of all caregivers of older persons with the Department of Social Development, and to practice under the supervision of a registered nurse (SAHRC, 2017b). With regards to guidelines for LTC, the Department of Social Development (DSD) published Generic Norms and Standards for Social Welfare Services, that set out the following: (1) that together with the Department of Health (DOH), practitioners should be trained and understand the dynamics of ageing and disability when rendering services to older people; and that (2) the application of this understanding should be monitored through performance management (DSD, 2011).

References:

DSD. (2011). Generic Norms and Standards for Social Welfare Services: Towards improved social services.

SAHRC. (2017b). South African Human Rights Commission Older Persons Amendment Bill. Available from: https://www.sahrc.org.za/home/21/files/SAHRC%20Submission%20on%20Older%20Persons%20Bill-%20Dept%20Soc%20Dev-%2030.6.17.pdf

Although no information was found that addresses staff vacancies within the long-term care system directly, the South African human resources for health (HRH) in general are characterised by attrition driven by factors such as poor workplace conditions, workload, workplace insecurity and morale, relationship with management, and risk to personal safety and health (DOH, 2011; Rawat, 2012). The Department of Health reported a staff turnover rate of up to 80% in some provinces (DOH, 2011; Rawat, 2012). Attrition of trained healthcare professionals are believed to be underestimated at 25% annually (excluding the 6% that is due to retirement, death and change in profession) (DOH, 2011).

References:

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805

Migration is a major challenge for the South African health system (Rawat, 2012). Due to poor working conditions (mentioned above), practitioners leave the public sector seeking employment opportunities in the private sector. In addition, health care workers are also migrating abroad due to a lack of employment opportunities and unfavourable working conditions in the public sector (DOH, 2011). Medical practitioners (8 921), nurses (6 844) and other health practitioners (7 642) are absorbed by countries like Australia, Canada, New Zealand, United Kingdom, and the United States sector (DOH, 2011).

References:

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805

The LTC workforce is characterised by poor remuneration, lack of professional development and unfavourable working conditions in terms of workload (WHO, 2017).

References:

WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care. Available from: https://www.who.int/publications/i/item/9789241513388

Volunteers are part of staff complements at facilities and service centres, with roles and numbers varying widely. In a report evaluating the services rendered to older persons in the Western Cape, a total of 13 out of 20 facilities evaluated in 2015 relied on volunteers (Baerecke, 2015). Volunteers’ responsibilities varied from assisting with administrative tasks, cooking, cleaning, driving and delivering meals to beneficiaries at home. The same report found that there were no formal requirements for staff and volunteers working at service centres for older persons, despite the Older Persons’ Act (no.13 of 2006), as well as the DSD’s Norms and Standards for acceptable levels of care for older persons requiring a formal recruitment programme with corresponding selection and appointment criteria of staff and volunteers (Baerecke, 2015), as well as training of volunteers at residential care facilities for older persons (see Older Persons’ Act, chapter 4, section 17(i)). With an overburdened system characterised by shortages of staff and volunteers, service centres do not apply strict criteria, with few admittedly providing any form of training on how to care and provide services to older persons (Baerecke, 2015). Bigger facilities generally had a more formal organisational structure, whereas smaller facilities with fewer staff relied more on informal organisational structures that generally depended on the services of volunteers.

References:

Baerecke, L. (2015). An Evaluation of Service Centres for Older Persons in the Western Cape. Commissioned by the Western Cape Department of Social Development. Available from: https://www.westerncape.gov.za/sites/www.westerncape.gov.za/files/evaluation_of_service_centres_for_older_persons_final_report_branded_cover.pdf

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

Dementia is indicated under the Department of Social Development’s Older Persons Act (no.13 of 2006), as for being responsible for developing community-based programmes aimed at prevention and promotion, as well as home-based care with regards to information, education, counselling services and care for Alzheimer’s disease and dementia (amongst others) (see section 11 (2)(c) of the Older Person’s Act, p.13) (Government Gazette, 2006). This Act also refers to dementia and Alzheimer’s disease as conditions for which services at residential facilities should be provided for, specified as care and supervision services as well as public education on ageing and dementia (see section 17 (b) and (d), p.17).

Dementia also falls under the portfolio of the Department of Health as well as the Department of Housing (Human settlements) which is the custodian of the Housing Development Schemes for Retired Persons Act, 64 of 1988 (HDSRP) (SAHRC, 2015).

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

SAHRC. (2015). Investigative Hearing Report: Investigating hearing into systemic complaints relating to the treatment of Older Persons. Available from: http://www.sahrc.org.za/construction-site/home/21/files/SAHRC Investigative hearing report.pdf

The departments of Health and Social Development.

Department of Social Development (DSD): Older persons programme (South African Older Person’s Forum (SAOPF)).

National Department of Health: Non-communicable diseases (NCDs), disability and older persons (which include eye health and palliative care) and in the Mental Health section.

No, there is none.

There is no dementia-specific national document, policy, or plan for South Africa.

Not applicable with regards to a national plan. Older Person’s Act on the other hand has been updated on the 29^th October 2006.

Not applicable, South Africa does not have a dementia-specific national plan.

Not applicable, South Africa does not have a dementia-specific national plan.

Not applicable, South Africa does not have a dementia-specific national plan.

Not applicable, South Africa does not have a dementia-specific national plan.

Not applicable, South Africa does not have a dementia-specific national plan.

Not applicable, South Africa does not have a dementia-specific national plan. In terms of the rights of older persons within the country’s broader legislative framework, older persons should be protected against abuse where failure to report or respond to elder abuse is considered a criminal offense with legal consequences (see Older Person’s Act, no. 13 of 2006, chapter 5, p.14- 19).

 References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

South Africa has an Older Person’s Act (no.13 of 2006) that broadly deals with issues pertaining to older persons and aging in general, and it mentions the care for older persons with dementia or Alzheimer’s disease.

The DSD also has an Older Person’s Programme that is responsible for coordinating services provided to older persons.

The country’s National government has also adopted the Mental Health Policy Framework and Strategic Plan (2013-2020) that promotes an integrated care model that decentralises primary care to home- and community-based services. Although there is no specific mention of dementia in this strategic plan, it is an important document (action plan) as the current focus on improving residential care services in South Africa (i.e., following the Life Health Esidimeni[1] tragedy in 2016), provides the opportunity to place Dementia on the agenda.

The White Paper on the Rights of Persons with Disabilities (Government Gazette, 09 March 2016, no.39792) briefly mentions older persons with dementia (see p.71) (White Paper on the Rights of Persons with Disabilities, 2015).

[1] The Life Health Esidimeni tragedy: Where 143 mentally incapacitated patients died due to starvation and neglect after the Gauteng Department of Health (in  a bid to save costs) terminated an outsourced care contract with Life Esidimeni (service provider) and transferred patients to NGOs etc, who were not prepared or equipped to care for these patients (see https://en.wikipedia.org/wiki/Life_Healthcare_Esidimeni_Scandal).

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

White Paper on the Rights of Persons with Disabilities, 1 (2015). https://www.gov.za/sites/default/files/gcis_document/201603/39792gon230.pdf

• Older Person’s Act (no.13 of 2006): Although it does not deal with dementia in detail, it refers to it as a consideration for community-based programmes (see section 11(2)(a), p.7); as well as service at residential facilities (see section 17(b) and (d), p.9) (Government Gazette, 2006).
• Older Person’s Programme: Covers awareness, information, education and communication programmes as part of their proposed basket of services offered to older persons (see DSD’s Older Person’s Programme concept paper) (Jordan, 2009).
• The White Paper on the Rights of Persons with Disabilities (Government Gazette, 09 March 2016, no.39792) briefly acknowledges the vulnerability of older persons with dementia to exploitation, neglect, abuse and homelessness (see p.71) (White Paper on the Rights of Persons with Disabilities, 2015). Beyond this, dementia is not specifically mentioned again – although the rights of persons with disability is addressed more broadly within a human rights framework.

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

Jordan, C. (2009). Older Person’s Programme: Concept paper. Available from: https://www.westerncape.gov.za/other/2009/10/concept_paper-_programme_older_persons.pdf

White Paper on the Rights of Persons with Disabilities, 1 (2015). https://www.gov.za/sites/default/files/gcis_document/201603/39792gon230.pdf

No, South Africa does not have dementia-specific documents operationalised.

Dementia is largely invisible in South African policies, with the exception of the Older Person’s Act. The Department of Social Development (DSD) has an underlying ‘Active Aging’ philosophy embedded in its Older person’s programme (also underlying the Older Person’s Act) that promotes the full participation of older persons in their societies, decision-making, and keeping them in their families/communities for as long as possible (Jordan, 2009). The State frames care for older persons largely as the family’s responsibility, with the threat of this philosophy equating to the promotion of (unpaid) care largely being located within the home/family. This burden of unpaid care fall especially on women with negative effects on their capacity to participate in the labour market, and positions women as being responsible for large-scale social and political challenges (Sevenhuijsen et al., 2003).

References:

Jordan, C. (2009). Older Person’s Programme: Concept paper. Available from: https://www.westerncape.gov.za/other/2009/10/concept_paper-_programme_older_persons.pdf

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

Not applicable as there is no dementia-specific policy or plan for South Africa.

As stated previously, there is no dementia-specific policy or plan for South Africa and therefore the questions for this section are not applicable.

There is no dementia-specific legislation in South Africa. For persons living with dementia, applying for curatorship or an administrator to manage affairs is the only option supported by legislation (Meyer, 2016), which is often inaccessible to the majority of South Africans due to high costs involved.

References:

Meyer. (2016). Legal positions of persons incapable of managing their own affairs.

Laws in South Africa generally protect against discrimination on the grounds of race, age, sex, gender, pregnancy, marital status, ethnic or social origin, colour, sexual orientation, disability, religion, conscience, belief, culture, language, and birth. However, provisions in South Africa are not dementia-specific.

South Africa lacks legislation that supports decision-making in persons with impaired capacity that need assisted decision-making provisions or a provision for an enduring power of attorney (Marilyn, 2015). The latter is practiced in other parts of the world; however, it does not currently form part of South African law despite being recommended in 1988 by the South African Law Commission (Meyer, 2016).

References:

Marilyn, H. (2015). Alzheimer’s – “The window of opportunity.” YE! Available from: https://youve-earned-it.co.za/finance/alzheimers-the-window-of-opportunity/

Meyer. (2016). Legal positions of persons incapable of managing their own affairs.

There are no provisions specifically for persons living with dementia. However, the South Africa Human Rights Commission (SAHRC) was established in 1995 as an institution that is mandated to support constitutional democracy and project human rights of all persons in South Africa. Violations and/or issues of concern can be lodged as complaints to the SAHRC and can be investigated in the interest of safeguarding against exploitation, violence, and abuse.

The Older Person’s Act is based in a philosophy of ‘active aging’, whereby older persons are promoted to participate and live in communities as long as possible, promoting a movement toward deinstitutionalising care (Government Gazette, 2006; Jordan, 2009). However, these legislative frameworks acknowledge that funding is still biased to residential care instead of community-based services (Jordan, 2009).

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

Jordan, C. (2009). Older Person’s Programme: Concept paper. Available from: https://www.westerncape.gov.za/other/2009/10/concept_paper-_programme_older_persons.pdf

Guided by the South African Human Rights Commission Act 40 of 2013 (South African Human Rights Commission Act 40 of 2013, 2014), the South African Human Rights Commission (SAHRC) is a body that investigates violations and conditions of human rights for all vulnerable populations in South Africa (safeguarding against exploitation, violence and abuse). The SAHRC has held an investigative hearing into systematic complaints relating to the treatment of older persons in 2015 (SAHRC, 2015). This investigation focused on stakeholder engagements, informing the public about violations brought to its attention, as well as identifying systemic issues that are in violation of older persons’ constitutional rights.

References:

SAHRC. (2015). Investigative Hearing Report: Investigating hearing into systemic complaints relating to the treatment of Older Persons. Available from: http://www.sahrc.org.za/construction-site/home/21/files/SAHRC Investigative hearing report.pdf

South African Human Rights Commission Act 40 of 2013, Pub. L. No. No.40 of 2013, 1 (2014). http://www.joasa.org.za/2013-040.pdf

South Africa has “Policy guidelines on seclusion and restraint of health care users” that guide practitioners on the use of these methods to contain only severely disturbed behaviours (i.e., where other techniques have failed) that are likely to cause harm to the self and others, including property (for more detail, see DOH, 2012).

References:

DOH. (2012). Policy Guidelines on Seclusion and Restraint of Mental Health Care users. Available from: https://www.knowledgehub.org.za/system/files/elibdownloads/2019-07/Policy%2520guidelines%2520on%2520seclusion%2520and%2520restraint%2520of%2520mental%2520health%2520care%2520users%25202012.pdf

Laws in South Africa generally protect against discrimination on the grounds of race, age, sex, gender, pregnancy, marital status, ethnic or social origin, colour, sexual orientation, disability, religion, conscience, belief, culture, language and birth. Provisions in RSA are not dementia-specific and despite recommendations and mobilisation for reform, advance directives or ‘living wills’ are not legally recognised as enforceable instructions in South Africa (Jordaan, 2011).

References:

Jordaan, L. (2011). The legal validity of an advance refusal of medical treatment in South African law (part 1). De Jure, 44(1), 32–48. http://www.scielo.org.za/pdf/dejure/v44n1/04.pdf

Legislative provisions for anti-discriminatory practices are not dementia-specific in South Africa. However, the Constitution of South Africa, chapter 2’s Bill of Rights protects the rights of all persons with safeguards against the unfair discrimination of anyone (including disability) (see section 9(3) and (4), p.5), protecting the right to human dignity (section 10, p.6), and freedom and security of the person (see section 12, p.6).

Additionally, the Older Person’s Act promotes the provision of services to older persons that includes public education on ageing including dementia (see chapter 4, section 17(d), p.9), supporting the combat of stigma and discrimination against persons living with dementia. Although it is not clear to which extent these programmes are operational and/or effective.

Legislative provisions for anti-discriminatory practices are not dementia-specific in South Africa, however, they are protected generically under the Bill of Rights, Constitution of South Africa. Refer to response above regarding generic provisions against discrimination of all persons in South Africa (section V, (c)(ii), p.38).

