Health and Related Indicators, 2023

undefined

Introduction

In his acclaimed book, The Emperor of All Maladies: A Biography of Cancer,¹ Siddhartha Mukherjee powerfully reminds us that cancer is not a singular disease but a collection of many, aptly describing it as “the defining plague of our generation”^1(p18) and a “lethal shape-shifting entity imbued with… penetrating metaphorical, medical, scientific, and political potency.”^1(p18) Mukherjee’s characterisation underscores the complex and multifaceted nature of cancer, which continues to pose significant challenges to healthcare systems around the world.

The South African Health Review 2023 (Review) focuses on examining the successes, challenges, and gaps in cancer treatment and care within the South African healthcare system. Central to this examination is the National Cancer Strategic Framework 2017–2022 (NCSF), the current guiding policy document for cancer control in the country. Despite its outdated status, the NCSF remains a critical framework for understanding and addressing cancer care in South Africa.²

The NCSF highlights the importance of the National Cancer Registry (NCR), established in 2011, and the subsequent regulations under the National Health Act of 2003, which mandate the reporting of confirmed cancer diagnoses. However, the strategy also exposes significant deficiencies in the availability of comprehensive data on the cancer burden in South Africa. For instance, while the strategy notes that cancer-related deaths account for approximately 9% of all-cause mortality in adults, it fails to provide data on cancer mortality among adolescents and children. Furthermore, the NCSF underscores the persistent inequities in access to cancer care, particularly affecting “black Africans, poor, uninsured, and rural residents.”^2(p9) These gaps highlight the urgent need for updated policies and more inclusive cancer care initiatives to ensure equitable access and improved outcomes for all South Africans. The next section presents the cancer indicators, focusing particularly on the cancer profile for South Africa, as captured from international databases such as the Global Cancer Observatory and the local databases such as the NCR and webDHIS.

Cancer indicators

The World Health Organization (WHO) defines cancer as a large group of diseases that can affect any part of the body, also known as neoplasms or malignancies.³ Cancer incidence is rising globally and locally in South Africa, with cancer being the second leading cause of global mortality.⁴ The burden of cancer on the African continent is expected to double in the next 20 years as the population ages, where currently, cancers account for 10-20% of morbidity.⁵

Global Cancer Statistics 2020 (GLOBOCAN) provides estimates of cancer incidence and mortality across 185 countries.⁶ In 2020, there were an estimated 19.3 million new cancer cases and almost 10.0 million cancer deaths worldwide. Female breast cancer was the most commonly diagnosed cancer, responsible for an estimated 2.3 million new cases in 2020, followed by lung, colorectal, prostate, and stomach cancers. Lung cancer remains the leading cause of cancer death, accounting for an estimated 1.8 million deaths globally. The global cancer burden is expected to reach 28.4 million cases in 2040.^5,6

The International Agency for Research in Cancer (IARC) is the driving force behind the Global Initiative for Cancer Registry Development (gicr.iarc.fr), a collaboration of leading cancer prevention organisations that aims to address data availability while ensuring the reliability of cancer incidence data by enhancing their quality, comparability, and use. Data collected in this framework is available through IARC’s GLOBOCAN database. The estimated number of cancer cases and deaths from 2002 through 2018 is available at the Global Cancer Observatory (http://gco.iarc.fr). In assembling regional and global profiles, the GLOBOCAN methods for incidence and mortality estimation rely on the best available data from a given country.⁷ The Global Cancer Observatory provides access to updated figures at a national level.⁸ The 2022 South Africa fact sheet reported 111 321 new cancer cases in 2022, 282 418 prevalent cases and 64 547 cancer deaths.⁹ Data from the NCR, for 2015 to 2022, are shown in Figure 1, Figure 2 and Figure 3. In the South African context, the most commonly diagnosed cancers in women are breast, cervical, skin and colorectal cancer. Similar to the global context, the most common cancers in males in South Africa are prostate cancer along with skin, colorectal and lung cancers.⁴

Despite recent initiatives aimed at improving cancer epidemiology in Africa, data on cancer rates remain fragmented and are often dispersed across multiple registries, making comprehensive analysis challenging.⁷ In South Africa, where the cancer incidence rate is notably high, the situation is further complicated by a significant lack of up-to-date, reliable data. The most recent data published by the NCR covers only up to 2022, leaving a substantial gap in our understanding of the current cancer burden. This lack of current data poses serious challenges to assessing the prevalence and impact of cancer in the country accurately. Without timely and comprehensive data, it becomes difficult to monitor trends, allocate resources effectively, and develop targeted interventions. Figure 1, which illustrates the number of cancer diagnoses among males and females in South Africa from 2015 to 2022, underscores this issue. While the figure provides some insight, it is widely believed that the numbers represented account for only a fraction of the actual cancer cases in the country.

There are significant concerns about the underreporting of cancer cases, which can be attributed to several factors. One major issue is the misattribution of death causes, where cancer is often not recorded as the primary cause of death, leading to inaccurate mortality statistics. Additionally, underreporting by medical facilities, due to insufficient training or inadequate reporting systems, further contributes to the data gap. Another critical limitation is the NCR’s reliance on pathology-based diagnoses, which excludes cases where cancer is diagnosed clinically or radiologically but not confirmed through pathology. This restriction means that many cancer cases, particularly in regions with limited access to pathology services, are not captured in the official statistics.

The cumulative effect of these factors is a substantial underestimation of the true cancer burden in South Africa. This underreporting hampers the ability of public health authorities to understand fully the scope of the problem, design effective cancer control programmes, and evaluate the success of existing interventions. To address these challenges, there is an urgent need to improve cancer data collection and reporting mechanisms, expand the scope of the NCR to include non-pathology-based diagnoses, and ensure that all healthcare facilities are equipped and mandated to report cancer cases accurately and consistently. Only with more reliable and comprehensive data can South Africa hope to combat the growing cancer epidemic effectively and improve outcomes for all affected individuals.

In 2023, Statistics South Africa (Stats SA) produced a report¹⁰ with a specific focus on cancer occurrences and their contribution to morbidity and mortality in South Africa. The report illustrates the trends over time and outlines their burden on each population group and age group between 2008 and 2018. Stats SA found that, in 2018, cancer and benign tumours accounted for 9.7% of all mortality in the country, making these the fourth leading cause of death.

