A Review of Health
Research in South Africa
from 1994 to 2007
14
Authors:
Elizabeth Lutgei
Irwin Friedmani
Thokozani Mbathai
Abstract
A review of health research conducted in South Africa between 1994 and 2007 will
be presented in this chapter. The purpose of this review was to assess the extent to
which health systems research has reflected the country’s emphasis on Primary Health
Care, and also the extent to which health research in general has reflected articulated
national research priorities. The review revealed that the proportion of health systems
research focusing on Primary Health Care issues has increased significantly since 1994.
However, this research has focused primarily on quality of care and human resources
for health, while aspects of Primary Health Care, like accessibility to, and equity of
care have been relatively neglected. The number of publications in the area of HIV
and AIDS has risen dramatically since 1994, and is an area which dominates all other
disease-related research. Conclusions are drawn that research institutions, oversight
bodies and researchers, should give more attention to those areas of Primary Health
Care and health problems, which have been relatively neglected in the past 14 years in
the South African research arena.
i Health Systems Trust
211
Background
Primary Health Care (PHC), especially community-oriented
Africa”.6 One of its goals is to develop a ‘coordinated, well-
primary care (COPC), has a long history in South Africa,
funded agenda for research’ and to this end, it recommended
initiated by efforts to establish a decentralised health care
that the process of reviewing research priorities should
system during the late 1940s and early 1950s in a variety
occur at least every five years, initiated by provinces and
of settings.1 In 1978, PHC was adopted in the Alma Ata
culminating in consolidated national research priorities.
Declaration as a vehicle to achieve ‘Health for All’ by the
year 2000. Since 1994, South Africa has based its health
care delivery strategy firmly on the philosophy of PHC. As
stated in the ‘Primary Health Care Package for South Africa
– a set of norms and standards’, which guides the delivery of
PHC in South Africa, “Primary health care is at the heart of
the plans to transform the health services in South Africa”.2
This commitment to PHC as the priority strategy for South
Africa was reaffirmed in the recent Birchwood Declaration,
to which a wide array of stakeholders including government
were party.3
In 2006, the third national conference on priority setting in
health research was held, to further refine the list of priority
areas for research in South Africa. One of the techniques
used at this conference was a voting system in which all
the delegates (including government officials, academics
and researchers) ranked the diseases or conditions that they
thought were of greatest priority for health research. These
‘votes’ were aggregated to develop a new list of research
priorities for the country, and the rankings compared to
those developed during the first ENHR Congress held a
decade earlier. Table 1 illustrates the top ten health priorities
In spite of this broad commitment, PHC still faces many
based on the perceptions of delegates in 1996 and 2006.
challenges in its realisation, including various political,
The top three priorities were very similar in both years, with
structural, managerial, financial and human resource
the movement of HIV and AIDS from fourth place in 1996,
obstacles, which constrain its effective implementation.
to first place in 2006. The range of issues addressed in the
Much of the current research on PHC emphasises these
rankings reflects the ‘quadruple burden of disease’ that faces
challenges.4 One way that government has sought to
the country. The four components are HIV and AIDS, other
address these challenges is through prioritising research
infectious diseases, injury and chronic diseases.7
that could contribute to improving PHC implementation.
Research prioritisation in South
Africa
Table 1: National health research priorities set at the
Essential National Health Research Congress, 1996
and 2006 rankings
Condition
1996
Ranking
2006
Ranking
The South African Essential National Health Research
HIV and Aids
4
1
(ENHR) approach was formally adopted in 1994, in order
Injury (all causes)
1
2
to focus health research on country-relevant issues. With
Tuberculosis (TB)
2
3
particular emphasis on vulnerable groups the ENHR should,
Diarrhoea (all causes)
7
4
if consistently applied, result in more effective PHC-oriented
Perinatal and neonatal mortality
spending. In 1996, the first ENHR Congress in priority
Nutrition
3
6
setting in South Africa established a list of priority health
problems and urgent research questions. The criteria for
Common risk factors (hypertension,
smoking, overweight, alcohol,
hyperlipidaemia)
-
7
priority setting were based on the government’s focus on
Cardiovascular diseases
-
8
the Reconstruction and Development Programme (RDP),
Orphans and child headed households
-
9
which itself recognised the value of PHC as a central part
Maternal mortality and morbidity
-
10