See response 04.05.03.03.

Policies in South Africa are situated within a familial framework that promotes a philosophy of ‘active aging’ that aims to keep older persons within the family and community setting for as long as possible. Although this philosophy to support their participation in their communities for as long as possible is commendable, it promotes a shadow discourse that locates the responsibility for care of older persons predominantly within the family, which often translates to women shouldering the burden of care at the expense of their participation in the labour market. For example, the White Paper for Social Welfare (1997) as well as the Older Persons Act no.13, 2006 (Government Gazette, 2006) draw on principles of ubuntu, framing the care of the aged as predominantly a social and moral practice that is situated within the private space of the family. Ubuntu refers to the social nature of people and defines people as people through their relations with others, and positioned within policy, it largely privatises care for the aged within the family (Sevenhuijsen et al., 2003) and, thus, influences the way in which health challenges faced by older persons are perceived and responded to, within South Africa. It also influences perceptions about how the burden of care within the family is distributed and socially sanctioned as being primarily the responsibility of a female family member. Currently in South Africa, the typical profile of caregivers to persons living with dementia is a middle aged, or older female, child or spouse (Gurayah, 2015; Khonje et al., 2015; Marais et al., 2006), positioning women as responsible for “large-scale social and political problems” (Sevenhuijsen et al.,  2003, p.311).

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Khonje, V., Milligan, C., Yako, Y., Mabelane, M., Borochowitz, K. E., & Jager, C. A. De. (2015). Knowledge , Attitudes and Beliefs about Dementia in an Urban Xhosa-Speaking Community in South Africa. Advances in Alzheimer’s Disease, 4, 21–36. https://doi.org/10.4236/aad.2015.42004

Marais, S., Conradie, G., & Kritzinger, A. (2006). Risk factors for elder abuse and neglect: brief descriptions of different scenarios in South Africa. International Journal of Older People Nursing, 1(3), 186–189. https://doi.org/10.1111/j.1748-3743.2006.00025.x

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

According to South African common law, appointing a power of attorney is only valid for as long as the principal (e.g., older person in need of support in managing their affairs) retains the legal capacity to act. Once the principal loses this legal capacity (i.e., due to mental illness, intellectual disability, or disease like dementia), the power of attorney lapses (Marilyn, 2015; Meyer, 2016), and is of no value to the person living with dementia. Despite calls for reform to legislation, the options for persons living with dementia currently exist: (1) applying to the High Court for the appointment of a curator (which is very expensive and inaccessible to most South Africans); and (2) applying for the appointment of an administrator via the Mental Health Care Act, 17 of 2002 (Meyer, 2016, pp. 4-6).

References:

Marilyn, H. (2015). Alzheimer’s – “The window of opportunity.” YE! Available from: https://youve-earned-it.co.za/finance/alzheimers-the-window-of-opportunity/

Meyer. (2016). Legal positions of persons incapable of managing their own affairs.

The South African Society of Psychiatrists (SASOP) has developed guidelines for treatment of a range of psychiatric disorders and has dedicated a chapter on Dementia. This document refers to the country’s private healthcare settings and provides guidelines for (a) the diagnosis, clinical characteristics, and course of the disease; (b) the assessment and differential diagnosis; as well as (c) treatment goals with clinical guidelines for the pharmacological and non-pharmacological treatment of dementia (Emsley et al., 2013, p.141-152). Many who rely on public healthcare do not have access to many of the pharmacological treatments recommended by these guidelines (Emsley et al., 2013) as the public sector is characterised by constrained and limited resources and lack of specialist treatments and approaches particular to dementia.

In the public sector, there are also Standard Treatment Guidelines available from the National Department of Health that provide guidelines for the treatment of dementia and focuses primarily on pharmacological/medicine treatment (National Department of Health, 2020).

South Africa has a National Strategic plan for nurse education, training and practice (DOH, 2016), and approved competencies for nursing to provide care throughout the lifespan. However, these are not dementia-specific and support generic models for care at hospitals and other facilities.

References:

DOH. (2016). The National Strategic Plan for Nurse Education, Training and Practice.

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

National Department of Health. (2020). Primary healthcare Standard Treatment Guidelines And Essential Medicines List (7th ed). Available from: https://www.knowledgehub.org.za/elibrary/primary-healthcare-standard-treatment-guidelines-and-essential-medicines-list-7th-edition

These guidelines are developed by the SASOP, to be utilised nationally by practicing psychiatrists within the private sector only.

Yes, they are.

Yes, see p.150 of Emsley et al., (2013).

 References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

Yes, see p.143 of Emsley et al., (2013).

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

Yes, see p.145-150 of Emsley et al., (2013) for pharmacological and non-pharmacological treatments.

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

The SASOP guideline briefly mentions accommodation and level of supervision required after diagnosis and refers the reader to seek support from primary care facilities, social clubs, senior centres, day-care and respite-care centres, as well as the NGO sector (Emsley et al., 2013). However, there is no mention in the SASOP guideline of information regarding questions 04.06.04.05-04.06.04.08 below. The Department of Health Standard treatment guidelines at hospital level mentions family counselling and support in a one-line statement under general measures and provide guideline for medication in palliative care generally (not dementia-specific) (DOH, 2018; Maartens et al., 2015).

References:

DOH. (2018). Standard Treatment Guidelines And Essential Medicines List for South Africa: Primary healthcare level. https://doi.org/10.1017/CBO9781107415324.004

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

Maartens, G., Benson, F., Blockman, M., Clark, C., Bamford, L., Bera, R., Brits, H., & Dheda, M. (2015). Standard Treatment Guidelines and Essential Medicines List for South Africa: Hospital Level. Available from: https://extranet.who.int/ncdccs/Data/ZAF_D1aia_Hospital%20level%20(Adult)%202015.pdf

No.

No.

No.

No.

The private sector guidelines discussed above were developed by the South African Society of Psychiatrists (SASOP) and published in 2013.

These guidelines currently refer to the private healthcare setting in South Africa with the expectation that various stakeholders (and hopefully policy makers and administrators) will make use of them. Practitioners are expected to use guidelines with caution and continue to be critical of approaches, maintaining their own level of expertise and keeping abreast of developments of evidence-based approaches within the field (Emsley et al., 2013).

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

South Africa is a multi-cultural country with a myriad of beliefs and practices. The use of traditional medicine and healers is a socially accepted practice amongst some cultures in the country, with the belief that the cause of some conditions/diseases/misfortune (especially mental, emotional and neurological conditions) is social (Mkhonto & Hanssen, 2018). Traditional healers are believed to be able to diagnose and treat conditions caused by social misconduct, spirits, spells and witchcraft where biomedicine is unable to ‘identify’ and treat (Audet et al., 2017). Traditional healers speak the local languages of the person seeking help, they often live within close proximity, they are easily available for consultation and they are believed to spend more time explaining diagnoses, causes and treatments to patients – hence preferred over mainstream biomedical approaches or used in conjunction with bio-medicine (Audet et al., 2017). A review of studies on plants used to treat Alzheimer’s disease in South Africa has found the following plants used to treat memory loss in the form of aqueous or ethanol extracts (Stafford et al., 2008), (see p. 533 for more detail):

• Malva parviflora (leaves),
• Boophone disticha (L.f.) Herb. (leaves and bulbs),
• Albizia adianthifolia (Schumach.) W. Wright (stem bark),
• Albizia suluensis Gerstner (root bark) and
• Crinum moorei f. (bulbs) for acetylcholinesterase (AChE) inhibitory activity.

References:

Audet, C. M., Ngobeni, S., Graves, E., & Wagner, R. G. (2017). Mixed methods inquiry into traditional healers’ treatment of mental, neurological and substance abuse disorders in rural South Africa. PLoS ONE, 12(2), 1–14. https://doi.org/10.1371/journal.pone.0188433

Mkhonto, F., & Hanssen, I. (2018). When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. Journal of Clinical Nursing, 27(1–2), e169–e176. https://doi.org/10.1111/jocn.13909

Stafford, G. I., Pedersen, M. E., van Staden, J., & Jäger, A. K. (2008). Review on plants with CNS-effects used in traditional South African medicine against mental diseases. Journal of Ethnopharmacology, 119(3), 513–537. https://doi.org/10.1016/j.jep.2008.08.010

Support services for persons living with dementia in South Africa are largely provided by the non-governmental organisation (NGO) sector, for example Alzheimer’s South Africa (ASA) and Dementia-SA.

There is no coordinated care, resource, or planning mechanism across departments in the government for persons living with dementia in South Africa. Care coordination services and support for persons living with dementia rely on the NGO sector. Government departments are not able to hold each other accountable for their relevant responsibilities.

Not applicable, see responses 04.07.01 and 04.07.02.

Not applicable, see responses 04.07.01 and 04.07.02.

Not applicable, see responses from 04.07.01 to 04.07.04.

Not applicable, see responses from 04.07.01 to 04.07.05.

Not applicable, see responses from 04.07.01 to 04.07.06.

The South African Human Rights Commission (SAHRC) has submitted their recommendations (SAHRC, 2017b) on the Older Persons Amendment Bill in June 2017 (Older Persons Act: Older Persons Amendment Bill, 2017: Comments Invited, 2017). These recommendations include revisions, for example, of (1) definitions, (2) registration clauses added with regards to assisted living facilities, and (3) registration of caregivers to be supervised by a registered nurse. Recommendations for policy changes are related to protecting the rights and care of older persons in general and not dementia-specific. Based on this review, it is unclear if these recommendations have been accepted and if there are expected changes to policies related to the care of older persons (and dementia) in the next 5 years.

References:

Older Persons Act: Older Persons Amendment Bill, 2017: Comments invited, 1 (2017). www.gpwonline.co.za

SAHRC. (2017b). South African Human Rights Commission Older Persons Amendment Bill. Available from: https://www.sahrc.org.za/home/21/files/SAHRC%20Submission%20on%20Older%20Persons%20Bill-%20Dept%20Soc%20Dev-%2030.6.17.pdf

No, there is no evidence found.

Not applicable.

Not applicable.

Not applicable.

Yes. Alzheimer’s South Africa hosts information talks (communities and radio), awareness campaigns and educational workshops annually. Other campaigns are targeted during September every year to coincide with World Alzheimer’s month’s awareness events, for example, an online art exhibition (see https://www.iol.co.za/capetimes/news/online-art-exhibition-to-raise-alzheimers-awareness-17161349), media releases, and radio talks.

According to the information available in the desk review, Alzheimer’s South Africa, and Dementia-SA (dementia-specific NGOs in South Africa) do not embark on a national-scale public awareness campaign. However, they do engage in occasional radio talks, and contribute to press-releases that raises awareness about dementia.

ASA volunteers received training on dementia.

No evidence found online.

No evidence found online.

No evidence found online.

No evidence found online.

No evidence found online.

No evidence found online.

No evidence found online.

Very few studies in South Africa directly deal with cultural/societal perceptions of dementia; however, there is agreement that dementia is largely viewed as a normal part of aging (De Jager et al., 2017; Gurayah, 2015; Kalula et al., 2010). Research in South Africa tends to agree that awareness of dementia as a medical condition is poor (De Jager et al., 2017; Kalula & Petros, 2011; Mkhonto & Hanssen, 2018; Prince et al., 2007; Ramlall et al., 2013). Persons living with dementia as well as their caregivers/families are often stigmatised  and prone to experience social rejection or isolation (Gurayah, 2015; Marais et al., 2006; Mkhonto & Hanssen, 2018; Pretorius et al., 2009).

A small study (N=100) in Khayelitsha examined the knowledge, attitudes, and beliefs about dementia among this urban isiXhosa speaking community in the Western Cape Province and found that only 10% of participants reportedly knew what dementia was (Khonje et al., 2015). Other perceptions of dementia included believing that it is a punishment from God (14%) or from the ancestors (18%), that it is a curse or due to witchcraft (28%), and that traditional healers can cure dementia (15%) (Khonje et al., 2015). In South Africa, there are reports supporting the belief that the origin of misfortune is social and that in certain African cultures, ‘witchcraft’ is responsible for the cause of tragedies, accidents, loss or destruction of property, illness, unexpected death, infertility, social disputes as well as drastic weather conditions (Goloova-Mutebi, 2005 as in Mkhonto & Hanssen, 2018). The labelling of persons as ‘witches’ in South Africa is gendered, often leaving women from lower social status in communities stigmatised and shunned (Mkhonto & Hanssen, 2018). Particularly older women that live alone, or widowed, that are of darker complexions are reportedly at risk of being labelled as ‘witch’ as they are seen as possessing the power to “blend into the night to do their evil deeds” (Benade, 2012, p.275).

Although some research (Benade, 2012; De Jager et al., 2015; Khonje et al., 2015; Law, 2012; Mkhonto & Hanssen, 2018) as well as media and other reports (GADAA, 2017; Health24, 2018a; SAPRA, 2014) refer to the ‘tendency’ of witchcraft allegations to result in violence and even homicide of older persons (especially older women) (Crime et al., 2018), the study in Khayelitsha found that, despite 19% of participants indicating that they know of persons living with dementia who had been abused, none of the motivations for this abuse was reportedly related to allegations of witchcraft (Khonje et al., 2015). Further research is needed to determine the extent to which these socio-cultural beliefs are placing older persons at risk of isolation, violence, and abuse.

A recent study (Mkhonto & Hanssen, 2018) explored the link between cultural beliefs and dementia care, interviewing family members and nurses caring for persons living with dementia in nursing homes in Tswhane, South Africa. They found that the participants (N=7) believed that the behavioural and psychosocial symptoms associated with dementia are viewed with suspicion and fear by certain communities, resulting in these persons living with dementia being labelled as a ‘witch’ or ‘bewitched’, socially rejected and isolated, subsequently stigmatised and reportedly vulnerable to violent attacks from the community. These perceptions prevent persons living with dementia and their families from seeking care and treatment as well as psychosocial support (Mkhonto & Hanssen, 2018).