Cancer profile in South Africa

Figure 3 presents cancer age standardised incidence (per 100 000) by sex and type of cancer among the top three invasive cancers in the South African male and female populations.¹² Across all cancers presented in Figure 3, cancer burden in males increased sharply from the year 2019 for prostate, colorectal, and lung cancers. However, a reduction in incidence was seen post-COVID-19 for prostate cancer only, while colorectal and lung cancer continued to increase. Male breast cancer incidence declined consistently from 2015 through 2019 and then increased sharply to 2022. The highest burden in females was seen during the COVID-19 pandemic period, where breast, cervical, and colorectal cancer presented with the three highest incidences per 100 000, respectively. Surprisingly, unlike the male cancers, female cancer incidences did not decline post-COVID-19. The apparent increases in new cancer cases could possibly be due to the reported decline in cancer diagnostics during the pandemic. A study to assess the impact of COVID-19 on cancer diagnostic services in 2020 in the Western Cape, found declines in six major histopathological diagnoses.¹² Substantial declines were seen for prostate, oesophageal, breast, gastric, and colorectal cancer. The smallest decline was seen in cervical cancer. These data, although generated from a single context, along with the current trends of the top three most invasive cancers, show evidence of the impact caused by national disruption of cancer diagnostic services as result of the pandemic. Additional efforts are required to optimise diagnostic services, ensuring timely initiation of treatment.

Cancer and Kaposi sarcoma

The high prevalence of HIV in South Africa necessitates an understanding of the burden of cancer associated with HIV. The age-adjusted incidence rate (per 100 000) trends from 2015 to 2019 remained consistent, reaching a peak in 2020 before reverting to the pre-COVID-19 trends in 2021, as per data from the NCR. Throughout this reporting period, males consistently demonstrated a heavier burden than females. Furthermore, a record linkage study, which evaluated the burden and association between HIV and cancer during the decade of 2004-2014, reported that 30 487/46 951 (65%) of all female cancer cases and 16 443/46 951 (35%) of all male cancer cases were among people living with HIV (PLHIV).¹³ Altogether, PLHIV were at higher risk of AIDS-defining cancers compared to HIV-negative patients. Collectively, the incidence of Kaposi sarcoma, and other AIDS-defining cancers needs to be monitored in PLHIV.

Cancer programme coverage in Africa

Overall, the evidence underscores the need for innovative interventions and strategies, including enhanced education about cancers and surveillance across all population groups. One of the most important interventions is vaccination against human papillomavirus (HPV), which has the potential to advance eradication of cervical cancer in women. Figure 4 shows the dramatic negative impact on HPV vaccine coverage during the COVID-19 pandemic, as reported by WHO.¹⁴ Coverage has not yet recovered to pre-pandemic levels. As per the Global Strategy for Cervical Cancer Elimination,³ each country should introduce HPV in the national immunisation schedule by 2030 and meet the target of 90% of girls fully vaccinated with HPV vaccine by age 15. A WHO dashboard contains data on the status of HPV vaccine introduction in WHO member states.¹⁴

Figure 5 shows a similar impact on cervical screening coverage, with modest recovery post-pandemic, presumably due to diagnostic service rearrangement following the brief suspension of cancer screening services.¹⁵

Lung cancer

The Tobacco Products and Electronic Delivery Systems Control Bill (Bill 33 of 2022) has been tabled but will need to be revived by the new Parliament.¹⁷ Van Eeden et al. have pointed out that there are no official lung cancer screening programmes in South Africa.¹⁸ These authors also note that improved thoracic surgery, systemic therapies, pathological research, and lung tumour radiation are mostly available in the private sector in South Africa. Public sector patients “have limited access to treatment, and those who do are often managed with the use of simpler techniques and very basic therapies.”^18(p27) Qualitative data reveal that KwaZulu-Natal public sector lung cancer screening, early diagnosis, treatment, and palliative care are inadequate.¹⁹ However, statistics for sector-specific treatment results are hard to find. In 2022, GLOBOCAN reported that lung cancer was the second most diagnosed new cancer in men (11.6%) and the fourth in women (5.8%). Lung cancer was diagnosed in 9 446 South African men and women in 2022. In the same year, 8 672 died from lung cancer.⁸

Breast cancer

Breast cancer data show large public-private care discrepancies. Breast cancer incidence has increased, but South Africa has a lower incidence and higher death rate than high-income countries due to lower screening rates and poorer access to care.²⁰ In addition, poorer outcomes may be linked to a higher proportion of triple-negative breast cancer in patients who are black African. Women in South Africa tend to present with late-stage disease, reflecting poor screening and access to diagnosis and care.

Health and socio-economic indicators: burden of disease and beyond

As in previous editions of the Review, the next sections of this paper aim to provide a repository of provincial and national data describing the current status of the South African health system (socio-demographic indicators and determinants, health-status indicators, and health-service indicators). The paper can also, at least in relation to the public sector, be read together with the most recent edition of the District Health Barometer (DHB), which has been published after a short hiatus.²¹ Like the DHB, the Review aims to highlight inequities in health outcomes and health-resource allocation and delivery. Cancer is by no means immune to the effects of those inequities.

Data sources

The key new or updated sources relied upon, at both an international and a national level, are shown in Box 1. Specific references and the current indicator definitions are provided in the data tables. Many of the indicators are normalised using population denominators.

The 2022 Census conducted by Stats SA is a cornerstone for policy development and resource allocation across the nation. While the census data is intended to provide an accurate snapshot of the country’s demographics, concerns have been raised regarding their validity and accuracy, with some stakeholders questioning the reliability of the published data.²² In response, Stats SA has strongly refuted these claims, defending the robustness of their methodologies and the accuracy of the results.²³ Despite this, the debate highlights the critical importance of data integrity in shaping informed decision-making.

Demographic indicators

Population dynamics influence the implementation of strategies for achieving sustainable development goals within a country. The COVID-19 pandemic, which lowered the country’s life expectancy in 2021 and had an influence on mortality and migration, began four years ago. The COVID-19 pandemic caused a demographic shift in death and morbidity, notably among older people. However, it is unknown whether the pandemic had any long-term consequences on demography, such as changes in age structure or fertility.⁴⁹ Every year, Stats SA produces mid-year population estimates (MYPEs). However, due to the release of Census 2022 findings in 2023, no MYPEs were issued for 2023.

According to the Census 2022 statistics, South Africa’s total population has climbed to 62 million individuals from 51 million in 2011. The findings also show that the populations of the Western Cape, Gauteng, North West, and Northern Cape have increased due to internal migration, with more individuals moving into these provinces rather than out. By contrast, Limpopo, the Eastern Cape, and KwaZulu-Natal have greater out-migration rates. These figures have significance for the National Treasury’s equitable share allocation mechanism, which determines the provincial allocation of budget for health programmes from the fiscus. The basic demographic figures are provided in Table 1.

