The District Health System must become a learning health system

In South Africa (SA), the district health system (DHS) is a critical platform both for the downstream provision of healthcare services and for addressing the upstream social determinants of health. Downstream, the DHS supports the delivery of community-based and facility-based primary care services, enables patient referral across the public system, co-ordinates with other local providers and has a key role to play in ensuring improved quality of care. In terms of upstream action, moreover, the DHS is well-positioned to co-ordinate action with societal actors and across government departments to meet community health and wellbeing needs and address the social determinants of health. These needs vary considerably from district to district, and change over time. The COVID experience clearly demonstrated that it is necessary for the DHS both to be able to flex quickly in response to new health challenges and to work locally with other sectors and actors to address those challenges.

Learning in the district health system: How can meetings become spaces of reflection?

The District Health System (DHS) is considered one of the key health system reforms in post-apartheid South Africa (SA). It is pivotal to both enabling the delivery of primary healthcare (PHC), including relevant patient referrals, and co-ordinating intersectoral action to address the social determinants of health. However, the DHS continues to face complex challenges that constrain its functioning – from inadequate delegations  to command-and-control forms of leadership, authoritarian attitudes towards both patients and staff and resource constraints. Acute crises such as the recent COVID-19 pandemic and the current austerity measures compound the chronic challenges. As a result, ‘new ways of being and doing’ are required in the DHS. A key approach to encouraging new ways of being and doing, supporting the DHS to be responsive to changing community needs and wider contextual conditions, is to embed learning as a routine of the DHS. This includes strengthening the current DHS monitoring and evaluation system.

Community-led monitoring and the role of Ritshidze in improving the quality of primary healthcare in South Africa

There has been ongoing debate on the ideal mechanisms of community participation in healthcare, and the extent to which community participation has a meaningful impact on the quality and outcomes of health services. The Alma Ata Declaration on primary healthcare situates communities and health users at the centre of healthcare, but community participation has since come to mean a wide variety of things, from minimal involvement to broad-ranging rights-based social mobilisations.

Acute gastroenteritis and unilateral vision loss leading to a diagnosis of aquaporin-4-IgG seropositive neuromyelitis optica spectrum of disorders in a child: A case of atypical optic neuritis in the era of biomarkers

Neuromyelitis optica spectrum of disorders (NMOSD) is rare in the paediatric population. It is an important differential to consider as it typically runs a more severely debilitating course than multiple sclerosis and other demyelinating disease, and is associated with a 5-year mortality rate of 30% worldwide. Paediatric optic neuritis accounts for 25% of acute demyelinating syndromes in this age group. Post-infectious (usually viral) or postimmunisation aetiologies usually predominate. Less commonly, it may be the first manifestation of multiple sclerosis (MS) or other diffuse demyelinating disorders such as acute demyelinating encephalomyelitis (ADEM), NMOSD and myelin oligodendrocyte glycoprotein-associated disease (MOGAD).

The antimicrobial susceptibility patterns of diabetic foot ulcers in the South African public healthcare sector

Diabetes mellitus (DM) is a metabolic disorder that affects approximately 537 million people worldwide. Diabetic foot syndrome, a complication of diabetes mellitus, is the most common cause of hospitalisation and lower-limb amputation among patients with diabetes. A diabetic foot ulcer (DFU) is a complication of diabetic foot syndrome that occurs in a person with diagnosed DM, and typically presents alongside neuropathy or peripheral artery disease in the lower extremity. These wounds often present as open lesions, with infection. South African (SA) data indicate that the prevalence of DFUs is 5.4% - 6.0% among patients with diabetes, with more recent studies noting that 28% of patients with diabetes presenting to primary healthcare facilities in SA had developed DFUs. It is estimated that >50% of DFUs become infected. Infection of a DFU occurs when a virulent micro-organism invades the host and ultimately results in local tissue damage. The microorganisms that cause infection in DFUs depend on patient factors such as the degree of immunosuppression and duration of diabetes, as well as pathogen-specific resistance patterns.

The utility of artificial intelligence in identifying radiological evidence of lung cancer and pulmonary tuberculosis in a high-burden tuberculosis setting

Medical imaging, particularly chest radiography, is well positioned for the application and adoption of artificial intelligence (AI) using deep learning (DL) systems. Radiological AI algorithms are now well established and serve several narrow image-analysis functions to aid clinicians and radiologists with the quantification, triage and enhancement of images. There is increasing evidence for the use of AI in pulmonary medicine, and numerous studies have suggested that it has the potential to expedite and improve the interpretation of chest radiographs.

Genetic trends and common BRCA1/2 pathogenic sequence variants in black African and Indian breast cancer patients presenting at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa

Breast cancer (BC) is the most commonly occurring cancer in the world, and the second leading cause of cancer mortality among women. It is a multifactorial disease with genetic and environmental factors. The risk of developing BC varies with age, race, lifestyle choices, reproductive choices and genetic predisposition. In South Africa (SA), at least 1 in 30 women is said to be at risk of developing BC by the age of 74 years, although the risk differs greatly between SA racial populations. Additionally, the majority of SA BC patients are black African, mainly of luminal subtype, and many patients present at a late stage.

A randomised trial comparing preoperative administration of single-dose kefazolin to kefazolin plus metronidazole as prophylactic antibiotics at caesarean section

Caesarean section is a life-saving procedure that is associated with high rates of maternal and neonatal complications. It has been estimated that globally, 29.7 million births occur by caesarean section annually.

The association between serum fructosamine and random spot urine fructose levels with the severity of non-alcoholic fatty liver disease – an analytical cross-sectional study

Liver disease not caused by alcohol, viruses or inborn errors of metabolism, but rather by metabolic risk factors associated with diet and obesity, is a global concern. Non-alcoholic fatty liver disease (NAFLD) in South Africa (SA) and Africa at large is considered a hidden threat. Our local population is burdened with increased metabolic risk factors for NAFLD. There is unfortunately a paucity of data in our local setting on NAFLD to reliably define our local health service needs. Our setting requires an affordable and feasible approach to screen and aid the diagnosis of NAFLD – including at the level of primary healthcare.


Health Professions Council of South Africa


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South African Medical Journal - June 2024 Vol 114 No 6