A lack of understanding of dementia has negative consequences for both persons living with dementia and their families, as well as influencing their care (Mkhonto & Hanssen, 2018). The belief of especially female persons with dementia as ‘witches’ within certain communities are identified as an important consideration when understanding the effects of stigma in South Africa. However, further evidence is needed to show the extent to which this is a problem.

References:

Benade, S. (2012). Support services for people suffering from dementia in the rural areas of Kwa-Zulu Natal, South Africa. Dementia, 11(2), 275–277. https://doi.org/10.1177/1471301212437458

De Jager, C.A., Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

GADAA. (2017). No Words for Dementia : Alzheimer ’ s Disease International highlights dementia epidemic in Africa. Global Alzheimer’s and Dementia Action Alliance.

Crime, E., Platzer, M., Project, F., Council, A., Nations, U., Chapter, C., & Online, F. (2018). Victimization of Elderly Women , “ Witches ,” and Widows. 1–6.

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Health24. (2018a). Alzheimer’s: ‘ They thought my mother was a witch and wanted to burn her. Available from: https://www.health24.com/Medical/Dementia/Alzheimers/alzheimers-they-thought-my-mother-was-a-witch-and-wanted-to-burn-her-20180413

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

Khonje, V., Milligan, C., Yako, Y., Mabelane, M., Borochowitz, K. E., & Jager, C. A. De. (2015). Knowledge , Attitudes and Beliefs about Dementia in an Urban Xhosa-Speaking Community in South Africa. Advances in Alzheimer’s Disease, 4, 21–36. https://doi.org/10.4236/aad.2015.42004

Law, L. (2012). Challenges Facing Older Persons. 1–6.

Marais, S., Conradie, G., & Kritzinger, A. (2006). Risk factors for elder abuse and neglect: brief descriptions of different scenarios in South Africa. International Journal of Older People Nursing, 1(3), 186–189. https://doi.org/10.1111/j.1748-3743.2006.00025.x

Mkhonto, F., & Hanssen, I. (2018). When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. Journal of Clinical Nursing, 27(1–2), e169–e176. https://doi.org/10.1111/jocn.13909

Pretorius, C., Walker, S., & Heyns, P. M. (2009). Sense of coherence amongst male caregivers in dementia: A South African perspective. Dementia, 8(1), 79–94. https://doi.org/10.1177/1471301208099046

Prince, Martin, Ferri, C. P., Acosta, D., Albanese, E., Arizaga, R., Dewey, M., Gavrilova, S. I., Guerra, M., Huang, Y., Jacob, K. S., Krishnamoorthy, E. S., McKeigue, P., Rodriguez, J. L., Salas, A., Sosa, A. L., Sousa, R. M. M., Stewart, R., & Uwakwe, R. (2007). The protocols for the 10/66 dementia research group population-based research programme. BMC Public Health, 7(generally 2000), 1–18. https://doi.org/10.1186/1471-2458-7-165

Ramlall, S., Chipps, J., Pillay, B., & Bhigjee, A. (2013). Mild cognitive impairment and dementia in a heterogeneous elderly population: Prevalence and risk profile. African Journal of Psychiatry (South Africa), 16(6), 456–465. https://doi.org/10.4314/ajpsy.v16i6.58

SAPRA. (2014). Witch-hunts in South Africa. Available from: https://www.paganrightsalliance.org/remember-their-names/

Research on dementia in South Africa is limited. Currently there is no research to date that provides evidence that perceptions regarding dementia are changing. News reports include articles that attempt to raise awareness of dementia (for example see https://www.dailymaverick.co.za/article/2018-09-21-living-with-alzheimers-memory-loss-is-not-a-normal-part-of-ageing/; and https://www.news24.com/tags/topics/dementia?mobile=true) but these do not suggest that perceptions of dementia in South Africa are shifting. In fact, these articles are calling for an increase in awareness and publishing media that increase knowledge and understanding of dementia.

Research suggests that socio-cultural factors play an important role in the understanding of and responding to dementia, and due to the ensuing stigma, results in the social rejection and isolation of people living with dementia and their families/caregivers. African cultures, along with other developing contexts, are characterised by a strong sense of familial responsibility that tend to respond to the care of persons living with dementia as a personal or family matter, rather than seeking help from formal health-care structures (Mukadam et al., 2011).

This sense of familial responsibility is mirrored in governmental approaches to the care of the aged. For example, the White paper for Social Welfare (1997) as well as the Older Persons Act no.13, 2006 (Government Gazette, 2006) draws on principles of ubuntu, framing the care of the aged as predominantly a social and moral practice that is situated within the private space of the family. Ubuntu refers to the social nature of people and defines people as people through their relations with others and positioned within policy. It largely privatises care for the aged within the family (Sevenhuijsen et al., 2003) and thus influences the way in which health challenges faced by older persons are perceived, and responded to, within South Africa. It also influences perceptions about how the burden of care within the family is distributed and socially sanctioned as primarily the responsibility of a female family member. Currently in South Africa, the typical profile of caregivers to persons living with dementia is a middle aged, or older female, child or spouse (Gurayah, 2015; Khonje et al., 2015; Marais et al., 2006), positioning women as responsible for “large-scale social and political problems” (Sevenhuijsen et al., 2003 p.311).

There is an emerging debate about how dementia should be positioned within South Africa: as a mental illness, a chronic medical condition (i.e., brain disease), or a disability:

1. Dementia as a mental illness: Since dementia is understood elsewhere as a brain disorder that affects cognition, it is commonly viewed as a mental illness that influences the thinking, the memory, and the executive functions of the brain (Alzheimer’s society, 2015). In South Africa it is unclear where exactly dementia is situated. The only treatment guidelines for dementia in the country was published by the South African Society of Psychiatrists, guiding private sector practitioners (psychiatrists) on the pharmacological- as well as non-pharmacological responses to dementia care. Mixed understandings of where dementia is situated is also evident within the Department of Health itself, where district level officials refer to it as a mental health condition that falls under the jurisdiction of the Directorate of Mental Health, where officials at national level are recognising dementia as a non-communicable disease.
2. Dementia as a (chronic) medical condition/disease: Dementia is poorly understood in South Africa (Prince et al., 2016b), especially amongst more rural communities (Kalula & Petros, 2011; Khonje et al., 2015; Mkhonto & Hanssen, 2018) and often seen as a normal part of aging (De Jager et al., 2017; Gurayah, 2015; Kalula et al., 2010). The behaviour symptoms associated with dementia are often viewed as mental illness and not as a medical condition that manifests cognitively and behaviourally. Positioning dementia as a mental illness subjects persons living with dementia (and their families) to stigmatisation by communities and subsequently curtails their health-seeking behaviour. There is an ongoing discussion on medical aid schemes in South Africa to recognise dementia as a chronic medical condition/disease, and, therefore, include it on the prescribed minimum benefits to allow families and persons living with dementia (i.e., those who have access to medical schemes), to be covered for the high cost of care (Gruber, 2016).
3. Dementia as a cognitive disability: Persons living with dementia associated with civil society movements (i.e., Dementia Alliance International and Human Rights Consultant, Professor Peter Mittler, at the Global Disability Summit of 2018) questioning why dementia is not recognised as a cognitive disability and share the same rights as other disabled persons under the United Nations Convention on Rights of Persons with Disability (Mittler, 2018). It calls for a shift away from locating it within the mental health sphere and locating it as a cognitive disability that affects persons living with dementia (and their carers) as a long-term condition. Dementia-SA (NGO) is also working closely with the Department of Social Development to recognise dementia as a ‘hidden’ disability and shift current perceptions on dementia within the government.

References:

Alzheimer’s Association. (2015). Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia 2015;11(3)332; Accessed at https://www.alz.org/media/documents/2015factsandfigures.pdf on 19 July 2022

De Jager, C.A., Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

Gruber, J. (2017). Delivering public health insurance through private plan choice in the United States. Journal of Economic Perspectives, Vol 31 (4); p3-22.

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

Khonje, V., Milligan, C., Yako, Y., Mabelane, M., Borochowitz, K. E., & Jager, C. A. De. (2015). Knowledge , Attitudes and Beliefs about Dementia in an Urban Xhosa-Speaking Community in South Africa. Advances in Alzheimer’s Disease, 4, 21–36. https://doi.org/10.4236/aad.2015.42004

Marais, S., Conradie, G., & Kritzinger, A. (2006). Risk factors for elder abuse and neglect: brief descriptions of different scenarios in South Africa. International Journal of Older People Nursing, 1(3), 186–189. https://doi.org/10.1111/j.1748-3743.2006.00025.x

Mittler, P. (2018) cited at the Global Disability Summit; cited in DAI at the 2018 Global Disability Summit in London. https://www.dementiaallianceinternational.org/tag/professor-peter-mittler/ – accessed on 19 July 2022

Mkhonto, F., & Hanssen, I. (2018). When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. Journal of Clinical Nursing, 27(1–2), e169–e176. https://doi.org/10.1111/jocn.13909

Mukadam, N., Cooper, C., & Livingston, G. (2011). A systematic review of ethnicity and pathways to care in dementia. International Journal of Geriatric Psychiatry, 26(1), 12–20. https://doi.org/10.1002/gps.2484

Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016b). World Alzheimer Report 2016 Improving healthcare for people living with dementia. Coverage, Quality and costs now and in the future. In Alzheimer’s Disease International (ADI). https://doi.org/10.13140/RG.2.2.22580.04483

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

ASA’s training of volunteers: Dementia Friends champions are trained about the personal impact of dementia on the person and the family, what can be done to support families who are living with dementia. Training includes the following: 1) about dementia; 2) how it affects people; 3) practical actions that Dementia Friends can take to help persons living with dementia in their community; 4) how to run Dementia Friends information sessions; and 5) inspire others to become Dementia Friends as well.

No evidence found.

The South African government has adopted initiatives to create enabling environments for persons with disabilities, for example, it has built environments, other infrastructures, assistive technologies as well as policies and laws in place to facilitate their socio-economic development. However, these initiatives are currently not dementia specific. Initiatives that include persons living with dementia stem from the NGO-sector, for example, a Memory Café was established in the Hout Bay area (near Cape Town) to create a safe, welcoming space for persons living with dementia This initiative is responding to a need to create social opportunities for persons living with dementia and their families and it hosts sessions that aim to listen, provide support and share ideas about increasing the inclusivity of public spaces (see article on radio talk held on Cape Talk on 10 April 2019 and listen to podcast at http://www.capetalk.co.za/articles/344420/new-cape-town-cafe-spot-a-safe-space-for-people-living-with-dementia).

No, there are no surveillance data on persons living with dementia and their caregivers in South Africa. Therefore, the questions from 06.01.01. to 06.01.05. are not applicable.

The prevalence of dementia in Sub-Saharan Africa and South Africa has not been established conclusively (Kalaria et al., 2008; Kalula et al., 2010). From 2006 to 2050, South Africa’s older population is projected to increase from 3.3 to 6.4 million people (i.e., from 7% to 13% of the country’s population). The World Alzheimer’s report (2015) estimated that in 2015 about 186 000 people were living with dementia in South Africa, for which nearly 75% were women (Prince et al., 2016a). This number is expected to increase to 275 000 by 2030 (Prince et al., 2016a).

Although there are a few research studies on dementia in Sub-Saharan Africa, there is currently no nationally representative prevalence data available for South Africa (De Jager et al., 2017), with large scale community studies needed to confirm the prevalence of dementia (Ramlall et al., 2013). Existing research in South Africa has, for example, investigated the knowledge, attitudes, and beliefs about dementia in an urban Xhosa speaking community (Khonje et al., 2015), has examined the caregiving experiences for people with dementia (Gurayah, 2015; Pretorius et al., 2009), and has explored the consequences of stigma and related socio-cultural beliefs regarding people with dementia (Mkhonto & Hanssen, 2018).

Smaller studies have provided estimations of prevalence of dementia in South Africa. In 2010, a study examined all patients (N=305) at the UCT/Groote Schuur Hospital memory clinic between 2003 and 2008. The study evaluated the role and function of this facility in a resource-limited context and found that family members cared for 79% of patients (of which 74% lived with a spouse or an adult child), whereas 6% were institutionalised and 10% lived alone (Kalula et al., 2010). Depression was associated with 15% of patients and although Alzheimer’s disease was still the most common, when compared to other countries, vascular dementia (VaD) had a higher prevalence in South Africa (Kalula et al., 2010). This finding is suggestive of a high prevalence of stroke and associated risk factors that are not adequately addressed by the current health care systems (Kalula et al., 2010).

Working with the 10/66 Group, the University of the Free State examined an urban black community and reported a higher than expected 6% prevalence rate for persons 65 years and older (De Jager et al., 2015), while previous rates for Southern Africa have estimated 2.1% (Radebe, 2010). A smaller household study (N=100) in another urban, isiXhosa-speaking community in the Western Cape (Khayelitsha) found that 22% of households had a person over the age of 60 living in the area, of which 10% reported having more than one over the age of 60 (Khonje et al., 2015).

The first large screening study for dementia in South Africa was conducted in a low income, rural isiXhosa speaking population in the Amatole district, within the Eastern Cape province (De Jager et al., 2017). This community is characterised by subsistence farming of maize, with local diets supplemented with vegetables and occasional meat. A total of 1394 households were screened in 3 clinic catchment areas and estimated a prevalence of 11% for 65 years and older, indicating a higher than expected burden of dementia in South Africa, than the estimated 4% indicated by the World Alzheimer Report (2016) (De Jager et al., 2017). For those screened as dementia-positive participants, 69.8% were female and 69.8% had less than 7 years education. Dementia-positive participants were twice as likely to report any depressive symptoms and 17.1% of these reported on all 3 out of 3 (EURO-D questions) symptoms of depression.