of its strategy and the significance of the socio-economic
Mental health
9
11
determinants of disease.5
Cancer
6
12
A follow-up conference, the second ENHR Congress in 2002,
Malaria
10
13
aimed to discuss the national framework for priority setting
Respiratory infections (all)
8
14
and reviewed, and refined research priorities set in the first
Sexually transmitted diseases (STDs)
5
15
ENHR Congress. It also aimed to popularise the then new,
5
Source: Schneider, 2001;8 Department of Health, 2006.9
national health research policy. The purpose of this policy
is to “provide an enabling framework for the conduct of
research that improves human health and wellbeing in South
212
Blank spaces in the 1996 ranking occur where diseases listed in
2006 were not present on the 1996 list.
A Review of Health Research in South Africa from 1994 to 2007
In addition to developing research priorities based on a
the health systems approach. In an allied aim, the chapter
burden of disease approach, the 2006 conference also
attempts to assess to what extent these priorities were
prioritised health systems issues for increased attention,
reflected in the research that has been conducted in the
resulting in a ranked list (see Table 2).
country. Such a review of health research is one of the
Although PHC is listed as an area for research on its own,
it must be noted that many of the health systems issues
identified are themselves important components of PHC and
vital to its effective implementation. Some of these include
first steps towards developing a ‘coordinated, well-funded
agenda for research’, which is one of the goals of the 2001
National Health Research Policy. Establishing what and
where research has taken place contributes to this goal.
human resources management, quality of care, health care
Thus the specific research questions of this review were as
financing, and community participation and involvement.
follows:
Table 2: Priorities for health systems research developed at
the Essential National Health Research Conference,
2006
1.
To what extent has health systems research conducted
in South Africa since 1994 reflected the emphasis on
PHC as the foundation of the country’s new health
system?
1
Human resources management (recruitment, retention and
supervision)
2
Health information systems
3
Human resources development
4
Quality of care
5
Health care financing
6
Quality of health delivery and support systems
7
Monitoring and evaluation
1994 and available in PubMed. To answer the first research
8
Poverty and inequalities
question, a focus on health systems research was taken.
9
Primary Health Care
Equity in contribution, access, utilisation, participation and
outcomes
Information, education and communication, behavioural
11
change communication, adherence education
2.
To what extent has health research in South Africa
reflected the articulated national research priorities?
Methods
The methodology used in this chapter was a review of all
published health research conducted in South Africa since
Health systems research was defined as “research that
focuses on the organised response to health and disease”.10
10
To answer the second research question, a burden of disease
approach was taken, in order to reflect the predominant
12 Quality of morbidity and mortality data
focus of the research prioritisation conferences, and to
13 Hospitals
reflect the importance of the approach to health systems
14 Physical infrastructure and maintenance
15 Surveillance and outbreak response
planning. The method to answer the second question was
an application of the results of this review, to the lists of
priorities identified in 1996 and 2006.
16 Drugs and other supplies
17 Community participation and involvement
18 Traditional health care and medicine
Research question one: Health systems
research focus
19 Policy influencing service delivery
PubMed was used to search the term ‘South Africa’ and
20 Health records, documents (Road-to-Health Chart)
the dates ‘1994 to 2007’, to identify country relevant
research from this period. This method has been used in
Source: Department of Health, 2006.9
similar exercises to review health research globally, in
Africa and in South Africa.11-13 A total of 19 172 abstracts
Research questions
As stated, the aim of this chapter is to review health research
were downloaded into EndNote. A systematic sample of
one in three abstracts was then reviewed, and abstracts
were retained if all of the following conditions were met:
conducted in South Africa since 1994, with a special focus
on research that contributes to the PHC philosophy or its
implementation. The review used the framework of health
research priorities already set by the country as well as a
framework based on the burden of disease approach and
PubMed is a service of the U.S. National Library of Medicine that
includes over 18 million citations from MEDLINE and other life
science journals for biomedical articles back to the 1950s. PubMed
includes links to full text articles and other related resources.
Access available at: http://www.ncbi.nlm.nih.gov/pubmed/
End Note is a software tool for publishing and managing
bibliographies.
213
14