Figure 6 depicts South Africa’s ageing population. An elderly population is also more likely to develop non-communicable diseases. South Africa has a higher proportion of females than males, with the gap becoming apparent between the ages of 54 and 59. Between 2013 and 2021, the adolescent fertility rate was 40.7 per 1 000 girls aged 15 to 19.²⁴ South Africa’s median age is 28 years, and it is predicted that 61.2% of the population is aged 15 to 34.³³ As a result, South Africa could profit from capitalising on the economic benefits of its age structure by boosting the proportion of working-age adults compared to young dependents.

Table 2 contains revised estimates for uninsured people by province and district, which are key denominators for a variety of health measures.

Socio-economic and environmental risk factors

The social pathways of health reflect conditions in which populations navigate life on a day-to-day basis, such as employment status, education, air pollution and climate change.³² All of these factors have an impact on people’s livelihoods and health status.

Human development and inequality

The United Nations Development Programme’s 2023/2024 Human Development Report investigates impediments that polarise the world’s inequities in health, education, gender, and income. According to this report, South Africa is ranked 105 out of 193 countries, in terms of the Human Development Index (HDI).²⁹ The HDI for South Africa shows improvements between 2000 (0.695) and 2019 (0.727), but then begins to decline in later years, particularly during the COVID-19 pandemic, and has continued to decline.

In understanding global poverty, the Human Development Report Office (HDRO) and the Oxford Poverty and Human Development Initiative produce the Multidimensional Poverty Index (MPI) for 110 developing countries, including South Africa.⁵³ The MPI is based on the latest household-level survey data and considers various dimensions of poverty, such as nutrition, years of schooling, school attendance, child mortality, cooking fuel, housing, sanitation, electricity, drinking water, and assets. The MPI value represents the proportion of the population that is multi-dimensionally poor, adjusted by the intensity of their deprivations.

Social inequality and unemployment

For South Africa, the MPI value is 0.025. Approximately 0.9% of South Africans are in severe multidimensional poverty, 12.2% are vulnerable to multidimensional poverty, and 20.5% are below the income poverty line.³⁰

South Africa continues to struggle with social inequality in a constrained economy and limited fiscal space. Table 3 shows that, by the conclusion of the fourth quarter of 2023, South Africa had about 7.9 million unemployed people. However, the economy contracted by 0.63%, following a 1.2% gain in the fourth quarter of 2022.⁴¹

Air pollution and health

It is reported that one in every eight deaths globally is due to air pollution exposure, that is, more than human immunodeficiency virus (HIV), tuberculosis (TB) and malaria combined.⁵⁴ According to the World Health Statistics, 8.8% of South Africans rely on clean fuels to use for cooking, heating and lighting, despite the fact that clean fuels such as solar and biogas have been shown to meet the guidelines for indoor pollution.^24,55 Aerodynamic pollutants with a diameter of less than 2.5μm, referred to as particulate matter (PM_2.5), can damage the respiratory tract. Figure 7 demonstrates that Gauteng and the Northern Cape have the highest amounts of PM_2.5. In the Northern Cape, this can be related to the dispersion of mining dust or sand from the Namib Desert, as well as salt from the Atlantic Ocean. In Gauteng, this is attributed to pollution from vehicles and industry.⁵⁶

Monitoring air pollution

Monitoring air pollution, specifically PM_2.5 levels, is critical for tracking progress towards the Sustainable Development Goals (SDG indicator 3.9.1). The WHO recommends limiting yearly PM_2.5 concentrations to 5 μg/m³ (annual average) and 15 μg/m³ (24-hour average) for more than 3-4 days per year. According to IQAir, a Swiss business, most countries are failing to meet the WHO health guideline for PM_2.5, based on data from at least 30 000 monitoring stations worldwide.⁵⁸ Figure 8 illustrates that PM_2.5 monitoring in South Africa is sparsely dispersed, with data accessible mostly in industrial and mining cities with high PM_2.5 concentrations. As such, air pollution research could focus on understanding the spatial heterogeneities of air pollution exposure that may occur in South Africa. Air pollution is a public health hazard, and the actions and instruments to combat it are unevenly distributed around the world. The WHO defines quality of life as the population’s physical health and social relationships with the environment, and there are major differences in how air pollution impacts them.⁵⁹

Adebayo et al. have pointed out that air pollution, in particular PM_2.5, is associated with the mortality of people with comorbidities.³⁵ Burnett et al. argue that exposure to PM_2.5 may be associated with additional causes of death than the usual top five considered by the Global Burden of Diseases.³⁶ According to the Air Quality Life Index (AQLI) report, if PM_2.5 pollution is permanently eliminated to meet the WHO guidelines, it would result in an increase in the average human life expectancy by 2.3 years.⁵⁷ The impact of PM_2.5 on global life expectancy is comparable to that of smoking elimination, over three times greater than that of alcohol use and unsafe water, more than five times larger than transport injuries like car accidents, and over seven times greater than that of HIV/AIDS.³⁴

Water quality and public health

The Department of Water and Sanitation’s Green Drop Watch Report is a crucial initiative to monitor wastewater systems, both at the municipal and provincial levels. The 2023 report highlights that 334 municipal wastewater treatment systems (spread across all provinces) were deemed to be in critical condition in 2022, having received Green Drop scores below 31%.⁴⁴ Similarly, the Blue Drop Watch Report sheds light on the present state of potable water infrastructure in South Africa.⁴³ Although the Stats SA General Household Survey 2022 results indicate that the majority of the population in South Africa has access to safe drinking water, the Blue Drop Watch Report reveals a concerning reality, where 51% of water systems across the country exhibit poor to bad microbiological water quality. Furthermore, only 16% and 14% of water systems demonstrate excellent and good water quality, respectively. A staggering 71% of water plants fail to meet chemical compliance standards.⁴³ Such findings have significant public health implications, as consumption of contaminated water can increase the risk of waterborne diseases such as cholera. For instance, contamination from the Apies River at the Rooiwal treatment plant led to an outbreak of cholera in the Hammanskraal community in 2023.⁶⁰