References:

De Jager, C. A., Joska, J. A., Hoffman, M., Borochowitz, K. E., & Combrinck, M. I. (2015). Dementia in rural South Africa: A pressing need for epidemiological studies. South African Medical Journal, 105(3), 189–190. https://doi.org/10.7196/SAMJ.8904

De Jager, C.A., Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Kalaria, R. N., Maestre, G. E., Arizaga, R., Friedland, R. P., Galasko, D., Hall, K., Luchsinger, J. A., Ogunniyi, A., Perry, E. K., Potocnik, F., Prince, M., Stewart, R., Wimo, A., Zhang, Z. X., & Antuono, P. (2008). Alzheimer’s disease and vascular dementia in developing countries: prevalence, management, and risk factors. The Lancet Neurology, 7(9), 812–826. https://doi.org/10.1016/S1474-4422(08)70169-8

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

Khonje, V., Milligan, C., Yako, Y., Mabelane, M., Borochowitz, K. E., & Jager, C. A. De. (2015). Knowledge , Attitudes and Beliefs about Dementia in an Urban Xhosa-Speaking Community in South Africa. Advances in Alzheimer’s Disease, 4, 21–36. https://doi.org/10.4236/aad.2015.42004

Mkhonto, F., & Hanssen, I. (2018). When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. Journal of Clinical Nursing, 27(1–2), e169–e176. https://doi.org/10.1111/jocn.13909

Pretorius, C., Walker, S., & Heyns, P. M. (2009). Sense of coherence amongst male caregivers in dementia: A South African perspective. Dementia, 8(1), 79–94. https://doi.org/10.1177/1471301208099046

Prince, Martin, Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016a). World Alzheimer Report 2016: Improving healthcare for people living with dementia. In Alzheimer’s Disease International (ADI). https://doi.org/10.13140/RG.2.2.22580.04483

Ramlall, S., Chipps, J., Pillay, B., & Bhigjee, A. (2013). Mild cognitive impairment and dementia in a heterogeneous elderly population: Prevalence and risk profile. African Journal of Psychiatry (South Africa), 16(6), 456–465. https://doi.org/10.4314/ajpsy.v16i6.58

According to the Global Burden Disease Study (2017), the South Africa’s years of life lost due to Alzheimer’s disease and related dementias for 2016 were estimated at 86571,76 person-years (0.41%) (Global Burden Disease Study, 2017c).

References:

Global Burden Disease Study. (2017c). Global Burden Disease study: Results Tool (YLLs).

According to the Global Burden Disease Study (2017), the South Africa’s years lived with disability due to Alzheimer’s disease and related dementias for 2016 were estimated at 24175.92 person-years (0.39%) (Global Burden Disease Study, 2017b).

References:

Global Burden Disease Study. (2017b). Global Burden Disease study: Results Tool (YLDs).

There are limited data published with regards to the prevalence of dementia in Africa as well as South Africa (De Jager et al., 2017; Meyer et al., 2016). Although prevalence is generally expected to be higher in urban areas, a rural community study in Amatole District (Kwazulu-Natal) found a higher than expected prevalence rate of 11%, where the World Alzheimer’s report (2016) estimated 4% (De Jager et al., 2017). Modelled prevalence estimated from the Global Burden Disease Study (2017) indicates 167424,23 (0.32%) persons living with dementia in 2016 (Global Burden Disease Study, 2017a). Although no population-based dementia prevalence rates exist for the urban–rural geographical areas, national statistics indicate that the 65.1% of the country’s population over the age of 60 live in urban areas (StatsSA, 2015b). When disaggregated by population group, the dominance of the urban bias holds true for all population groups with the exception (although marginal) of the black African population, where most older persons (50.6%) for this group were found in rural areas in 2016 (StatsSA, 2015b).

References:

De Jager, C.A., Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

Global Burden Disease Study. (2017a). Global Burden Disease study: Results Tool (Prevalence). Available from: https://ghdx.healthdata.org/gbd-2017

Meyer, J. C., Harirari, P., & Schellack, N. (2016). Overview of Alzheimer ’ s disease and its management. South African Pharmaceutical Journal, 83(9), 48–56.

StatsSA. (2015b). Vulnerable Groups Series I: The Social Profile of Youth, 2009–2014. In StatsSA (Vol. 03, Issue 03). Available from:  http://www.statssa.gov.za/?p=6395%5Cnhttp://www.statssa.gov.za/?p=6135

Specific age of onset data is not found for South Africa; however, globally, age is identified as an important risk factor with the risk of developing dementia reported by the 10/66 Group as increasing for those 60 years and over in 21 Global Burden of Disease regions (De Jager et al., 2017; Prince et al., 2003).

References:

De Jager, C.A., Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

Prince, M, Acosta, D., Chiu, H., Scazufca, M., & Varghese, M. (2003). Dementia diagnosis in developing countries: a cross-cultural validation study. The Lancet, 361, 909–917. https://doi.org/10.1016/S0140-6736(03)12772-9

This varies with type of dementia and the age of the person when symptoms are noticed; however, on average, the life expectancy is believed to vary between 8 to 10 years from when the first symptoms are observable (The Alzheimer Society of Ireland, 2019).

References:

The Alzheimer Society of Ireland. (2019). What is Dementia and Alzheimer’s? The Alzheimer Society of Ireland. Available from: https://alzheimer.ie/about-dementia/what-is-dementia-and-alzheimers/

No nationally representative data on the prevalence or incidence of dementia. However, a smaller dementia prevalence study conducted in a rural, isiXhosa-speaking area in South Africa found no association with sex (De Jager et al., 2017). No representative data available to report on different ethnic groups (as study mentioned here did not have ethnic representativeness in sample).

References:

De Jager, C.A., Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

See 06.02.06.

Due to the country’s high HIV/AIDS prevalence, HIV-associated dementia (HAD) is a potentially significant sub-group of dementias. The prevalence for HIV-Associated Neurocognitive Disorders (HAND) is estimated to range between 15-60% (between settings) (Mogambery et al., 2017).

References:

Mogambery, J. C., Dawood, H., Wilson, D., & Moodley, A. (2017). HIV-associated neurocognitive disorder in a KwaZulu-Natal HIV clinic: A prospective study. Southern African Journal of HIV Medicine, 18(1), 1–5. https://doi.org/10.4102/sajhivmed.v18i1.732

There is limited data published with regards to the prevalence of dementia in Africa as well as South Africa (De Jager et al., 2017; Meyer et al., 2016). Although prevalence is generally expected to be higher in urban areas, a rural community study in Amatole District (Kwazulu-Natal) found a higher than expected prevalence rate of 11%, where the World Alzheimer’s report (2016) estimated 4% (De Jager et al., 2017). Although no population-based dementia prevalence rates exist for the urban–rural geographical areas, national statistics indicate that the 65.1% of the country’s population over the age of 60 live in urban areas (StatsSA, 2015b). When disaggregated by population group, the dominance of the urban bias holds true for all population groups with the exception (although marginal) of the black African population, where most older persons (50.6%) for this group were found in rural areas in 2016 (StatsSA, 2015b).

References:

De Jager, CA, Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

Meyer, J. C., Harirari, P., & Schellack, N. (2016). Overview of Alzheimer ’ s disease and its management. South African Pharmaceutical Journal, 83(9), 48–56.

StatsSA. (2015b). Vulnerable Groups Series I: The Social Profile of Youth, 2009–2014. In StatsSA (Vol. 03, Issue 03). Available from:  http://www.statssa.gov.za/?p=6395%5Cnhttp://www.statssa.gov.za/?p=6135

In South African media there are examples of journalistic articles written to raise awareness about Alzheimer’s disease and Dementia, as well as reducing the risk of dementia (see

– https://theconversation.com/why-special-steps-need-to-be-taken-to-reduce-the-risk-of-dementia-in-africa-47533;

– https://www.health24.com/Medical/Dementia/News/9-ways-to-reduce-the-risk-for-dementia-20170725;

– https://www.health24.com/Medical/Dementia/Overview/Managing-dementia-20120721;

– https://www.health24.com/Medical/Dementia/Overview/causes-of-dementia-20160303-2) (Health24, 2016; 2017; 2018a; Hugo, 2016; De Jager, 2019). These media coverages are often supported by the NGOs and academic sectors, with no formal campaign for reducing risks coming from the government sector.

References:

Health24. (2016). Causes of Dementia. Health24. Available from: https://www.news24.com/health24/Medical/Dementia/Overview/causes-of-dementia-20160303-2

Health24. (2017). 9 ways to reduce the risk for dementia. News24. Available from: https://www.health24.com/Medical/Dementia/News/9-ways-to-reduce-the-risk-for-dementia-20170725

Health24. (2018a). Alzheimer’s: ‘ They thought my mother was a witch and wanted to burn her. Available from: https://www.health24.com/Medical/Dementia/Alzheimers/alzheimers-they-thought-my-mother-was-a-witch-and-wanted-to-burn-her-20180413

Hugo, F. (2016). Managing dementia. Health24. Available from: https://www.health24.com/Medical/Dementia/Overview/Managing-dementia-20120721

De Jager, C. (2019). Why special steps need to be taken to reduce the risk of dementia in Africa. The Conversation. https://theconversation.com/why-special-steps-need-to-be-taken-to-reduce-the-risk-of-dementia-in-africa-47533

• Age

In line with international research, dementia risk in South Africa was associated with older age (De Jager et al., 2017; Kalula & Petros, 2011). The landscape of age-associated risk of dementia with older age is however changing. HIV-associated dementia (HAD) is considered to be the most common cause of dementia among adults 40 years and younger (Rowland and Pedley, 2010 as in Robbins et al., 2011; Kalaria et al., 2008). Emerging research in South Africa on developing appropriate screening for HIV-associated dementia (HAD) has found that 80% of the study’s 65 participants were on average 40 years of age (range 19-68 years; SD 9.26) and screened positive for HAD (Robbins et al., 2011). Therefore, the expected risk of dementia with older age is changing with the sequelae of the high HIV/AIDS prevalence in South Africa.

• HIV/AIDS

Depending on the progression of the disease, 30-60% of people living with HIV (PLWH) will manifest some degree of neurocognitive disturbance, whereas an estimated 50% will develop a HIV-associated neurocognitive disorder (HAND) (Fogel et al., 2014; Grant, 2008). HIV-associated dementia (HAD) is recognised as the most severe form of HAND and identified as the most common neurocognitive consequence of untreated HIV infection (Robbins et al., 2011).

In a study validating the International HIV Dementia Scale in South Africa, a sample of 96 HIV-positive individuals who are not receiving ART, displayed greater impairment on a range of neuropsychological tests (including HAD) when compared to HIV-negative controls (Joska et al., 2011). Another study examining the rates of positive HIV-associated dementia (HAD) screens at a general medical clinic in the Western Cape Region found that in a sample of 65 HIV-positive participants, 80% (n=52) were at risk for having HAD (Robbins et al., 2011). These participants have been diagnosed with the HIV virus for just over 5 years and have been on ART for more than 3 years, with less than 90% adherence. Majority of participants were female (65%) and ranged between the ages of 19 and 68 (mean 40 yrs, SD 9.26). Significant relationships were found with known associated risk factors for HAD such as low CD4 count, the presence of an alcohol disorder, and a current alcohol dependence disorder (Robbins et al., 2011). Therefore, suggesting that HIV-positive South Africans on ART, with low CD4 count and adherence issues may be at a very high risk for developing HAD.

• Family history

The aetiology of AD/dementia are not fully understood yet; however, generic factors such as the apolipoprotein E (APOE) epsilon 4 (e4) allele) and having a family history of dementia has been linked to the development of the disease (Kowall et al., 2018; Meyer et al., 2016). It is believed that where there is a first degree relative with dementia, the risk in developing AD increases by 10-30% (Meyer et al., 2016). Genetic links to dementia in the African region is inconclusive as research in Sub-Saharan Africa on aetiology of dementia and AD has not supported these genetic associations found elsewhere (Olayinka & Mbuyi, 2016).

• Sex

The incidence and prevalence of Alzheimer’s disease (AD) or dementia is not conclusively associated with sex, but research in developing countries suggest that it is more prone amongst women with increasing age (Kalaria et al., 2008; Meyer et al., 2016). However, the largest prevalence study in a South African rural community, to date, found no association between being female and screening positive for dementia, despite 68.6% of participants being female  (De Jager et al., 2017). Given the known increased risk with increasing age, women are more likely to develop dementia as they tend to have longer life expectancies.

• High prevalence of stroke and associated risk factors

Stroke is a major cause of long term mortality and disability in developing countries (Kalaria et al., 2008). However, there is no compelling evidence that controlling for or modifying vascular risk factors can prevent dementia (Ramlall et al., 2013). However, clinical factors such as hypertension and cardiovascular diseases are commonly associated with dementia risk (Olayinka & Mbuyi, 2016). Although international prevalence research on developing countries suggest that vascular dementias are low, Kalula et al., (2010) found that vascular dementia (VaD) (28%) and mixed dementia (15%) had a higher prevalence in South Africa. This finding suggests that a high prevalence of stroke and associated risk factors (e.g., hypertension and cardiovascular diseases) require improved management within health care practices. A study describing the clinical and risk profile of a sample of older participants in Durban (Kwazulu-Natal) (n=140) who were assessed for dementia and mild cognitive impairment (MCI), found that vascular risk factors were most prevalent (Ramlall et al., 2013). Thirty-six point four (36.4%) percent of those who screened positive for dementia (n=38) had a history of stroke and 66.4% had hypertension (i.e. 36.7% in dementia and 57.9% in MCI) (Ramlall et al., 2013). Therefore, in the absence of specific, accessible treatment of dementia, researchers call for the optimum and aggressive management of vascular risk factors such as hypertension, diabetes, weight, and use of substances (e.g., smoking) (Ramlall et al., 2013; Wilson et al., 2011).

• Low levels of education and literacy

Globally, as well as in Sub-Saharan Africa, low literacy levels has been identified as a risk factor for dementia (Olayinka & Mbuyi, 2016). In  certain communities in South Africa more than 80% of older persons people do not read or write (Kalaria et al., 2008). Low literacy is often linked to poverty or lower socio-economic status and therefore associated with constrained access to health care, poorer health, and increased risk of dementia (Kalaria et al., 2008). A cross-sectional community prevalence study has found a negative association between increasing education level and dementia, thus supporting the notion that formal education, cognitive reserve and resulting informed lifestyle choices, are protective against cognitive decline (De Jager et al., 2017). In fact, 69.8% of the 1394 participants had less than 7 years of education. The educational qualifications and better remuneration of caregivers in rural context in Kwazulu-Natal was also found to play a protective role in the care for persons with dementia, as it was found to guard against caregiver burden (Gurayah, 2015), and promote access to care resources.