the authors of the article were listed;

the article was not a letter, comment or editorial;

the research was conducted in South Africa;

the research was not a global, multicentre project;

the research had a health systems orientation; and

the research contributed to the development or
particular health problems over the period of the review.
implementation of PHC in South Africa.
The reason for this is that all types of studies should be
Research question two: Burden of disease
focus
This aspect of the review was much less detailed than the
review of health systems research described above, and
sought only to identify studies that had investigated
The criteria used to establish the PHC orientation of the
articles were based on the essential components of PHC
derived from the Alma Ata Declaration. Thus, research
that investigated at least one of the following issues was
included:
the

included, from epidemiological to health systems, and
from intervention to descriptive, in order to fully capture
the numbers of studies focusing on each area. The same
database, which contained articles downloaded using the
search term ‘South Africa’, was searched for the specific
health problem concerned, using the appropriate search
appropriateness
of
health
services
for
the
terms (such as HIV and AIDS, TB, injury, etc.). The numbers
community or country;
of articles resulting from these searches was then recorded

the comprehensiveness of care offered;
and compared.

the quality of care offered (including ethical issues);

the accessibility of care offered;

community or individual empowerment;

a multidisciplinary or intercollaborative approach to
health care;
health care financing or resource use in health care;

Limitations of the review
This literature review had a number of limitations. These
included:

included only published research, would have limited
and
the range of studies included. The inclusion of more
the education and functioning of health workers.

databases and ‘grey’ literature may alter the findings of
this review.
Designation to only one of these aspects was made. For
example, if an article had relevance to both quality of care
The use of only one database (i.e. PubMed), which

The use of only one search term (i.e. ‘South Africa’)
and comprehensiveness of care, the criterion felt by the
may also have skewed the type of articles downloaded.
reviewers to be the main focus of the article was chosen.
However, the use of other search terms such as ‘health
Where more than one article arose from a piece of research
systems research’ or ‘PHC’, may have excluded other
and these articles were substantively similar to each other,
articles which were potentially relevant to this review.
the article was included only once.

or ‘non-PHC’ health systems research was inherently
It is important to note that articles focusing on higher
subjective, notwithstanding the participation of three
levels of care were also included, since the PHC philosophy
reviewers. It is possible that different reviewers would
applies to the health system in its entirety, and not only to
have come to different conclusions. However, given the
the primary level of care. Where the full text was available
significant nature of some of the findings (such as the
electronically, the entire article was read, otherwise only the
relative lack of research into accessibility and equity
abstract was reviewed. No quality assessment of articles was
of care, and the dominance of HIV and AIDS research
done, as the aim of this review was to provide a descriptive
over all others), it is likely that such findings would be
overview of the areas of research and not a critical appraisal
of individual research projects.
The methodology of assigning articles to either ‘PHC’
repeated by other reviewers.

The fact that, in many cases, the abstracts were
reviewed and the full article only assessed if the text
were available free of charge, may have affected the
findings. This is unlikely to be significant though, since
the abstracts reviewed contained enough information
to make the designations required for this review.
Adapted from the Alma Ata Declaration, 1978. Available at:
http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
214
A Review of Health Research in South Africa from 1994 to 2007