Disability

Globally, an increase in the reported number of people with disabilities is linked to an ageing population, particularly in high-income countries.²⁶ Similar trends are expected to be observed in low- and middle-income countries, where the impact of successful treatments for conditions that were previously life threatening has increased life expectancy.⁶³ The Fordham Research Consortium on Disability released a report in 2023 on the availability of disability data and the potential to produce disability disaggregated indicators at national and subnational levels.⁴⁰ The report showed that data on the inequities experienced by people with disabilities between and within nations is insufficient, with most national statistics offices failing to publish on data disaggregated by disability status. Only one in five of the datasets that were reviewed between 2009 and 2022 had any questions on functional difficulty.²⁶ People with disabilities will continue to be left behind in global agendas unless the prevalence of disability is quantified accurately. Households headed by people with disabilities have been found to have less access to basic services than households headed by people without disabilities.⁶⁴

According to the Fordham study, 22.4% of persons aged 15 years and older had functional difficulty, with hearing and vision difficulties accounting for 5.4% and 14.4% respectively.²⁶ These estimates are in contrast with the recently reported disability prevalence from the 2022 Census, which was merely 6%.³³ Both assessments indicated that the Eastern Cape had the highest prevalence of disability. This is illustrated in Table 4.

Cataract surgeries

From 2009 to 2016, the Western Cape had the highest rate of cataract operations. However, from 2017 to 2019, the Free State led in cataract surgery rates, rising from 2 140 to 2 628 per 1 million uninsured population. From 2020 to 2022, KwaZulu-Natal had the highest cataract surgery rate, at a time when cataract surgery rates were low across all provinces (Figure 9).

The overall number of cataract surgeries performed in all provinces has steadily increased from 49 383 in 2017 to 58 808 in 2019. Although the national number of cataract surgeries increased by approximately 18.7% between 2017 and 2019, this is a consequence of KwaZulu-Natal almost doubling their rate and the Free State increasing the number of surgeries performed in this period. Generally, however, the surgery rate declined across the provinces, with Limpopo experiencing the largest drop in cataract surgery rate (Figure 10). All provinces experienced a reduction in 2020, followed by an increase after 2020. After 2020, KwaZulu-Natal, Gauteng, and the Western Cape showed the greatest recovery in the total number of surgeries performed. Limpopo had the third highest recovery in terms of the rate of cataract surgeries in the same period. Notably, no operations were reported for Mpumalanga after 2019. This pattern matches the issues faced by other South African health facilities during and after the COVID-19 pandemic.

Health status indicators

Infectious Disease

Tuberculosis

Global mortality and incidence

The Global Tuberculosis Report 2023 noted that, despite being avoidable and usually curable, TB was the second highest cause of mortality from a single infectious agent in 2022, accounting for nearly twice as many fatalities as HIV.²⁷ In the post-pandemic age, TB is expected to reclaim the top spot. However, the globe is falling short of its TB targets, in part due to disruptions caused by COVID-19. In 2022, TB was expected to kill 1.30 million people worldwide, nearly the same number as in 2019. The WHO End TB Strategy sets a global target of 75% mortality reduction between 2015 and 2025.²⁷ In 2022, the global incidence of TB was expected to be 133 new cases per 100 000 population. In 2022, an estimated 10.6 million people contracted TB. The global treatment gap between the projected number of persons newly infected with TB (incident cases) and the reported number of people diagnosed (notified cases) was 3.1 million.

Local impact and changes in South Africa

The local numbers presented in Table 5 mask a number of significant changes over time. According to WHO, South Africa was one of just 21 countries that had at least a 50% decline in TB incidence between 2015 and 2022, and was the only high-burden country among this group. However, it is sobering to note that South Africa continues to appear on all three high-burden lists for TB, HIV-associated TB, and multi-drug resistant/rifampicin-resistant TB. China, India, Indonesia, Mozambique, Myanmar, Nigeria, the Philippines, and Zambia also appear on all three lists.

Although their impacts will eventually be detectable in the outcome measures reported, the most recently reported figures do not yet show the effects of changes in treatment and prevention regimens that are in the process of being implemented in South Africa. The National Guidelines on the Treatment of Tuberculosis Infection were updated in 2023.⁶⁵ Notably, these guidelines included expanded access to TB preventive treatment (TPT). In addition, new TPT regimen options were included, including isoniazid and rifapentine given once weekly for three months (3HP) and daily rifampicin and isoniazid for three months (3RH), in addition to the longer isoniazid-only regimens (daily isoniazid for six months (6H) or daily isoniazid for 12 months (12H)). The guideline states that shorter treatment options should be offered where feasible and available.⁶⁵

Management of rifampicin-resistant TB

The national guidelines for the Clinical Management of Rifampicin-Resistant Tuberculosis (RR-TB) were also updated in 2023.⁶⁶ South Africa has adopted the WHO recommendation to follow a 6-month, all-oral regimen of bedaquiline, pretomanid and linezolid, with or without moxifloxacin or levofloxacin (BPaLM or BPAL-L). The impact of de-institutionalised and decentralised RR-TB care has yet to be seen in the routine data but will be closely watched. Of note for the indicators reported, the term RR-TB is used in the guidelines to refer to all forms of resistant TB.

HIV

Progress towards global targets

South Africa adopted WHO’s Universal Test and Treat (UTT) recommendation in 2016.⁶⁸ The UTT standards support the UNAIDS 90-90-90 treatment target to end the AIDS pandemic, which has now been revised to 95-95-95. The initial target was that by 2020, 90% of PLHIV would know their status, 90% of those would be on antiretroviral treatment (ART), and 90% of those on treatment would achieve viral suppression. WebDHIS reported figures of 89-76-88 for South Africa in 2020.¹⁶ Despite the UTT recommendations, South Africa failed to meet ART uptake and virus suppression targets, with only 78% virally suppressed.²⁹ Figure 11 shows progress towards the 2030 goal of 95-95-95.

UTT estimates as of the 2022/23 financial year reported by the Thembisa model v4.6,⁶⁹ the Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI),³⁵ and the Antenatal Survey of Pregnant Women³⁶ across both sexes and at varying age ranges are presented in Figure 12.

The steady decline in almost all epidemic estimates demonstrates the benefits of HIV services provided in accordance with UTT recommendations. The number of new HIV infections fell from 210 000 in 2021 to 160 000 in 2022, across all ages. AIDS-related deaths declined from 51 000 in 2021 to 45 000 in 2022. However, as treatment access improves, prevalence also increases. In 2021 and 2022, the number of PLHIV increased from 7.5 million to 7.6 million. Table 6 presents additional provincial HIV indicators.^29,70

Women aged 15 to 49 continue to have higher infection rates than other age groups. In 2021 and 2022, this group reported 130 000 and 100 000 new cases, respectively.^29,70 According to a recent Human Sciences Research Council national population survey, age-disparate relationships, limited access to testing and treatment facilities, and a lack of condom use may increase the burden on the 15-49-year-old demographic.^71–73 Continued focus on disaggregated data relevant to this and other vulnerable groups is therefore critical.