References:

De Jager, CA, Msemburi, W., Pepper, K., & Combrinck, M. (2017). Dementia Prevalence in a Rural Region of South Africa: A Cross-Sectional Community Study. Journal of Alzheimer’s Disease, 60(3), 1087–1096. https://doi.org/10.3233/JAD-170325

Fogel, G. B., Lamers, S. L., Levine, A. J., Valdes-Sueiras, M., McGrath, M. S., Shapshak, P., & Singer, E. J. (2014). Factors related to HIV-associated neurocognitive impairment differ with age. Journal of NeuroVirology, 21(1), 56–65. https://doi.org/10.1007/s13365-014-0296-9

Grant, I. (2008). Neurocognitive disturbances in HIV. International Review of Psychiatry, 20(1), 33–47. https://doi.org/10.1080/09540260701877894

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Joska, J., Westgarth-Taylor, J., Hoare, J., Thomas, K. G. ., Paul, R., Myer, L., & Stein, D. (2011). Validity of the International HIV Dementia Scale in South Africa. Arquivos de Neuro-Psiquiatria, 25(2), 95–101. https://doi.org/10.1089/apc.2010.0292

Kalaria, R. N., Maestre, G. E., Arizaga, R., Friedland, R. P., Galasko, D., Hall, K., Luchsinger, J. A., Ogunniyi, A., Perry, E. K., Potocnik, F., Prince, M., Stewart, R., Wimo, A., Zhang, Z. X., & Antuono, P. (2008). Alzheimer’s disease and vascular dementia in developing countries: prevalence, management, and risk factors. The Lancet Neurology, 7(9), 812–826. https://doi.org/10.1016/S1474-4422(08)70169-8

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

Kowall, N. W., Raby, B. A., & Disclosures, C. (2018). Authors: Rick Sherva, PhD, Neil W Kowall, MD Section Editors: Steven T DeKosky, MD, FAAN, FACP, FANA, Benjamin A Raby, MD, MPH Deputy Editor: Janet L Wilterdink, MD Contributor Disclosures. 1–16.

Meyer, J. C., Harirari, P., & Schellack, N. (2016). Overview of Alzheimer ’ s disease and its management. South African Pharmaceutical Journal, 83(9), 48–56.

Olayinka, O. O., & Mbuyi, N. N. (2016). Epidemiology of Dementia among the Elderly in Sub-Saharan Africa Epidemiology of Dementia among the Elderly in Sub-Saharan Africa. 2014(August 2014). https://doi.org/10.1155/2014/195750

Ramlall, S., Chipps, J., Pillay, B., & Bhigjee, A. (2013). Mild cognitive impairment and dementia in a heterogeneous elderly population: Prevalence and risk profile. African Journal of Psychiatry (South Africa), 16(6), 456–465. https://doi.org/10.4314/ajpsy.v16i6.58

Robbins, R. N., Remien, R. H., Mellins, C. A., Joska, J. A., & Stein, D. J. (2011). Screening for HIV-Associated Dementia in South Africa: Potentials and Pitfalls of Task-Shifting. AIDS Patient Care and STDs, 25(10), 587–593. https://doi.org/10.1089/apc.2011.0154

Wilson, D., Ritchie, C. W., Peters, R., & Ritchie, K. (2011). Latest advances on interventions that may prevent, delay or ameliorate dementia. Therapeutic Advances in Chronic Disease, 2(3), 161–173. https://doi.org/10.1177/2040622310397636

Census 2011 data indicates that 63.6% (14 557 877) of men and 62.5% (15 686 381) of women in South African has attained primary education (StatsSA, 2015a).

References:

StatsSA. (2015a). Census 2011: A profile of education enrolment, attainment and progression in South Africa. Available from: http://www.statssa.gov.za/publications/Report-03-01-81/Report-03-01-812011.pdf

Census 2011 data indicates that 27.8% (i.e. 6 362 982) of men and 27.5% (i.e. 6 913 982) of women in South African has attained secondary education (StatsSA, 2015a).

References:

StatsSA. (2015a). Census 2011: A profile of education enrolment, attainment and progression in South Africa. Available from: http://www.statssa.gov.za/publications/Report-03-01-81/Report-03-01-812011.pdf

Prevalence of hypertension in the South African Demographic Health Survey (DHS) in 2016 was 48.2%, with crude prevalence estimated between 6-18% across the 9 provinces (Kandala, et al., 2021). About 46% of women and 44% of men have hypertension (systolic blood pressure above 140mmHg), rising with age and most common among white, followed by coloured men and women (StatsSA, 2017b).

References:

Kandala, N.B., Nnanatu, C.C., Dukhi, N., Sewpaul, R., Davids, A., Reddy, S.P. Mapping the Burden of Hypertension in South Africa: A Comparative Analysis of the National 2012 SANHANES and the 2016 Demographic and Health Survey. Int. J. Environ. Res. Public Health 2021, 18, 5445. https://doi.org/10.3390/ijerph18105445

StatsSA. (2017b). South Africa Demographic and Health Survey: Key Indicator Report 2016. Available from: https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf

The South African Demographic and Health survey of 2016 revealed that obesity has increased since 1998, with women having higher rates of obesity (68%) and severe obesity (i.e., 1 in 5 women with a BMI ≥35.0), compared to 31% of men being obese (StatsSA, 2017b).

References:

StatsSA. (2017b). South Africa Demographic and Health Survey: Key Indicator Report 2016. Available from: https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf

Modelled estimates from the Global Burden of Disease study (2016) show a prevalence of 16.9% for hearing loss (age-related and other) in South Africa.

References:

Global Burden of Disease Study. (2016).  IHME GBD results tool.  Available [online] at https://vizhub.healthdata.org/gbd-results/. IHME, healthdata.org.

The South African Demographic and Health survey of 2016 reports that 37% of men, compared to 7% of women, 15 years and over smoke tobacco cigarettes in South Africa (StatsSA, 2017b). Thirty percent of men and 6% of women smoke daily (StatsSA, 2017b). About 1 in 5 (21%) of adolescents smoke in South Africa, with 6.8% reportedly having their first cigarette before the age of 10 (Byrne et al., 2016).

References:

Byrne, J., Eksteen, G., & Crickmore, C. (2016). Cardiovascular Disease Statistics Reference Document. Available from: https://www.heartfoundation.co.za/wp-content/uploads/2017/10/CVD-Stats-Reference-Document-2016-FOR-MEDIA-1.pdf

StatsSA. (2017b). South Africa Demographic and Health Survey: Key Indicator Report 2016. Available from: https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf

Modelled estimates from the Global Burden of Disease study (2016) show a prevalence of 3.93% for depressive disorders in South Africa.

References:

Global Burden of Disease Study. (2016). IHME GBD results tool. Available [online] at https://vizhub.healthdata.org/gbd-results/. IHME, healthdata.org.

It is estimated that 27.9% of men and 45.2% of women in South Africa are physically inactive (Byrne et al., 2016). For South African 50 years and older, 60.5% are involved in low, 10.9% in moderate, and 28.6% in high physical activity (Peltzer K & Phaswana-Mafuya, 2012).

References:

Byrne, J., Eksteen, G., & Crickmore, C. (2016). Cardiovascular Disease Statistics Reference Document. Available from: https://www.heartfoundation.co.za/wp-content/uploads/2017/10/CVD-Stats-Reference-Document-2016-FOR-MEDIA-1.pdf

Peltzer K & Phaswana-mafuya, N. (2012). Physical inactivity and associated factors in older adults in South Africa. African Journal of Physical, Health Education, Recreation and Dance, 6018.

Modelled estimates from the Global Burden of Disease study (2016) show a prevalence of 5.66% for diabetes in South Africa.

References:

Global Burden of Disease Study. (2016). IHME GBD results tool.  Available [online] at https://vizhub.healthdata.org/gbd-results/. IHME, healthdata.org.

South Africa’s total per capita alcohol consumption for persons 15 years and over is estimated between 10 and 12.4 litres, and it is considered high compared to the global average of 6.2 litres (WHO, 2014).

References:

WHO. (2014). Global Status report on alcohol and health 2014. Available from: https://apps.who.int/iris/bitstream/handle/10665/112736/9789240692763_eng.pdf?sequence=1

Total cholesterol is estimated at 23.9%, with LDL-cholesterol at 28.8%, and 47.9% have low HDL-cholesterol (Byrne et al., 2016).

References:

Byrne, J., Eksteen, G., & Crickmore, C. (2016). Cardiovascular Disease Statistics Reference Document. Available from: https://www.heartfoundation.co.za/wp-content/uploads/2017/10/CVD-Stats-Reference-Document-2016-FOR-MEDIA-1.pdf

Visiting the family practitioner for advice is the typical path to access a diagnosis for suspected dementia (Vally, 2010). These pathways may differ across the two healthcare sectors, whereby private sector users approach the family doctor (GP) for assistance and public sector users’ first port of call typically is community healthcare clinics, day hospitals, and/or traditional healers. Mental health service users who access a mental healthcare facility will be assessed for dementia using neuropsychological assessment techniques (Vally, 2010, p.393).

Persons with suspected dementia should undergo further tests via specialist investigations and referrals (Vally, 2010). However, with constrained resources in the public sector, it is unclear how many service users are indeed referred for specialist testing and thorough physical and neurological examination (no routine monitoring and surveillance). Limited research in South Africa shows that dementia, if recognised and understood by health practitioners, is often viewed as a normal part of aging (Kalula & Petros, 2011; Prince et al., 2016a). This means that persons with suspected dementia are not referred for further investigation, diagnosis, and treatment.

References:

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016a). World Alzheimer Report 2016: Improving healthcare for people living with dementia. In Alzheimer’s Disease International (ADI). https://doi.org/10.13140/RG.2.2.22580.04483

Vally, Z. (2010). The assessment and management of dementia. South African Family Practice, 52(5), 392–395. https://doi.org/10.1080/20786204.2010.10874014

See response 07.01.01, no surveillance or descriptive data available on persons living with dementia in South Africa.

No surveillance or descriptive data available on persons living with dementia in South Africa.

As stated previously, there are no dementia-specific monitoring and surveillance data available in South Africa. However, medical attention (including diagnostic assessments) across geographical areas vary considerably, with access to healthcare services in both private and public sectors being concentrated to more urban areas (Competition Commission SA, 2018; Department Planning Monitoring and Evaluation, 2017; Mahlathi & Dlamini, 2015) (see Part 2 also). Furthermore, resources including specialist medical services are skewed to the private sector, accessible only to South Africans who can afford it, and usually of improved socio-economic status.

References:

Competition Commission SA. (2018). Health market injuiry. Available from:  http://www.compcom.co.za/wp-content/uploads/2018/07/Executive-Summary.pdf

Department Planning Monitoring and Evaluation. (2017). Socio-Economic Impact Assessment System (SEIAS) Final Impact Assessment (Phase 2): White Paper on National Health Insurance (Issue May).

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

See response under Part 3, question 03.01.02.01.

Dedicated services for persons living with dementia are provided by the NGO-sector and typically comprise of psycho-educational support, training of caregivers, and linking to support groups for persons living with dementia and their families. NGOs work in collaboration with multiple organisations and partners to provide services to families.

Government mental health services include support from mental health practitioners (e.g., psychiatrists, psychiatric nurses) to those who enter service systems, with further referral to the NGO-sector (e.g., for family and caregiver support) or private sector (counselling, specialist medical intervention) for care when public sector resources are unable to meet service needs. There are no known support services dedicated specifically to persons living with dementia after diagnosis and their families from government outside of generic provisions for older persons in general, and that which is provided through overburdened mental health care facilities. A memory-clinic study in Cape Town revealed that 79% of patients’ care were located within the family (Kalula et al., 2010), with unpaid female carers being the most typical care-providers in South Africa (Lloyd-Sherlock, 2019b).

References:

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

Lloyd-Sherlock, P. (2019b). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Currently in South Africa persons living with dementia and their families seeking care services from local practices (e.g., local general practitioners) are linked to dementia-care services provided by the NGO-sector and/or specialists in the private sector. These links are dependent on these local practices/individuals. Persons seeking help from PHC within the public sector may be referred to the Department of Social Development (DSD), who in turn relies on social partnerships with the NGO-sector to link individuals with community-based services. DSD may provide subsidies to these NGOs as a source of funding for services provided, and as a way of maintaining these links. There is policy support for designating responsibility for the provision of services to older persons by a third party, for example, the Older Person’s Act (no.13 of 2006, chapter 2, section 8(1)(a), p.6) indicates that the minister “…may provide financial awards to service providers that provide social services to older persons from funds appropriated by Parliament for that purpose” (Government Gazette, 2006). There was no information found to what extent this actually happens with regard to dementia-specific community-based services.

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

If access to adequate care and treatment via the public sector is not possible, people tend to seek help from the private sector at their own expense. There is however no data found on to what extent out-of-pocket expenses are undertaken with regard to accessing diagnosis, care and treatment for dementia specifically (no dementia and dementia-care surveillance in South Africa).

Within the private sector, long-term care arrangements can be purchased, for example, assisted living, frail care, convalescence, as well as old age care (nursing/retirement homes) where they can buy or rent accommodation and are responsible for the full cost of their stay. There are 8 registered residential care facilities in the public sector, with eligibility restricted to the frail and destitute (see discussion under Part 3). Long waiting lists and constrained resources (see Part 2) despite eligibility, create an inequitable situation where access to long-term care are usually confined to the minority who can afford it, while most South Africans rely on home-based care provided by an unpaid carer (usually a female family member) (Sevenhuijsen et al., 2003). Furthermore, older persons with dementia are often not accepted for residential care as well as denied admission to hospitals for fear of bed-blocking (Kalula & Petros, 2011; Patel & Prince, 2001), and are also sent home because of a lack of awareness and understanding of dementia amongst healthcare workers where dementia is seen as a normal part of ageing and that nothing can be done with regards to treatment (Kalula & Petros, 2011).