Although a concerted effort was made to include
Table 3: Number of articles relating to various aspects of
Primary Health Care, 1994-2007
only reports of research in this review, some articles
were based on further interpretations or syntheses of
Number of
articles
Primary Health Care criterion
previous research projects.
Results
Research question one: The emphasis on
Primary Health Care in health systems
research conducted in South Africa
Among the 19 172 articles downloaded from PubMed,
there was an average of 1 369 articles per year. In 2006,
this decreased to only 887 articles and in 2007 only 890
articles. This may be due to the delay in publishing articles
electronically on PubMed. The proportion of all articles on
health research in South Africa between 1994 and 2007, that
contributed to the PHC approach are presented in Figure 1.
Quality of care
274
Human resources
206
Multidisciplinary, interdisciplinary and
intercollaborative care
185
Financing of health care, including
affordability
59
Comprehensiveness of care
57
Acceptability of care (including patients’
responses to care and assessments of
appropriateness of care)
55
Ethics of health care provision or research on
public sector patients
36
PHC (where the PHC approach or the primary
level of care was the focus)
33
Accessibility of care
17
Equity of provision of care
12
Empowerment of individuals or communities
1
Over the past three years, 2005–07, there has been a
Source: Compiled by authors.
significant increase in the proportion of articles on health
research in South Africa that focused on aspects of PHC. The
average for the first ten years was around 4%, whilst in the
Most articles focused on quality of care, human resources
last three it has increased to around 8%. These abstracts
and interdisciplinary or multidisciplinary approaches to care.
or articles were read, and according to their area of focus,
There were markedly fewer articles relating to the other
assigned to one of the categories listed in Table 3.
aspects of PHC that were investigated.
Figure 1: Percentage of all articles on health research in South Africa with a Primary Health Care focus, 1994-2007
10
9.3
8
6.9
6
3.8
3.8
4.2
4.6
5.1
4.9
3.9
4.0
2003
3.9
1995
4
4.3
2002
5.2
2007
2006
2005
2004
2001
2000
1999
1998
1997
1996
2
0
11.3
1994
Percentage of articles with PHC orientation
12
Note: N (total number of PHC articles) = 940
Source: Graph generated by authors.
Based on the inclusion criteria.
215
14
Articles that focused on quality of care included: the
accuracy or utility of diagnostic tools;14 an audit of treatment
Table 4: Number of articles focusing on aspects of human
resources covered
outcomes;15 an evaluation of a new treatment modality;16
and areas where the health system had failed.17,18
Aspects of human resources
Number of articles
Nurses
40
Doctors (including specialists)
33
numbers reflected in Table 3 show an obvious lack of
Nursing education
27
research in three areas of PHC, namely accessibility of care,
Dentists (including oral hygienists)
26
equity of provision of care and empowerment of individuals
Medical education
26
or communities.
Human resources (general)
15
Articles relating to access to care included primary research
Traditional healers
10
projects, as well as reflections on the issue of access.19-21
Community health workers (including lay
health workers)
6
Health worker education (general)
6
Managers
5
Pharmacists
3
were often discursive, including many aspects of health care
Speech and hearing therapists
2
provision such as financing, access and the historical legacy
Psychologists
2
of apartheid.
Dental education
1
Social workers
1
dedicated programme of empowerment, but on the issue
Physiotherapists
1
of empowerment of communities involved in research
Occupational therapists
1
projects.25 Although research projects that do specifically
Dieticians
1
focus on empowerment are known to the authors, these did
Total
Implicit in the purposes of this investigation was the
identification of areas that are under-researched. The
Studies included not only geographical access, but also other
barriers, such as economic and cultural factors.22 Articles
on equity focused mainly on South Africa as a whole, as
opposed to inequity within smaller geographic areas, and
23,24
The single article on empowerment does not focus on a
not appear in the articles downloaded.26 Whilst this reflects
to some extent a limitation of this study (the dependence on
206
Source: Compiled by authors.
only one database of published research), it also highlights
the relative lack of dedicated research in this area.
Articles about nursing covered a comprehensive range of
issues, including: the role of women in nursing;27,28 the views
Human resources
A variety of aspects of human resources were investigated in
the articles reviewed, with a number of different cadres of
health workers included in research, and a strong focus on
of nurses on various aspects of their working lives;29,30 the
evaluation of nursing interventions in the delivery of health
services;31 the role of politics in nursing and vice versa;32 and
levels of job satisfaction among nurses.33
the education of health professionals (see Table 4). However,
The range of articles about doctors, including specialists,
it is clear that the overwhelming focus of health research