Retention on ART

At the end of March 2023, a total of 5 326 130 adults and adolescents in South Africa were reported to be on ART in the public sector, according to webDHIS.¹⁶ KwaZulu-Natal had the most patients on ART, with 1 529 901, while the Northern Cape had the fewest, with 65 167 (Figure 13). In addition, 111 783 paediatric patients were reported to be on ART. Figure 14 shows that 31 389 paediatric patients were from KwaZulu-Natal, while only 3 696 were from the Northern Cape.

The 2017 and 2019 National Prenatal HIV Sentinel Surveys reported results of 96-87-64 and 98-96-66, respectively, for the 90-90-90 HIV objectives among prenatal patients by the end of 2020. The 2022 survey findings, which included 10 726 participants, revealed that 96% (10 300) of these women already knew they were living with HIV before being screened at an antenatal visit. Of those who knew their status, 99% (10 166) had already started on ART, and 74% were virally suppressed.⁷⁵ Thus, while the second 95 target had already been met by 2022 in pregnant women, the third 95 target, related to viral suppression, showed a concerning deficit, as depicted in Figure 15.

The shift to a Dolutegravir (DTG) containing first-line ART regimen in December 2019 was done due to an expected improvement in adherence and also viral suppression.⁷⁶ A study conducted by Asare et al.,⁷⁷ in 2024 in the eThekwini municipality, involving patients transitioned between December 2019 and November 2020, demonstrated that DTG-based regimens were associated with comparable or superior retention in care and enhanced viral suppression when compared to the previously recommended treatment protocols. Figure 16 shows KwaZulu-Natal had the highest uptake (80.8%) of the DTG-based regimen in antenatal women, with uptake the lowest in the Northern Cape (35.6%). It will be critical to monitor prenatal viral loads at both national and provincial levels, in order to track progress against the targets.³⁶

HIV drug resistance

Antiretroviral drugs are at risk of being partially or fully inactive against HIV, due to the ever evolving genetic structure of HIV.⁷⁸ Inability to reach viral suppression targets due to HIV drug resistance (HIVDR) can have human cost and negative impacts on the national health budget. WHO’s Africa Regional Action Plan 2019-2023 was intended to monitor and actively conduct HIVDR surveillance in Africa through nationally representative surveys.⁷⁹ From 2014 to 2016, the only South African data reported were for infants under 18 months of age, with 63.7% resistance to efavirenz or nevirapine. Other populations have been surveyed outside of South Africa.

While South Africa and other low- and middle-income countries have employed DTG to combat HIVDR, more regular nationally representative surveys are required for effective HIVDR surveillance. The HIV indicators by province are captured in Table 6.

Maternal and reproductive health

Table 7 presents the maternal and reproductive health indicators by province for the financial year 2022/23.

Maternal mortality

The number of maternal deaths that occurred in public health institutions peaked in 2020/21, and then began to decrease in 2021/22. As depicted to Figure 20, the number of maternal deaths was highest in Gauteng, while the Northern Cape recorded the lowest number. Since the COVID-19 pandemic, maternal mortality rates have decreased, perhaps indicating that maternal services have recovered. Likewise, the maternal mortality ratio (MMR) per 100 000 live births peaked in 2020/21 and then declined in 2021/2022. The MMR was highest in the Free State in 2020/21 (178.8 per 100 000 live births). In 2021/22, the MMR was highest in the North West province (129.9 per 100 000 live births). Following the COVID-19 pandemic, the MMR and the number of maternal deaths continue to decrease, as shown in Figure 20.

Condoms

A recent Spotlight NSP report, based on data from the District Health Barometer, revealed a substantial drop in condom distribution in South Africa over the past five years.⁸⁰ Contrary to this tendency, female condom distribution was steadily increasing prior to the epidemic. Figure 17 depicts how the distribution of female condoms grew dramatically across most areas following the pandemic. Data from the Thembisa 4.2 and 4.6 models demonstrate a consistent increase in condom use during last sexual encounter among both sexes in the 15-24 and 15-49 age groups, despite disruptions in health care due to COVID-19.⁶⁹

Teenage pregnancy

According to Stats SA General Household Survey reports, teenage pregnancy steadily ranged between 5.1-5.7% from 2017 to 2019³⁴, reaching a high of 5.7% at the beginning of the COVID-19 pandemic as shown in Figure 18. Although there was a declining trend from 2019 to 2021, there was a sharp increase in 2022. Teenage pregnancy is associated with poor access to contraceptive services, risky behaviour, coercive and unprotected sexual contact, and increased exposure to sexually transmissible infections.⁸¹ Unwanted pregnancies in teenage mothers are therefore indicative of poor access to sexual and reproductive health rights and services.

From 2020 to 2023, South Africa experienced slight declines in the number of births occurring in healthcare facilities under supervision of trained staff, as shown in Figure 19. This trend warrants monitoring, given reports of mistreatment of pregnant women.^82,83 Anxieties about attending health facilities during the COVID-19 pandemic most likely contributed to reduced in-facility live births between 2020 and 2022. Marginal recovery post-COVID-19 in some provinces suggests that fear of contracting COVID-19, and other structural factors such as lack of transport, potentially persist.⁸⁴

The maternal and reproductive health indicators are presented in Table 7.

Child health

Childhood immunisation coverage

Immunisation represents the most cost-effective child health intervention, as outlined in the Immunisation Agenda 2021-2030.⁸⁵

South Africa continues to experience unacceptable under-five mortality. In 2022/23, 723 children died from diarrhoea, and 939 from pneumonia. KwaZulu-Natal had the highest diarrhoea and pneumonia deaths, while the Northern Cape had the fewest. The Eastern Cape had the highest diarrhoea case fatality rate, whereas Mpumalanga and Eastern Cape had the highest pneumonia rates, as depicted in Table 8. In 2022 and 2023, the third dose of the pneumococcal conjugate vaccine (PCV) recorded coverage of 89.2% and 84.2%, respectively. Coverage of the second dose of the rotavirus vaccine (RV) in the same years was 83.5% and 77.6%, respectively. Vaccine coverage for both antigens was therefore lower than in the previous year, as shown in Figure 21. National or provincial coverage percentages can hide other disparities, such as delays in immunisation scheduling. Four Western Cape public sector facilities found that coverage fell from birth to 18 months, with the third diphtheria-tetanus-pertussis (DTP) vaccination dose delayed the most (defined as receiving immunisations more than 28 days after the recommended schedule age).⁸⁶ Lower socioeconomic status and upper-middle socioeconomic status were risk factors for delayed or skipped immunisation, possibly due to work demands.⁸⁷

As an indicator of the efficacy of routine immunisation services for children, the WHO recommends that countries achieve a minimum of 90% coverage for the third dose of diphtheria-tetanus-pertussis (DTP3).²⁸ South Africa’s immunisation coverage is still below optimal levels, not only for DTP3, but also for all age-specific immunisations. Additional age-specific immunisation data are documented in Table 8 and Figure 22.