References:

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Patel, V., & Prince, M. (2001). Ageing and mental health in a developing country: who cares ? Qualitative studies from Goa, India. Psychological Medicine, 31, 29–38. https://pdfs.semanticscholar.org/8896/600da12a3c3c4b8cbb55ce3c9a8bd8cc6d6e.pdf

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

No evidence found for cost of dementia in South Africa.

South Africa has moved towards community-based care services for older persons in general (not dementia-specific). Although the Older Person’s Act, along with its suggested amendment recommendations to have all caregivers be registered with the Department of Social Development (SAHRC, 2017b, see p.3), these services remain largely unregulated (Prince et al., 2016a). Community-based care is also divided along two tiers, i.e. profit-based private care that is usually urban-biased as well as non-profit care that is resource-constrained and typically offered by faith-based organisations (FBOs), NGOs (Prince et al., 2016a), civil society and public welfare bodies (WHO, 2017). South Africa has examples of multi-purpose centres that provide housing, support services, carer training, community outreach programmes, as well as frail care (e.g., the Centurion Council for the Aged) (Lombard & Kruger, 2009). However, the vast majority of South Africans do not have access to these pockets of comprehensive care (Lombard & Kruger, 2009), with very few formal/organised services for most older persons in South Africa that do not have access to the two tiers of care mentioned here (WHO, 2017).

References:

Lombard, A., & Kruger, E. (2009). Older persons: The case of South Africa. Ageing International, 34(3), 119–135. https://doi.org/10.1007/s12126-009-9044-5

Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016a). World Alzheimer Report 2016: Improving healthcare for people living with dementia. In Alzheimer’s Disease International (ADI). https://doi.org/10.13140/RG.2.2.22580.04483

SAHRC. (2017b). South African Human Rights Commission Older Persons Amendment Bill. Available from: https://www.sahrc.org.za/home/21/files/SAHRC%20Submission%20on%20Older%20Persons%20Bill-%20Dept%20Soc%20Dev-%2030.6.17.pdf

WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care. Available from: https://www.who.int/publications/i/item/9789241513388

There is a lack of dementia and geriatric specialists in South Africa (see Part 2). Pathways to diagnosis in the public sector are confounded by a lack of understanding and misconceptions of dementia among PHC workers (Kalula et al., 2010; Kalula & Petros, 2011); as well as beliefs that dementia is a natural part of aging without being referred for further investigation, treatment and care. Diagnostic services in the private sector are usually obtained via general practitioners, where persons with suspected dementia seek advice via their family practitioners (Vally, 2010).

References:

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

Vally, Z. (2010). The assessment and management of dementia. South African Family Practice, 52(5), 392–395. https://doi.org/10.1080/20786204.2010.10874014

Mental health service users in the public sector are assessed using neurophysiological tests (see Vally, 2010, p.393). The following are largely provided by the private sector, NGOs and FBO’s which provide services to persons living with dementia and their families: non-pharmacological approaches include identifying environmental triggers for behavioural and psychological symptoms of dementia (BPSD) and empowering carers to manage these symptoms. Organisations such as ASA and Dementia-SA assist caregivers, providing support and training on how to care for a person living with dementia, monitoring their well-being, and link to support services (e.g. respite care, home-based care, support groups and counselling, and legal advice) (Emsley et al., 2013). Community-based services refer families where necessary to family physicians, specialists (i.e., private sector) for pharmacological approaches to manage BPSD as State facilities continue to be challenged by (1) serious shortages of essential list medications, (2) lack of understanding of dementia as a disease (and not a natural part of aging), and (3) lack of human resources to manage cases and monitor pharmacological treatments, effects, and dosages.

References:

Emsley, R., Seedat, S., & Van Staden, W. (2013). South African Journal of Psychiatry PART 2. The South African Society of Psychiatrists (SASOP) Treatment Guidelines for Psychiatric Disorders Head of Publishing. South African Journal of Family Practice, 19(No. 3), 196. https://doi.org/DOI:10.7196/SAJP.474

Vally, Z. (2010). The assessment and management of dementia. South African Family Practice, 52(5), 392–395. https://doi.org/10.1080/20786204.2010.10874014

Yes, these largely rely on the NGO-sector, FBO’s, and private care facilities to provide psychosocial support. Alongside the private sector, dementia care services are largely provided by the NGO-sector (neither public or private sector) (for examples see TAFTA: Care of the elderly at https://www.tafta.org.za/ and Hospice Palliative Care Association of South Africa at https://hpca.co.za/). Services in this sector range from psychosocial support and education, training of carers, daily living support, palliative, and end-of-life care.

Yes, non-profit as well as for-profit (private) organisations offer these services at a cost to the family (e.g., respite care).

The two-tiered system of community-based care referred to above provide these services at a cost.

Organisations like ASA provide legal and care advice services, linking persons living with dementia and their families with other organisations that can guide and support. The State also provides social protection in the form of old age pension or a disability grant (either or). However, these are not dementia-specific.

Community-based services are skewed to more urban areas and rely on private organisations that provide nursing care for those who can afford to pay for it, as well as non-profit organisations (e.g., FBOs and NGOs) that cater for the needs of less wealthy older persons (at a lesser cost than private care).

The public sector provides services for older persons in general (not dementia-specific) through 8 registered facilities in the country, eligible to the frail and destitute, as well as an Older Persons Programme (housed by the Department of Social Development) that proposes services based on an ‘active aging’ framework (i.e., promoting the participation of older persons in their communities and decision-making for as long as possible). Based on this review, the extent to which these proposed services are implemented is unclear. Dementia-specific services, however, largely rely on the private sector as well as NGOs and FBO’s.

No data available for dementia-specific community-based care (no monitoring and surveillance of dementia in South Africa).

These mechanisms (dementia advisor or dementia-care manager) do not exist formally within the public sector. Family practitioners (general practitioners/physicians) are largely the ‘first port of call’ for seeking care (Vally, 2010), and are usually within the private sector and act as case managers for care, treatment, and referral. There is currently no coordinated care, resource or planning mechanism across departments in government for persons with dementia in South Africa. Care coordination services and support for persons living with dementia rely on the NGO sector, which primarily provide support in terms of psychoeducation, training of carers, and linking service users to support groups in their areas.

References:

Vally, Z. (2010). The assessment and management of dementia. South African Family Practice, 52(5), 392–395. https://doi.org/10.1080/20786204.2010.10874014

Family and other unpaid carers are increasingly recognised in South Africa as a central base of care-provision for older persons (Sevenhuijsen et al., 2003). The Older Persons Act (no.13 of 2006) calls for the registration of all home-based care services with the Department of Social Development. However, these are not formally recognised as part of dementia-specific diagnostic services.

References:

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

Pharmacological as well as non-pharmacological approaches (see 07.02.01.02.02).

None found beyond those mentioned under 07.02.01.02.02.

See urban-bias for community-based services description under section 07.02.

Yes, at a cost to the family with services skewed to more urban areas (see description under section 07.02). Examples of services offered in people’s homes are as follows (TAFTA, 2019a):

• Personal care and hygiene (washing, bathing, grooming, dressing);
• Home cleaning (tidying, making beds, laundry);
• Shopping;
• Issuing of medication;
• Nursing care (administering injections, nursing procedures such wound dressing, etc.).

In addition, the Older Person’s Act (No.13 of 2006) includes the following services to be provided by home-based care programmes (see chapter 3, section 12 (3), p.8) of Act):

• Rehabilitation programmes that include assistive devices;
• Respite care;
• Information, education and counselling for family, carers and community regarding ageing and associated conditions;
• Provision of free health care to the frail and destitute (Government Gazette, 2006).

References:

Government Gazette. (2006). Older Persons Act, No.13 of 2006 (Vol. 13, Issue 1098). Available from: https://www.westerncape.gov.za/other/2012/3/older_persons_act.pdf

TAFTA. (2019a). Home-based care. Available from: https://www.tafta.org.za/home-based-care/

Access to community-based care is based on affordability. Charges for home-based care within the NGO/non-profit sector are assessed according to income and assessments of needs are done by an intake social worker (TAFTA, 2019a).

References:

TAFTA. (2019a). Home-based care. Available from: https://www.tafta.org.za/home-based-care/

Yes, Alzheimer’s South Africa (ASA) (see https://alzheimers.org.za/). There is also Dementia-SA that has a strong presence in the Western Cape province, but also provides a national service through a national helpline (see https://www.dementiasa.org/media/we-are-always-there-to-help/).

ASA has a national office based in Pretoria and managed by a national executive council, with sub-national/regional offices in each of the 9 provinces in South Africa.

No information on NGO staff complements and structures available via desk review. This information should be sourced via stakeholder interviews within the NGO-sector.

• Support groups for persons living with dementia and their carers and families;
• Information, education, and training of carers/families;
• Home carers and nursing agencies;
• Connecting families and persons living with dementia with affiliate members who can provide dementia-specific services.

NGOs can apply for subsidisation of services provided to the community. For example, ASA receives a subsidy for services from the Department of Social Development (DSD). These subsidies are, however, restricted by funds available and competing priorities within the public sector.

There is no dementia-specific policy in South Africa. However, NGOs are involved in advocacy work and policy reform. For example, Dementia-SA (NGO) has contributed to the development of the White paper on Social Development and actively working with the DSD to acknowledge dementia as a disability, as well as collaborating with the South African Law Reform Commission to address the concerns around power of attorney (described under Part 4).

Services are predominantly available in more urban areas. ASA, for example, is represented regionally and provides services in all 9 provinces.

Information services (e.g., medical, legal) and joining local support groups are usually free. However, where other services like respite care, home-based care, etc. are needed, these are sourced at a cost to the family.

No data/information found on how many persons living with dementia and their carers are served by NGOs. The South African government relies heavily on the services of NGOs to make up for the deficits in care provisions for older persons (and all vulnerable populations and their service needs more broadly). In general, NGOs support national development priorities and build strong public-private partnerships (Volmink & Van Der Elst, 2017) that target their services at vulnerable populations, providing services and social protection for the socio-economically disadvantaged. Vulnerable populations include historically marginalised population groups, women, children, older persons, and persons with disabilities. However, with regard to the long-term care of older persons, South Africa still reflects the legacy of Apartheid whereby availability and access to residential care services (usually in the more affluent, urban areas) cater primarily for older white population (see audit of residential care facilities report: Department of Social Development, 2010); while promoting familial frameworks of care for black South Africans, and positioning care for older persons as primarily a family responsibility (Lloyd-Sherlock, 2019a).

References:

Department of Social Development. (2010). Audit of Residential Facilities. April, 1–87. Available from: https://social.un.org/ageing-working-group/documents/FINAL%20REPORT%20DSD%20Audit%20of%20Residential%20Facilities%20April2010.pdf

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Volmink, J., & Van Der Elst, L. (2017). The evolving role of 21^st Century Education NGOs in South Africa: Challenges and Opportunities. Available from: https://www.mietafrica.com/wp-content/uploads/2017/04/The-evolving-role-of-21st-Century-Education-NGOs-in-South-Africa.pdf

There was no information found on the number of neurologists registered in South Africa as specialist categories are merged under the category “medical specialists” in the Department of Health (DOH), and furthermore categorised broadly under “medical practitioner” with the Health Professions Council of South Africa (HPCSA).

It was noted that there were about 8 geriatricians in 2010 for a population of 4 million people of 60 years and older (Lloyd-Sherlock, 2019a). There are an estimated 650 psychiatrists across the country (0.4% per 100 000 in the public sector), with only 3 specialising in old-age psychiatry (psychogeriatricians) (Health24, 2018b).

References:

Health24. (2018b). SA has only 3 psychiatrists specialising in old-age. https://www.health24.com/Mental-Health/News/sa-has-only-3-psychiatrists-specialising-in-old-age-20180813

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

It is unclear from a desk review of medical school and related curricula whether dementia is included in undergraduate or graduate training, residencies, etc. However, gerontology was removed by the South African Nursing Council (SANC) from its specialist training curriculum (Lloyd-Sherlock, 2019a), and despite being urged by the South African Human Rights Commission (SAHRC) to reconsider this decision (SAHRC, 2015), this topic has not been restored to nursing curricula.

The NGO sector provides dementia care training predominantly to carers, where facilities pay organisations to train care-staff to provide care for persons living with dementia and support families of persons living with dementia. It is unclear to what extent this training reaches beyond non-pharmacological approaches to caring for persons living with dementia.

References:

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

SAHRC. (2015). Investigative Hearing Report: Investigating hearing into systemic complaints relating to the treatment of Older Persons. Available from: http://www.sahrc.org.za/construction-site/home/21/files/SAHRC Investigative hearing report.pdf

There is no evidence found to suggest that PHC workers receive training on dementia. NGOs provide training to carers from LTC facilities as well as home-carers (although there is no information found that can describe the extent to which this occurs across public and private sectors). These training sessions (NGOs) are delivered in the form of short courses, for example Dementia-SA offers 1 day courses on (i) understanding dementia; (ii) unpacking the Older Person’s Act; (iii) communication and dementia; and (iv) activities for persons living with dementia (see https://www.dementiasa.org/training/). It is unclear from the desk review how these are assessed.

NGOs provide training to carers in LTC facilities as well as home-carers (see 07.03.03).

See response under 07.03.03. It is unclear from desk review whether any dementia-training is incorporated in training programmes, curricula, etc.

Yes, with those providing dementia-specific services skewed to the NGO and private sector.

There is no routine monitoring and surveillance of LTC-sector. Therefore, no information is available on the total number of beds for each of these facilities and how many are dedicated (if at all) to dementia-specific care/services.

For hospice facilities, according to the Hospice Palliative Care Association of South Africa (see https://hpca.co.za/province/western-cape/), there is a total of 97 hospice facilities across the nine provinces.  The table below illustrates the total facilities in each province, with a noticeable bias towards urban areas:

As with LTC-sector, there is no information available that indicates the total bed availability across these facilities and how many (if any) are available for dementia.

For adult day centres or respite care services, some LTCFs offer these services in South Africa although it’s unclear how many do. According to an online search directory named ‘Fyple’ (see www.fyple.co.za), there are 4 adult day care centres in the private sector in South Africa (see https://www.fyple.co.za/category/organisations-government/adult-organization/adult-day-care-center/). However, this excludes any community, lifestyle, and social centres (e.g., luncheon clubs, faith-based organisations) that host daily or weekly services where older adults from communities gather to socially engage and participate in group activities. These data do not exist.