was similar and they focused on the role of women in
to date has been on nurses, doctors and dentists, and that
medicine;34,35 the views of doctors on various aspects of their
other allied health professionals, traditional healers and
working lives;36,37 the evaluation of doctors’ functioning
community health workers have received considerably less
in the working environment;38 the influence of apartheid
attention.
politics on doctors’ attitudes and practices;39 and stress
levels amongst junior doctors.40
Some articles focused on the systemic issues of medical
staffing, such as community service for doctors that was
implemented during the study period and the recruitment
of foreign doctors to the country.41-43
Although most articles on doctors focused on those in the
public sector, some considered those in the private sector.44,45
A larger proportion of articles on dentists focused on those
in the private sector.46,47
216
A Review of Health Research in South Africa from 1994 to 2007
Nursing education was extensively covered, both in
evaluations of teaching methods and programmes, as well
Figure 2: Provinces in which health research was conducted,
1994-2007
Number of articles/percentage population
as outcomes of these programmes, stress levels of student
nurses in these programmes and practical aspects of nurse
training.48-52
Important themes in the literature on medical education
were the changes that should (or should not) be introduced
in medical education after the transition to democracy, and
also the new problem-based curricula that were instituted in
some medical schools during the period of the review.53-56
Geographical spread of research
140
120
100
80
60
40
20
0
WC
articles, from those where it was specified, a clear gradient
in the spread of research was evident (see Figure 2). It was
clear that more research was conducted in the Western Cape,
KwaZulu-Natal and Gauteng than in the rest of the country
combined. This distribution does not reflect the percentage
of the population in each province, but it does mirror fairly
closely the distribution of established medical schools in the
country.
KZN
GP
EC
LP
FS
MP
NW
NC
Percentage distribution of population per province
Number of articles downloaded per province
Although the location of research was not specified for all
Source: Graph generated by authors.
Research question two: The extent to
which health research in South Africa has
reflected the articulated disease-related
research priorities
HIV and AIDS research has rapidly increased since 1994 (see
Figure 3). Those relating to TB also increased, but with a
much flatter gradient. Research relating to cancer declined
during the last few years of the study period, and research
relating to diarrhoea (incorporated in the ‘other’ category)
remained fairly constant although at a very low level.
Figure 3: Comparison of HIV and AIDS and other health research conducted, 1994-2007
350
300
250
200
150
100
Cancer
Nutrition
HIV and AIDS
Other
Injuries
Tuberculosis
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
1995
50
1994
Number of studies published in PubMed
400
Malaria
Note: ‘Other’ research refers to hepatitis, diarrhoea, diabetes, stroke, circumcision and termination of pregnancy.
Source: Graph generated by authors.
217
14
HIV and AIDS research
figure prominently in current concerns about the health
Unsurprisingly the number of South African research articles
research. However, the relative lack of focus on other
dealing with HIV and AIDS cited in PubMed rose in a largely
important aspects of PHC (e.g. accessibility of care, equity
linear fashion, from 43 papers in 1994 to 355 in 2006. HIV
of provision of care and empowerment of individuals or
and AIDS research has grown to such an extent that it now
communities) is worrying.
dominates all health research.
system, it is appropriate that this is reflected in published
Relating to the issue of equity is the distribution of
Tuberculosis research
publications emanating from the various provinces across
TB research has grown approximately three fold, from 37
province and not by institution, the distribution of
papers in 1994 to 97 in 2007. Although it has grown less
research points indirectly to the presence of well-established
rapidly than HIV and AIDS research, TB research is undertaken
universities and medical schools. As was found in a similar
almost three times as often as injury research, which appears
review conducted in 1994, the institutions in the Western
above it in the priority ranking for both 1996 and 2006.
Cape, Gauteng and KwaZulu-Natal still seem to produce
Injury research
Although injuries, which include homicides, road traffic
accidents and other injuries, consistently ranked within the
top two national health research priorities over the decade,
the level of research in this area remained much lower
than the research into HIV and AIDS. Although the number
the country. Although the analysis was carried out by
the majority of published articles when compared to the
historically disadvantaged institutions in other provinces.13
Given that research is a tool for improving health and health
care, and that “inequalities in health research contribute to
inequalities in health”, the lack of publications emanating
from traditionally poorer provinces does not bode well for
improving their situations in the future.57