Vaccine preventable disease outbreaks

It is crucial to achieve optimal coverage in childhood immunisation to prevent disease outbreaks and ensure community immunity.⁸⁸ A situation report regarding a measles outbreak was published by the NICD on 26 January 2023. The report confirmed 421 laboratory-diagnosed cases from epidemiological week 40 of 2022 to the middle of week 3 of 2023. In provinces that were affected by outbreaks, the 5-9-year-old age group comprised the majority of cases (160/406, 39%). The under-1-year age group accounted for the highest proportion of cases, with 15/27 (59%), originating from hospitals rather than primary health care clinics. Nevertheless, the age group of 10-14-years continued to experience cases (64/406,16%), underscoring the importance of including this demographic in a vaccination campaign.⁸⁸

Similarly, a rise in laboratory-confirmed pertussis cases from the pneumonia surveillance programme was seen in 2022/3, particularly in the Western Cape, Mpumalanga, Gauteng, KwaZulu-Natal, and North West, as depicted in Figure 23.⁸⁹ The NICD received 818 pertussis case reports from 1 January 2022 to 19 January 2023, with 95.8% (784/818) occurring between July 2022 and January 2023. The Western Cape reported 60.2% (472/784) of the 784 cases. The majority (58.0%, 455/784) of reported cases were in children under five, with 78.0% (355/455) under three months old.⁸⁹

A recent study found a link between health expenditures (as a percentage of gross domestic product (GDP)) and vaccination coverage for Bacillus Calmette-Guerin (BCG) and DTP3 in sub-Saharan Africa.⁹⁰ This highlights the significance of proper funding for vaccination programmes in order to achieve high coverage rates. The District Health Service programme spent a total of R2 348 per capita on vaccines per population under one year during 2022/23 (Figure 24). All provinces spent an average of R2 079 per capita on children under the age of one, with Limpopo and KwaZulu-Natal spending the most and Northern Cape and North West spending the least.²¹

Non-communicable diseases

Globally, the World Health Statistics 2023 has noted that the “epidemic of NCDs poses devastating health consequences for individuals, families and communities”.^24(p10) The four major NCDs (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) were collectively responsible for 33.3 million (uncertainty interval (UI): 24.5 – 43.3 million) deaths in 2019, representing a 28% increase compared to 2000. However, the increase in absolute numbers of deaths due to NCDs was driven mainly by population growth and ageing. Age-standardised mortality rates have been declining for the main NCDs, other than diabetes. In 2021, the Global Burden of Disease (GBD) study estimated that there were 529 million people living with diabetes worldwide, of which 96.0% were living with type 2 diabetes.⁹² Based on data from 44 low- and middle-income countries, poor access was shown to four diabetes prevention activities (physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening).⁹³

The consequences of poor NCD care were laid bare in the Stats SA report entitled Non-communicable diseases in South Africa: Findings from death notifications 2008–2018, published in 2023.⁹⁴ The report showed that deaths attributable to NCDs increased by 58.7% over 20 years, from 103 428 in 1997 to 164 205 in 2018, possibly due to population increases. For diabetes in particular, the age-standardised mortality rates (ASMR) increased from 58.5 per 100 000 in 2008 to 62.9 per 100 000 in 2018. The diabetes ASMR for females was higher in 2018 (64.3 per 100 000) than for males (60.3 per 100 000). The report noted that “recommendations for a comprehensive surveillance and monitoring system for NCDs need to be implemented to establish baselines and monitor the 90-60-50 target cascade for non-communicable diseases”.^94(piv)

As shown in Table 9, with the webDHIS reports on diabetes screening rates, there are no measures of diabetes control. Based on a large cohort of 373 889 patients tested for either glycosylated haemoglobin (HbA1c) or blood glucose by the National Health Laboratory Service (NHLS) over a 27-month period (January 2012 to March 2015), it was estimated that only 30.9% of those diagnosed with diabetes were retained in care and only 8.7% achieved glycaemic control.⁹⁵ Prevalence data reported by the Council for Medical Schemes, based on claims data, also cannot provide any information on effective treatment coverage.

In stark contrast to the plethora of indicators available to track diagnosis, treatment, and outcomes related to infectious diseases, routine data on NCDs remains sparse. This is despite the commitment in the National Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2022-2027 to 90-60-50 cascade states, where 90% of all people over 18 will know whether or not they have raised blood pressure and/or raised blood glucose, 60% of people with raised blood pressure or blood glucose will receive intervention, and 50% of people receiving such interventions will be controlled.⁹⁶

Commenting on the monitoring and evaluation system used to measure the performance of primary healthcare delivered through the district health system in South Africa, Barron et al. pointed to “a general lack of patient-centred and community responsiveness indicators”.^97(p1519) The authors identified a mismatch between the number of indicators in the National Indicator Data Set (NIDS) and the importance attached to each category of indicators. While there were 70 indicators for the HIV programme, for instance, there were only 6 indicators for all NCDs.

Despite the National Strategic Plan’s ambitious goals, challenges in data collection and evaluation persist, especially in tracking patient outcomes and ensuring effective treatment. The increasing burden of NCDs, as evidenced by rising mortality rates and poor disease control, underscores the urgent need for comprehensive surveillance systems. The available NCD indicators are shown in Table 9.