Public sector: Outpatient health clinics in the South African public health system are not dementia-specific, offering general reproductive and maternal health, and the clinical management of communicable (e.g., HIV/AIDS and TB) and non-communicable diseases at 3500 primary health clinics and health centres across the country (McKenzie et al., 2017). The extent to which the clinical management of dementia occurs at these clinics are unknown (no dementia surveillance in South Africa).

Private sector: By 2013, there were approximately 3500 private outpatient clinics and 314 private hospitals with a total beds capacity of 34,572 (hospitals and clinics combined) (Econex, 2013). Since there is no dementia surveillance in South Africa, it’s unclear how many (if any) are dementia-specific.

Community Mental Health centres: There are 3460 outpatient mental health facilities and 80 day treatment facilities across South Africa’s public sector (WHO, 2007). In the private sector, there is the Life Healthcare care group that has a division for Mental Health with 9 facilities across 4 provinces with selected facilities (not disclosed how many) offering a neuro-geriatric wellness programme that includes a mental gymnasium for elderly patients (see https://www.lifehealthcare.co.za/patient-information/patient-services/complementary-services/life-mental-health/ ). Life Esidimeni centres are a subsidiary of the private Life Healthcare group and are contracted by the National and Provincial Department of Health to provide out-of-hospital health and care services to public service users (see https://www.lifehealthcare.co.za/about-us/clinical-and-support-functions/out-of-hospital-services/ ). Life Esidimeni has 10 facilities across 5 provinces, of which 7 are centre-based and include frail care with provisions that include dementia care (see https://www.lifehealthcare.co.za/about-us/life-esidimeni/ and https://www.lifehealthcare.co.za/about-us/life-esidimeni/frail-care-services/). This list of private mental health centres is not exhaustive and may include more private facilities that were not found in the time desk review period.

Memory clinics: This desk review found that there were 5 memory clinics based across the country’s two capital provinces, (Western Cape and Gauteng), with only 1 in Cape Town based at the public healthcare system.

Links:

1. MemoryCare (Johannesburg), see https://www.memorycare.co.za/about-us/
2. The Albertina and Walter Sisulu Institute of Ageing in Africa, Groote Schuur Hospital (Public): http://www.instituteofageing.uct.ac.za/sites/default/files/image_tool/images/126/IAA/Facilities/Memory%20Clinic%20Brochure.pdf
3. Cape Town Mind and Memory, (Cape Town) (Private): http://ctmindandmemory.co.za/about-us/
4. Panorama psychiatry and memory clinic (Cape Town) (Private): see https://mentalhealthsa.org.za/mental-health-service-providers/3646/panorama-psychiatry-and-memory-clinic/
5. Specialist geriatric and memory clinic, Vincent Pallotti Hospital, Pinelands (Cape Town) (Private): http://sgmclinic.co.za/

Outpatient (community) social centres: South Africa relies heavily on the NGO-sector to provide services to persons with dementia and their families within their homes, with 2 dementia-specific care organisations identified (i.e. Alzheimer’s South Africa with 9 branches across the country [see https://alzheimers.org.za/services-and-activities/] and Dementia South Africa [see https://www.dementiasa.org/help-and-support/#family-interventions] located within the Western Cape province). Other NGOs also exist, for example, the Care Company that provides outpatient care services to older persons in general, with specific services also catering for dementia home care needs. The Care Company has 2 expert teams across 2 provinces (see http://www.carecompany.co.za/dementia-care/), but the total amount of NGOs that offer dementia-specific social care is unknown (i.e., minimum of 12).

References:

Econex. (2013). The South African Private Healthcare Sector: Role and Contribution to the Economy. https://econex.co.za/wp-content/uploads/2016/09/Econex_private_health_sector_study_12122013-1.pdf

McKenzie, A., Schneider, H., Schaay, N., Scott, V., & Sanders, D. (2017). Primary Health Care Systems (Primasys). In World Health Organization and Alliance for Health Policy and Systems Research. Available from: https://apps.who.int/iris/bitstream/handle/10665/341145/WHO-HIS-HSR-17.38-eng.pdf?sequence=1

WHO. (2007). WHO-AIMS Report on Mental Health System in South Africa. In World Health Organisation and the Ministry of Health South Africa. Available from: https://pmhp.za.org/wp-content/uploads/2015/01/WHO-2007-AIMS-report.pdf

As described in Part 3, there are an estimated 1150 residential care homes for older persons in South Africa, of which 415 are officially registered with the Department of Social Development (as mandated by the Older Person’s Act) (Mahomedy, 2017). Residential care is largely run by Non-profit organisations (NGOs) and Faith-based organisations (FBOs), and only 8 of these registered facilities are managed directly and fully subsidised by the State (Lloyd-Sherlock, 2019a; Mahomedy, 2017). All registered facilities can apply for subsidies for individual residents and will only qualify for this financial support if the older person is frail and destitute, in need of full-time care, 60 years and older, and is a South African resident (South African Government, 2019). Reductions in the subsidy received from the Department of Social Development has led to facilities failing to provide services to poor, frail persons (who are eligible), while admitting wealthier persons (who pay themselves) (Lloyd-Sherlock, 2019a). No data were found that specify the total number of beds across all long-term residential care facilities in South Africa.

References:

Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326

Mahomedy, Y. (2017). Residential Facilities for Older Persons. Who Owns Whom: African Business Information.

South African Government. (2019). Old age pension. 1–7. Available from: https://www.gov.za/services/social-benefits-retirement-and-old-age/old-age-pension

There is no dementia-surveillance in South Africa.

South Africa has reduced its psychogeriatric units at its universities from 5 across the country to 1 remaining unit at Stikland Hospital in Bellville (Western Cape) (Health24, 2018b). This unit has 3 wards with a bed capacity of 77 (i.e., 33 for men and 44 women). Based on the information available from online sources, it is unclear whether any of these beds are dementia specific (Health24, 2018b).

References:

Health24. (2018b). SA has only 3 psychiatrists specialising in old-age. https://www.health24.com/Mental-Health/News/sa-has-only-3-psychiatrists-specialising-in-old-age-20180813

Based on the information available from the desk review, it is unclear whether general hospitals have geriatric-specific beds outside of psychiatric facilities/psychogeriatric units.

There is no dementia-surveillance in South Africa.

See question 07.04.02.

The South African Associations of Retired Persons (SAARP) is an example of a social service provider that offer free membership to older persons as well as encourage activities such as arranging outings and excursions (subsidised), public talks, and computer training to empower older persons to keep in contact with their children using email, etc. (for more information see https://saarp.net/). Services provided by community social centres include for example, free will services, reading and social clubs, and assistance benefit plans (e.g., funeral plans and short-term insurance). The SAARP has about 28 social clubs that are run by volunteers and charge a small membership fee (to cover running costs) across the country (see https://saarp.net/social-clubs/social-clubs).

No formal training/intervention programmes for dementia at community social centres were found.

Based on this desk review, dementia seems to largely be acknowledged as falling under a psychiatric jurisdiction (mental health and not a non-communicable disease). As described previously, South Africa has 1 remaining psychogeriatric unit (3 wards, 77 beds) at Stikland Hospital in Bellville (Western Cape) (Health24, 2018b). Based on the information available from online sources it is unclear whether these beds are dementia specific. However, specialised treatment for dementia is usually provided by a psychiatrist (Health24, 2018b). There are an estimated 650 psychiatrists across the country (i.e., 0.4% per 100 000 in the public sector), with only 3 specialising in old-age psychiatry (Health24, 2018b).

References:

Health24. (2018b). SA has only 3 psychiatrists specialising in old-age. https://www.health24.com/Mental-Health/News/sa-has-only-3-psychiatrists-specialising-in-old-age-20180813

No medications can be sold or prescribed in South Africa without the South African Health Products Regulatory Authority’s (SAHPRA) approval. Anti-dementia medications are available in South Africa, for example:

Acetylcholinesterase inhibitors:

1. Donepezil (Aricept)
2. Rivastigmine (Exelon)
3. Galantamine (Reminyl)
4. Memantine (Ebixa)

Anti-depressants:

1. Citalopram
2. Sertraline
3. Mirtazapine
4. Agomelatine
5. Escitalopram
6. Venlafaxine

These medications are prescribed as treatment guidelines by the South African Society of Psychiatrists (SASOP) (Emsley et al., 2013) that primarily guides the private sector in psychiatric practice. It is unclear to what extent these are adopted by the public sector, especially considering the health care system’s challenges in maintaining medicinal stocks and supplies at health care facilities.

Anti-dementia medications are expensive and not all medical insurance schemes will pay for these (Truter, 2013). Dementia is not listed as a chronic condition and, therefore, do not cover full costs of anti-dementia drugs as chronic medication.

References:

Emsley, R., Seedat, S., & Van Staden, W. (2013). South African Journal of Psychiatry PART 2 The South African Society of Psychiatrists (SASOP) Treatment Guidelines for Psychiatric Disorders Head of Publishing The South African Society of Psychiatrists (SASOP) Treatment Guidelines. South African Journal of Family Practice, 19(No. 3), 196. https://doi.org/DOI:10.7196/SAJP.474

Truter, I. (2013). Antipsychotic drug prescribing to patients with dementia in a South African patient population. African Journal of Pharmacy and Pharmacology, 7(41), 2755–2762. https://doi.org/10.5897/ajpp2013.3893

Yes.

The State provides, maintains, and recycles assistive devices (walkers, wheelchairs, hearing aids) as well as adult hygiene products to people who need them; however, these are in short supply and rely heavily on donations and the purchase of new equipment (see https://www.westerncape.gov.za/service/assistive-devices). For older persons in general, these can be accessed via day-hospitals or State hospitals. With regards to housing adjustments, these can be hired or purchased from specialised service providers, for example see http://disabilityinfosa.co.za/mobility-impairments/assistive-devices-equipment/ for suggested providers and products.

Not reimbursable by medical insurance.

Reimbursable.

Not reimbursable.

If medications are accessed at a PHC facility, they will be free (but with continuity challenges due to stock shortages). Private sector service users will carry the cost of these medication via medical aid support (depending on the user’s insurance plan option), and/or via out-of-pocket-payments.

The International Cognitive Stimulation Therapy centre at the University College of London (UCL) has South Africa listed as one of its countries that form part of the international CST group and reported to be used in the country by speech-language pathologists in the Johannesburg area with regards to adult neuro-rehabilitation. It is unclear from the desk review to what extent these services are available to persons living with dementia; however, specialised services in general are usually skewed/restricted to the private sector (and accessible to those who can afford private health-and specialist care). No research studies were found to date that provide an evaluation of CST as an intervention for South Africa specifically.

Other non-pharmacological approaches used in South Africa relate to the support and monitoring of the well-being of carers. The NGO-sector plays a critical role in training carers on how to care for persons living with dementia, also providing or linking to community-based respite care and home-care where possible (Emsley & Seedat, 2013).

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidlelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

This technology is not provided by the State to any service user. However, GPS tracking technology is available to private purchasers of this technology in South Africa via, for example, Singer Photographic (see https://trackimo.co.za/) which are the distributors of Trackimo (US-based solution provider) devices for children and adults. This provider also comes with a GeoFence (a defined boundary that alerts the monitor via SMS when the device passes in our out of an area) (see https://trackimo.zendesk.com/hc/en-us).

The average cost of Donepezil per prescription in South Africa (2009) was R634.76, and R551.35 for memantine (Truter, 2019). Today the following costs are expected per pill (see https://www.pharmaris.net/order-exelon-online-en.html?key=exelon for online purchase prices):

1. Donepezil: R18.08 per pill (generic)
2. Galantamine: R40.55 per pill (generic)
3. Rivastigmine: R15.40 per pill (generic)
4. Memantine (Ebixa): Not found.

References:

Truter, I. (2019). Prescribing of drugs for Alzheimer’s disease: a South African database analysis. International Psychogeriatrics, 22(2), 264–269. https://doi.org/10.1017/S1041610209991530

There are indications that persons living with dementia are largely cared for by informal carers, especially family members. A study in the Western Cape found that 79% of patients (n=305) at a memory clinic are cared for by family members (of which 74% reported living with a spouse and/or an adult child), compared to 6% that were cared for at a residential care facility, and 10% living alone (Kalula et al., 2010).

References:

Kalula, S. Z., Ferreira, M., Thomas, K. G. F., De Villiers, L., Joska, J. A., & Geffen, L. N. (2010). Profile and management of patients at a memory clinic. South African Medical Journal, 100(7), 449. https://doi.org/10.7196/SAMJ.3384

South African labour law does not cater for long-term care employment conditions to care for a family member. This will most likely be at the discretion of the relevant employer, for which these long-term care arrangements may be rare.

In South Africa, informal caregiving largely fall on women with lower socio-economic status (Sevenhuijsen et al., 2003; Yakubu & Schutte, 2018). A study in two communities (N=200) in the Cape Town area revealed that most informal carers in the area had an average age of 47.9 years (SD=11.7), with the majority having some secondary school education [i.e., 54% had grade 8-11, while 31% had grade 12 (matric)], and never married (28.1%) or formerly married (33.7%) (Yakubu & Schutte, 2018).

References:

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

Yakubu, Y. A., & Schutte, D. W. (2018). Caregiver attributes and socio-demographic determinants of caregiving burden in selected low-income communities in cape town, South Africa. Journal of Compassionate Health Care, 5(3), 1–10. https://doi.org/10.1186/s40639-018-0046-6

No studies/information were found on informal carers specifically for dementia-care in South Africa.

The findings of the 10/66 Dementia Research group indicate that caregivers are often required to give up formal, paid employment in order to care for their family member on a full time basis, with resulting financial strain, stress and family poverty (Kalula & Petros, 2011). Giving up formal employment to care for a family member (unpaid) or being appointed as an informal carer (paid), leads to these carers remaining at a lower socio-economic status.

References:

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Informal carers are believed to earn less than R1001 per month (Yakubu & Schutte, 2018).

