Background: Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures. Methods: This was a mixed-methods, cross-sectional study in GP’s five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members’ perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively. Results: Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. Conclusion: In light of South Africa’s move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.

Background: As mortality declined significantly during the fourth and fifth waves compared to previous waves, the question of the future role of COVID-19 vaccination arose among both experts and the public in South Africa. Turning attention away from the general public, now considered to be at very low risk of severe COVID-19 disease, a commonly held view was that the vaccination campaign should focus only on those who remain highly vulnerable to severe disease and death from COVID-19. Primary amongst this group are patients with common chronic diseases attending hospital outpatient departments. We hypothesized that providing COVID-19 vaccinations on-site at a central hospital will increase uptake for the patients with co-morbid chronic conditions who need them most in the Omicron phase of the pandemic. Aim: Evaluate the acceptability, need, and uptake of a hospital-based vaccination site for patients attending the medical hospital outpatient departments. Objectives: To assess vaccination uptake, coverage, and hesitancy in people attending a central hospital, to determine factors associated with and influencing vaccination uptake, and to document implementation and assess acceptability of the vaccination project among staff and persons attending the hospital. Methods: Mixed-methods study using quantitative and qualitative methods. Results: Of the 317 participants enrolled in the study, 229 (72%) had already received at least one dose of the COVID-19 vaccine. A total of 296 participants were eligible for a first vaccination, additional vaccination, or booster vaccination according to the South African Department of Health guidelines. Of those previously vaccinated, 65% opted for an additional dose on the day it was offered (same day). Only 13 previously unvaccinated participants (15% of vaccine naïve participants) opted for vaccination, increasing vaccine coverage with at least one dose from 72% to 76%. Approximately 24% (n = 75) of all participants refused vaccination (vaccine hesitant). Variables tested for an association with vaccination status demonstrated that age reached statistical significance. Emerging themes in the qualitative analysis included perceptions of vulnerability, vaccine safety and efficacy concerns, information gaps regarding vaccinations, the value of convenience in the decision to vaccinate, and the role of health promoters. Conclusions: This study has shown that it is logistically acceptable to provide a vaccination site at a large hospital targeting patients attending outpatient services for chronic medical conditions. This service also benefits accompanying persons and hospital staff. Access and convenience of the vaccination site influence decision-making, increasing the opportunity to vaccinate. However, vaccine hesitancy is widespread with just under one-quarter of all those offered vaccinations remaining unvaccinated. Strengthening health education and patient–clinician engagement about the benefits of vaccination is essential to reach highly vulnerable populations routinely attending hospital outpatient departments with an appropriate vaccination program.

Background: Before coronavirus disease 2019 (COVID-19), global health was improving, with declining mortality trends. The pandemic disrupted this progress, increasing mortality in South Africa between April 2020 and March 2022. Pre-pandemic data establishes a baseline for assessing COVID-19’s impact on all-cause mortality. Objectives: This study examines changes in hospital-based mortality trends in a Gauteng hospital complex from April 2018 to March 2022, addressing the scarcity of such studies during the COVID-19 era. Method: A retrospective review of 7815 deaths from April 2018 to March 2022 was conducted. Chi-squared tests were used to analyse deaths by age group and gender, with correlations reported. Results: Mortality rates rose from 3.2% in 2018–2019, peaked at 5.1% in 2020–2021, and declined to 4.2% in 2021–2022. Patients aged 15 years–64 years had the highest death rates, with an increase among those over 65. Male deaths exceeded female deaths, with the smallest difference observed in 2020–2021. Leading causes of death included diseases of the circulatory and respiratory systems, neoplasms, digestive system diseases, and infectious and parasitic diseases. Conclusion: The study highlights COVID-19’s impact on mortality, showing variations by year, age, gender, and disease. Contribution: Excess non-COVID-19 deaths likely stemmed from disrupted healthcare services. These findings underscore the need for ongoing monitoring of hospital mortality to identify pandemic-related service disruptions and guide interventions to strengthen healthcare services, improve access to care, and enhance referral systems during unexpected disasters.

Background: Screening for traditional risk factors of cardiovascular disease is well known in primary healthcare (PHC) settings. However, other risk factors through newer tools (such as bioelectrical impedance analysis [BIA]) could also be predictors of increased cardiovascular risk (CVR). Body composition estimates (body fat percentage, body water percentage, body lean mass) by BIA and its association to CVR have been studied with variable results. Aim: This study assesses the body composition estimates and their association with CVR in the South African PHC setting. Methods: A retrospective record analysis was conducted on a cohort of de-identified patients utilising the ABBY® Health Check Machine at a PHC facility in South Africa between May 2020 and August 2022. The ABBY Machine estimates body fat percentage (BF%) and body water percentage (BW%) estimates from BIA. Cardiovascular risk based on the Framingham-risk-score was stratified into high, medium and low CVR. An analysis of variance was used to determine mean differences of BF% and BW% among these groups. Results: A total of 4008 records (n = 4008) were used in the final analysis. The majority of patients were female (70.1%) with a mean age of 33.6 years. Higher mean BF% (35.75% vs. 31.10% vs. 27.73%; p < 0.0001) and lower mean BW% (49.46% vs. 53.15% vs. 56.18%; p = 0000) were found to be significantly associated with high CVR. Lessons Learnt: This study demonstrated the use of newer technologies that could assist in the identification of CVR in low resource PHC settings.

Background Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the National Health Insurance policy, which underscores the importance of primary health care, delivered through the district health system (DHS). In light of this, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province, and the perceptions of members on the functioning and effectiveness of these structures. Methods The study was done in all five districts in Gauteng. The population of interest was members of existing governance structures. Members completed an electronic-self- administered questionnaire (SAQ), which collected perceptions on the functioning and effectiveness of the governance structures, using a seven-point Likert scale. STATA® 13 was used to analyze the survey data. In-depth interviews with the chairpersons of the DHCs and the District Health Council Technical Committees complemented the survey. Interviews were analyzed using thematic content analysis. Results Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD=0.7) and 4.8. (SD=0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, exacerbated by political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. Conclusion In light of South Africa’s move toward NHI, strengthening the governance of the DHS is imperative. The governance gaps identified need to be addressed to ensure the successful implementation of UHC reforms.