Injuries and risk behaviours

Road and pedestrian safety

Annually, the Road Traffic Management Corporation (RTMC) reports on the state of road safety, covering a 12-month period. The RTMC states that, nationally, road accident fatalities have decreased from 12 541 in 2021 to 12 436 in 2022. As expected, Gauteng reported the highest and Northern Cape the lowest number of fatalities. In addition, the fatality rate per 100 000 people decreased slightly from 20.7 in 2021 to 20.5 in 2022. Many of these fatalities were among pedestrians, followed by passengers, drivers and cyclists, in both 2021 and 2022.⁹⁹

Drug abuse

The South African Community Epidemiology Network on Drug Use (SACENDU) gathers information from individuals who use drugs (PWUD), including those who inject drugs (PWID). According to the SACENDU Phase 54 policy brief, data from the first half of 2023 (January-June 2023) shows that there were 11 563 admissions for alcohol and other drug abuse across all age groups and sexes. This represents a decrease from 11 923 in the first half of 2022 (January to June 2022) and an increase when compared to 10 170 in the second half of 2022 (July to December 2022).^47,100 Primary drugs of abuse are presented in Table 10 along with the prevalence of smoking among both sexes aged 15 years and older.

Gender-based violence

Statistics on gender-based violence (GBV) in South Africa are available, although there are substantial gaps and limitations in data collection and reporting.¹⁰¹ The country’s statistics are compiled from a variety of sources, including police records, health services, and non-governmental organisations. However, these sources frequently present an incomplete picture due to underreporting, stigma, and a lack of comprehensive national data systems. In 2020, Stats SA released a report of an analysis of the phenomenon of GBV and femicide using data from the 2018/19 Governance, Public Safety and Justice Survey.¹⁰¹ It was reported that about 50% of assaults were committed by persons known to the victim. That is, 22% were friends/acquaintances, 15.2% were spouses or intimate partner, and 12.6% were relatives/other household member of the female victims. In addition, when stratified by marital status, it was found that divorced or separated women were more likely to experience physical (40%) and sexual violence (16%), than those living together (physical: 31%; sexual: 10%), widowed (physical: 24%, sexual: 8%), never married (physical: 18%, sexual: 5%), and married (physical: 14%, sexual: 4%).

Intentional and unintentional injuries

The South African Medical Council’s Burden of Disease Unit conducted three nationally representative injury mortality (IM) and causes surveys in 2009, 2017, and 2020/21. Non-natural deaths are defined in these studies as homicides, suicides, and other unintentional harm deaths. The anticipated national age-standardised injury rate was reported to be 109, 95.3, and 89.9 per 100 000 people in 2009, 2017, and 2020/21, respectively, indicating a decline in any injury-related death over time.^102,103

Homicide

Between 2009 and 2021, the rate of homicide decreased from 38.4 to an adjusted 37.1 and 37 per 100 000 population, respectively, over the course of three years. In 2009, the number of firearm homicides increased from 11.2 to an amended 12.0, and then to 16.0 in 2020/21. The homicide rates of males were consistently higher than those of females in all reports.^102,103

The age-standardised suicide mortality rate fell from 13.4 (95% CI: 11.6-15.2) in 2000 to 12.1 in 2017 and 11.5 in 2020-21. The age-standardised rates of other unintentional injury deaths have risen in the last three years. The age-standardised injury fatality rates increased by 25.9% between 2009 and 2017, and by 12.4% between 2017 and 2020/21.¹⁰³

The IM surveys show that homicide and suicide rates are declining over time. This suggests that other unintended injuries should be monitored more rigorously. Annual nationally representative surveys are required to better document the number of deaths from violence and injury. Due to the scarcity of current statistics, covering other causes of death such as femicide, interpersonal violence, and GBV will be beneficial.

Health services indicators

Health facilities

Health facility indicators are crucial metrics that provide insight into the performance of and challenges faced by healthcare services in South Africa. These indicators include the inpatient crude death rates, bed utilisation rates, primary healthcare (PHC) utilisation rates, and Universal Health Coverage (UHC) index.

Inpatient crude death rate

The crude mortality rate of inpatients is a critical health facility indicator that quantifies the percentage of patients who demise during their admission to a healthcare facility within a specified time frame. This rate offers a variety of critical insights into the healthcare system, including the quality of care, the severity of illness, the impact of epidemics and pandemics, and appropriate resource allocation. The inpatient crude death rate in South Africa was 4.6% in 2022/23, a decrease from the peak of the COVID-19 pandemic at 5.7%, as shown in Table 11.

Primary healthcare and bed utilisation rates

Nationally, the bed utilisation rate increased from 60.7% in 2022 to 66.9% in 2023. This increase indicates that more patients were discharged after being admitted, reflecting an improvement in hospital turnover rates and possibly in patient care efficiency.

The PHC utilisation rate was higher among children under five years old compared to the general population. This could be due to the fact that under-five-year-olds require more frequent encounters at primary care level, such as immunisation visits.

The number of clients seen by professional nurses and doctors has decreased over time, from 120 million in 2019 to 101 393 994 in 2022. This figure marginally increased to 106 401 284 in 2023. There are a number of possible reasons that could be contributing to the decreased PHC headcount, including higher utilisation of the chronic medicine decentralisation programmes, changes in health-seeking behaviours, and significant increases in home visits by community-based services. Nevertheless, KwaZulu-Natal and Gauteng reported a higher number of patients seen by professional nurses or doctors, which may indicate regional disparities in healthcare access.

UHC index and coverage of essential health services

The Universal Health Coverage (UHC) index for 2023 assigned South Africa’s health system a score of 51.6, reflecting significant challenges in the provision of essential, effective health services across the population. This score, derived from the Global Burden of Disease (GBD) 2016 scale, underscores the gaps in service coverage that persist within the country’s health system. These deficiencies indicate that South Africa is not on track to achieve the targets set by Sustainable Development Goal (SDG) 3.8, which aims to ensure universal access to quality health services and financial protection.¹⁰⁴

However, the calculation of the UHC index is not without its challenges, particularly in the context of limited data availability on NCDs. Scarcity of reliable data on the prevalence, treatment, and outcomes of NCDs complicates the assessment of service coverage and effectiveness. This data gap may result in an underestimation of the true burden of NCDs and the corresponding inadequacies in health service provision. As NCDs constitute a growing proportion of the disease burden in South Africa, the lack of comprehensive data further complicates efforts to accurately gauge progress towards UHC and to identify areas most in need of intervention. The current UHC index score of 51.6, therefore, not only reflects existing service coverage gaps but also highlights the critical need for improved data collection and analysis to better inform health policy and resource allocation, particularly in relation to NCDs. Without addressing these data challenges, South Africa may struggle to fully understand and address the barriers to achieving SDG 3.8 and improving overall population health outcomes.¹⁰⁴

Health services indicators by province are presented in Table 11.