References:

Yakubu, Y. A., & Schutte, D. W. (2018). Caregiver attributes and socio-demographic determinants of caregiving burden in selected low-income communities in cape town, South Africa. Journal of Compassionate Health Care, 5(3), 1–10. https://doi.org/10.1186/s40639-018-0046-6

In South Africa, there is a small caregiver allowance called the ‘Grant-in-aid’ that can be used by a carer for an older person with dementia (Kalula & Petros, 2011). This is a social protection grant that is an additional payment to those older persons who are living on a social grant (e.g., disability, pension, or war veteran’s grant) but are unable to care for themselves, and therefore for the purpose of paying the carer.

References:

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

The Grant-in-aid amounts to a payment of R410 per month (in 2019) and is paid together with the social grant via one of 3 payment methods: (a) cash withdrawal at specific pay point; (b) electronic transfer to bank account; or (c) payment via an institution acting as administrator of the grant (welfare organisation).

Although included in the mandate of the DSD’s Older Person’s programme, the NGO-sector is currently the leader on training, awareness, and education on dementia-specific issues in South Africa.

Psychosocial support services for carers are limited; however, where these services are offered, for example, they are in the form of support groups by Alzheimer’s South Africa (9 regions/8 provinces) and Dementia-SA (Western Cape province), as well as support services in the home environment in resource constrained settings by NGOs (Van Pletzen, 2013).

References:

Van Pletzen, E. (2013). COMMUNITY CAREGIVERS: THE BACKBONE FOR ACCESSIBLE CARE AND SUPPORT. Available from: https://www.cordaid.org/en/wp-content/uploads/sites/3/2013/09/SA_CAN_Report_26_July2013.pdf

Formal respite services are available in South Africa but are skewed to the private sector. Where public services are available, it is outsourced to the NGO sector to provide this form of care and family support.

The provision of this falls within the mandate of the Older Person’s programme as part of their proposed basket of services for the Integrated service delivery strategy promoting awareness and prevention (see Jordan, 2009), p.12).

References:

Jordan, C. (2009). Older Person’s Programme: Concept paper. Available from: https://www.westerncape.gov.za/other/2009/10/concept_paper-_programme_older_persons.pdf

South Africa is largely a patriarchal society, whereby care is framed as a social practice and places women at the primary location of care within the family/community (Sevenhuijsen et al., 2003) and is viewed as a socially imposed occupation (Gurayah, 2015).

References:

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Sevenhuijsen, S., Bozalek, V., Gouws, A. and Minnaar-Mcdonald, M. (2003). South African social welfare policy: An analysis using the ethic of care. Critical Social Policy, 23(3), 299–321. https://doi.org/10.1177/02610183030233001

Caring for a person living with dementia has been linked to increased stress (e.g., emotional, financial) (Gurayah, 2015), high levels of care burden (Pretorius et al., 2009), and that an increase in social-/relational conflict and stressors may result in the declining physical health of the caregiver (Gurayah, 2015).

References:

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Pretorius, C., Walker, S., & Heyns, P. M. (2009). Sense of coherence amongst male caregivers in dementia: A South African perspective. Dementia, 8(1), 79–94. https://doi.org/10.1177/1471301208099046

Employment: carers are often required to give up formal, paid employment in order to care for their family member on a full time basis, with resulting financial strain, stress and family poverty (Kalula & Petros, 2011; Pretorius et al., 2009).

Younger carers are required to give up employment or their educational attainment in order to care for an ailing parent/family member.

Other impacts include relational deprivation, restrictions of social activities, and being prone to social isolation (Gurayah, 2015; Pretorius et al., 2009).

References:

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

Kalula, S. Z., & Petros, G. (2011). Responses to Dementia in Less Developed Countries with a focus on South Africa. Global Aging, 7(1), 31–40.

Pretorius, C., Walker, S., & Heyns, P. M. (2009). Sense of coherence amongst male caregivers in dementia: A South African perspective. Dementia, 8(1), 79–94. https://doi.org/10.1177/1471301208099046

Caregiving for persons living with dementia in South Africa leads to reduced employment and increased financial burden (Gurayah, 2015), increasing family’s reliance on State social protection mechanisms such at the old age pension grant as well as grant-in-aid.

References:

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

No evidence found.

Research in South Africa has shown that carers for persons living with dementia need substantial material (i.e., cash, food, transport) and emotional support, and that this need increases as the disease progresses (Gurayah, 2015). Carers of persons living with dementia are found to engage in more caregiving tasks than other physical chronic diseases and this was found to be linked to lower quality of life, higher anxiety, and depression (Gurayah, 2015).

References:

Gurayah, T. (2015). Caregiving for people with dementia in a rural context in South Africa. South African Family Practice, 57(3), 194–197. https://doi.org/10.1080/20786190.2014.976946

The NGO and non-profit sector (e.g., TAFTA, ASA, Dementia-SA), and well as faith-based organisations.

According to an online news article, a Facebook support group has been launched by the Livewell Villages (i.e., a private dementia care facility in Cape Town and Johannesburg – see https://www.iol.co.za/lifestyle/health/online-dementia-support-group-launched-16682452), and is reportedly well received by the limited number of participants that are able to access it. This platform is used as a safe space for persons living with dementia as well as family members and carers to come to terms with the diagnosis, as well as manage the effects of dementia (IOL, 2018). GPS tracking technologies are available in the county and are purchased as subscription costs to track the movements of children, vulnerable adults, and belongings. Although these platforms are available in South Africa, it is unclear to what extent social media and technologies are used to provide support in the role of caring for persons living with dementia in South Africa as this data is not publicly available.

References:

IOL. (2018). Online dementia support group launched. IOL Health and Wellness. Available from: https://www.iol.co.za/lifestyle/health/online-dementia-support-group-launched-16682452

Persons with dementia, if eligible, can receive an old age grant (R1780 per month as of 2019) as well as an additional grant-in-aid (R420 as of 2019) to pay for a carer if they cannot care for themselves any longer. If under the age of 60 years, persons living with dementia can apply for a disability grant (also R1780 per month) – which will transfer into an old age pension when the person reaches the age of 60.

No dementia-specific policy/legislation was found that protects employment in the case of a dementia diagnosis. However, South Africa has sound policies on employment equity and employing persons with disabilities (including mental impairment). Although these policies are limited in its reference to persons living with dementia, the following employment protection legislation are relevant:

• Employment Equity Act (no.55 of 1998) provides rules and guidelines to make the workplace free of discrimination for persons with disabilities, including physical and mental impairment (see (Employment Equity Act No.55 of 1998.Pdf, 1998);
• The Employment Equity Act (no.55 of 1998)’s Code of good practice on the employment of people with disabilities provide a framework on the reasonable accommodation and retaining of employment for people with disabilities. In the event where termination of employment becomes an operational requirement (due to the disability), employers are expected to provide employees with the opportunity to apply for any disability benefits available from the organisation (see Government Gazette, 1998).

References:

Employment Equity Act No.55 of 1998.pdf, 1 (1998).

Government Gazette. (1998). EMPLOYMENT EQUITY ACT 55 OF 1998: Code of good practice on the employment of people with disabilities. https://gestaltconsult.com/wp-content/uploads/2017/02/Employment-Equity-Act-People-with-Disabilities.pdf

See 09.01.01, the older person with dementia can apply for a grant-in-aid (R420 as of 2019), and if eligible, can use this to pay for a carer (although the amount is too little to support a full-time carer per month).

Paid leave is a temporary condition of service as long as the person is employed. Once the person is living with dementia, his/her capacity deteriorates and is no longer employed, the need for long term care/absence from work is not supported under the employment conditions. The organisation’s policy on special leave arrangements will apply while still employed, whereas for extended periods of absence beyond policy prescriptions or permanent absence (e.g., resignation or termination of employment), the Employment Equity Act’s (no.55 of 1998) Code of good practice on employment of people with disabilities will apply (Government Gazette, 1998). Medical boarding is a further option as a way for the person to retire.

References:

Employment Equity Act No.55 of 1998.pdf, 1 (1998).

Government Gazette. (1998). EMPLOYMENT EQUITY ACT 55 OF 1998: Code of good practice on the employment of people with disabilities. https://gestaltconsult.com/wp-content/uploads/2017/02/Employment-Equity-Act-People-with-Disabilities.pdf

There is no mechanism in place specifically for persons living with dementia.

There is no mechanism in place specifically for persons living with dementia. Pensioners (i.e., 60 years and over) in South Africa, however, enjoy discounted municipal rates on their property (should they own property) between 40 and 100%.

There is no mechanism in place specifically for persons living with dementia. Pensioners (i.e., 60 years and over) in South Africa, however, enjoy discounted TV-licence rebates.

There is no mechanism in place specifically for persons living with dementia. Pensioners (i.e., 60 years and over) in South Africa, however, enjoy discounted municipal rates on long-distance travel transportation (train and bus liners), as well as discounted access fees to public national parks (Qukula, 2019).

References:

Qukula, Q. (2019). 30 discounts , freebies and rebates for pensioners to take advantage of. Cape Talk. http://www.capetalk.co.za/articles/338645/30-discounts-freebies-and-rebates-for-pensioners-to-take-advantage-of

There is no mechanism in place specifically for persons living with dementia.

Not applicable.

This desk review did not find a published government policy, statement or document detailing the government’s plan or programme for dementia research. Although very limited, there are some research projects in SA on dementia for example:

“Strengthening responses to dementia in South Africa” (STRiDE) project:  Funded by the UK Research and Innovation’s Global Challenges Research Fund (GCRF), the STRiDE Project (2018-2021) aims to contribute to improving dementia care, treatment, and support systems so that people living with dementia are able to live well and family and other carers do not shoulder excessive costs, risk impoverishment or compromise their own health. STRiDE aims to help countries to develop or refine national plans for dementia and achieve its objectives through ten Work packages (WPs) across seven countries: Brazil, India, Indonesia, Kenya, Jamaica, Mexico, and South Africa (see https://stride-dementia.org/).

No evidence found.

Rarely. The STRiDE project is an example of how persons with dementia are involved in the research development process, for example participating in the project’s Theory of Change workshop and serving on the national advisory committees across the 7 STRIDE participating countries (including South Africa).

Moreover, investigational pharmaceutical trials for dementia are available in South Africa, as all clinical trials in South Africa listed as follows: AD and dementia listed under ‘behaviours and mental disorders’ and List of pharmaceutical trials in South Africa on Alzheimer’s (2008-2019): http://www.sanctr.gov.za/SAClinicalTrials/tabid/169/Default.aspx.

Yes. For example, the STARSHINE (i.e., Study of Idalopirdine in patients with mild-moderate Alzheimer’s Disease treated with Donepezil) (see https://clinicaltrials.gov/ct2/show/NCT01955161) clinical trial completed in 2016 sponsored by H. Lundbeck A/S, a Danish research-based pharmaceutical company.

No evidence found.

There is currently no information collected or analysed to assess the healthcare system’s performance for persons living with dementia specifically.

There is no national or provincial dementia plan or strategic framework in South Africa that guides the care, treatment and support needs for persons living with dementia and their families. There is however an Older Person’s Act (no.13 of 2006) and an Older Persons’ Programme, but these are not dementia-specific. Policy developments for dementia also needs to include a focus on HIV-associated dementia (HAD) that, due to the high prevalence of HIV/AIDS in South Africa, changes the landscape of age-associated dementias to include persons 40 years and older (Robbins, Remien, Mellins, Joska, & Stein, 2011; Kalaria et al., 2008). Another important policy gap relates to the legal environment in South Africa that does not cater for dementia-specific needs such as enduring power of attorney and ‘living wills’ for persons living with dementia. South Africa lacks legislation that support decision-making in persons with impaired capacity and needs assisted decision-making provisions or a provision for an enduring power of attorney (Marilyn, 2015). The latter is practiced in other parts of the world, however, does not currently form part of South African law despite being recommended (just over 3 decades ago) in 1988 by the South African Law Commission (Meyer, 2016).

References:

Kalaria, R. N., Maestre, G. E., Arizaga, R., Friedland, R. P., Galasko, D., Hall, K., Luchsinger, J. A., Ogunniyi, A., Perry, E. K., Potocnik, F., Prince, M., Stewart, R., Wimo, A., Zhang, Z. X., & Antuono, P. (2008). Alzheimer’s disease and vascular dementia in developing countries: prevalence, management, and risk factors. The Lancet Neurology, 7(9), 812–826. https://doi.org/10.1016/S1474-4422(08)70169-8

Marilyn, H. (2015). Alzheimer’s – “The window of opportunity.” YE! Available from: https://youve-earned-it.co.za/finance/alzheimers-the-window-of-opportunity/

Meyer. (2016). Legal positions of persons incapable of managing their own affairs.

Robbins, R. N., Remien, R. H., Mellins, C. A., Joska, J. A., & Stein, D. J. (2011). Screening for HIV-Associated Dementia in South Africa: Potentials and Pitfalls of Task-Shifting. AIDS Patient Care and STDs, 25(10), 587–593. https://doi.org/10.1089/apc.2011.0154

Based on the desk review above, the following have emerged as service provision gaps in South Africa:

• Care pathways and diagnostic services for dementia: Differential diagnostics (types of dementia, co-morbidities influencing symptoms for example dehydration, urinary tract infection, etc.);
• Training of primary healthcare workers to recognise and respond to dementia-care needs;
• Specialist training: (1) Re-institutionalisation of specialist training curricula for geriatric nursing by the South African Nursing Council (SANC) that includes a special focus on dementia treatment, care, and support (nurses are the backbone of the country’s PHC system); and (2) Geriatricians and Psychogeriatricians in both the public and private sector;
• Dementia pharmacological treatments for public service users;
• Non-pharmacological approaches to dementia care: Home-based/community-based dementia-care services (i.e., for public service users that are dementia-specific in terms of care, treatment and support for persons living with dementia and their families). For example, home-based nursing care, respite care, training and support of family carers.

• Dementia surveillance (prevalence, epidemiological patterns and trends, health outcomes);
• Monitoring and evaluation of dementia-care services offered (i.e., performance of healthcare system on treatment, care and support for persons living with dementia and their families);
• Effectiveness of dementia interventions (pharmacological as well as non-pharmacological) in South Africa.