Health personnel

It is important to note that the health personnel data reported in Table 12 and Table 13 only reflect the position in the public sector, with the uninsured population used as the denominator. Reconciling PERSAL data with the total number of health professionals registered with the respective statutory health councils is also fraught with difficulty, as those sources cannot show how many registered persons are non-practising or have emigrated. The National Department of Health Strategic Plan 2020/21-2024/25 includes a commitment to “improve equity, training and enhance management of Human Resources for Health”, in order to improve the provision of care (Goal 3).^106(p77) However, evidence to show that the Human Resources for Health Operational Plan has, in fact, been ‘augmented’, is lacking.

Challenges in human resources for health

Despite commitments to fill critical vacant posts, integrate community health workers into the public health system, consolidate nursing colleges, and supplement the production of medical practitioners and other health professionals, there has been persistent media coverage of regression, of frozen posts, and unemployed graduates. The inability to employ newly graduated health professionals has several long-term implications. First, it contributes to an underutilisation of skilled labour, leading to a mismatch between the availability of trained professionals and the needs of the health system. This mismatch can result in increased workloads for existing staff, higher burnout rates and, ultimately, a decline in the quality of care provided to patients. As identified in the 2030 Human Resources for Health Strategy: Investing in the Health Workforce for Universal Health Coverage, “Even when a projected need has been determined, the mechanisms and fiscal arrangements required to support the implementation of the HRH plans have been ineffective.”^107(p46)

Monitoring and evaluation

Of specific relevance to this paper, the Strategy also stated: “Insufficient information hampers the monitoring and evaluation of HRH plans, contributing to the lack of or inadequate implementation” and “Access to private sector data is limited and thus poorly integrated into the national picture.”^107(p50)

Health financing

Tables 14 to 16 provide the basic financial indicators for the public health sector over time. Between 2012/13 and 2022/23, there has been almost a doubling in total expenditure in terms of provincial and local government expenditure on health, from R125.5 billion to R247.7 billion per annum (Table 14). Whether this has been accompanied by a commensurate improvement in health outcomes is questionable, as has been shown in the preceding sections of this paper.

Primary health care expenditure

The shift towards primary health care is evident in the proportion of expenditure on district health systems, which represented 47.0% of provincial and local government health expenditure at a national level in 2022/23 (Table 15). That this proportion varied widely among provinces, from 31.8% in Gauteng to 65.5% in Limpopo, is reflective of the relative contribution of higher level hospital services among provinces. The relative changes between financial years 2021/22 and 2022/23 per province are also depicted in Figure 24.

Health services in the public sector are still almost exclusively dependent on the fiscus. As shown in Table 16, the proportion of provincial and local government health expenditure that is provided by development partners (external donors) remains modest, at US$1.40 per capita in 2021 (including support for medical research).

Medical scheme coverage

Medical scheme coverage, as estimated from both the Stats SA General Household Survey³⁴ and the annual reports of the Council for Medical Schemes,⁴⁸ remains around the 15% mark. However, according to the 2022 report from the Council for Medical Schemes, total disbursements in the insured sector in 2022 were R224.1 billion.⁴⁸ This represented a 9.2% increase from the amount reported for 2021 of R205.3 billion. The amount spent in the insured private sector was thus comparable to the total spent in the public health sector in 2022. Consolidation of the number of medical schemes continues, with the total number declining from 144 in 2000 to 72 in 2022. Modest increases in the number of beneficiaries covered by both open (30 930) and restricted schemes (69 457) were recorded between 2021 and 2022, bringing the total number of insured persons to 9.04 million. Notably, in 2022, ten government-linked or funded medical schemes represented 72% of all restricted scheme beneficiaries and 33% of the total number of beneficiaries.

Conclusion and recommendations

As South Africa strives to become more data driven and evidence informed in its healthcare decision making, improving information systems and data quality remain key objectives. Given that the majority of the existing information systems are still manual, the dangers of transcribing errors, as often observed by the Auditor General, necessitate more rigorous data quality and verification processes at all levels of the system.

Monitoring and evaluation (M&E) processes need strengthening at all levels of the health system. These processes should move away from simply tracking target achievement in a linear, mechanistic manner, towards ‘deeper dives’ that incorporate not only routinely collected data, but also research evidence and lived experience; processes that include a broader range of participants to enrich the analysis with different perspectives. These are critical procedures to rectify as South Africa seeks to track the health system’s performance in an integrated manner, better informing priority setting and decision making.

The National Health Insurance Act¹¹⁴ envisions better integration of the public and private sectors into a single health system, making obtaining and combining data from both sectors even more important. Governance systems that enable this must also be prioritised.

Despite South Africa’s high cancer incidence rate, the availability of reliable and up-to-date cancer data remains insufficient. This data gap poses significant challenges to effective cancer monitoring, policy formulation, and resource allocation. The National Cancer Registry (NCR), which serves as the primary repository for cancer data in the country, plays a crucial role in tracking the burden of cancer and evaluating patient outcomes. However, the registry currently faces limitations in data collection, coverage, and timeliness, which impede its ability to provide a comprehensive picture of the national cancer landscape.

Prioritising the enhancement and support of the NCR is critical not only for accurate tracking of cancer incidence and prevalence but also for generating detailed insights into cancer risk factors, survival rates, and the social, economic, and environmental determinants of cancer mortality. Enhanced data collection and reporting mechanisms would enable more precise identification of high-risk populations and regions, facilitating targeted public health interventions and tailored treatment strategies. Furthermore, robust cancer data can inform the development of prevention programmes, early detection initiatives, and evidence-based policy decisions aimed at reducing cancer disparities across different demographic groups.

In addition, strengthening the NCR will contribute to better understanding the impact of emerging trends, such as the rise in NCDs, the intersection of HIV/AIDS and cancer, and the influence of lifestyle changes on cancer patterns. Comprehensive, high-quality data is essential for evaluating the effectiveness of ongoing cancer control efforts and for guiding future research and funding priorities. By investing in the NCR and addressing the current data limitations, South Africa can significantly improve its ability to monitor and combat the growing cancer burden, ultimately leading to better health outcomes for its population.

Acknowledgements

This paper is a result of years’ worth of combined efforts at all levels of the health system. We would like to acknowledge the National Department of Health for the use of data from the web-based District Health Information System and National Treasury for the finance and human resources data. We would particularly like to acknowledge the work done on this section of the Review over the years by Candy Day. We also appreciate the valuable input received from the reviewers and thank them for their time.