of research projects grew over the study period, this was
There were a considerable number of publications dealing
at a much slower rate than HIV and AIDS, and in terms of
with human resources for health. Given the importance of
magnitude in 2006, comprised only about a tenth of the
a well-trained and committed workforce to delivering good
number of studies of HIV and AIDS.
quality health care, and concerns about staff shortages
in the South African health care system, this emphasis is
Discussion
Health research that contributes to
Primary Health Care
The proportion of health research with a PHC orientation has
increased dramatically from 1994 to 2007. This is heartening
as it affirms the spirit of PHC implementation in this country,
even though this review cannot determine whether it has
enhanced the actual implementation of PHC.9
This review only investigated the supply of knowledge
around PHC, not the demand for or use thereof. However,
supplying knowledge around PHC is at least a first step in
the right direction; the next step is to bridge the gap
between research and practice, with all its attendant
political, social and economic ramifications.
The most frequent areas of focus of health systems research
publications reflect the priorities for health systems research
appropriate. Doctors and nurses were the focus of the majority
of studies about human resource for health, reflecting the
predominance of these professions in the health care system.
However, the relative neglect of publications on professions
allied to medicine, such as occupational, speech and hearing
therapists and physiotherapists is a concern. It impacts on the
ability of the health system to provide comprehensive care,
and to respond to the basic health needs of the community
it serves; both are fundamental aspects of PHC.
Similarly, the small number of publications on traditional
healers, ignores a section of the health system used by
approximately 80% of the population.58 This implies limited
collaboration between allopathic and traditional healers. It
also implies a failure of both traditional and allopathic healers
to utilise the resources available between them. If traditional
healers provide the kind of health care that is acceptable
to the majority of the population, then more collaboration
between the two systems of health care is required to
increase the cultural acceptability of allopathic care.
articulated in 2006. Based on the number of articles relating
to the topics, it seems that there is strong interest by
Disease-related health research
researchers, academics, health workers and others, in the
areas of quality of care and in the staffing of the health
On the publications relating to specific health problems, HIV
system. Since these are important components of PHC and
and AIDS research has come to dominate all other health
218
A Review of Health Research in South Africa from 1994 to 2007
research. Since the number of publications reflects both
Studies focusing on HIV and AIDS dominate disease-
interest in and funding available for research, HIV and AIDS
orientated research in South Africa. Conversely research into
could be crowding out research on other important health
injuries, and to a lesser extent TB, diarrhoeal and chronic
problems. Research into TB, which is the leading cause of
diseases, is disproportionately low compared to their
death in patients with HIV in South Africa is relatively lacking,
ranking on research priority lists and their disease burden.
and presents an important limitation to implementing
Discussions on how to address this should take place within
integrated care in coinfected patients.59
the provincial and national research committees, as well as
The number of publications on injuries, one of the leading
in individual research institutions.
causes of death in South Africa, is low. South Africa has one
Coordinating health research is a massive undertaking, as
of the highest burdens of injuries in the world, with seven
this exercise has shown. Just documenting the subject and
times the global rate of interpersonal violence and double
location of research across the country takes much time and
the global rate of road traffic injuries.60 Although it ranked
effort, and is itself subject to a number of limitations.
first on the list of research priorities for 1996 and second in
2006, publications on injuries are only a fraction of those on
HIV and AIDS. The reasons for this are likely to be complex,
and warrant further investigation, so that the issues can
be addressed. They may be related at least in part to the
successful advocacy of powerful groups both in South Africa
(such as the Treatment Action Campaign) and abroad (such
as the International HIV / AIDS Alliance), which have put HIV
and AIDS in the public domain and generated global concern
for the problem. Although advocacy groups for trauma and
injury exist (e.g. the Trauma Society of South Africa), they
have not had the same success in advocacy. Another factor
that may contribute to the relative lack of injury publications
is the fact that the causes of injury are multifactorial, and
relate to complex social, economic and behavioural factors.
The biomedical approach to research, which is relatively
simpler, may be easier to fund and can be applied to both
HIV and AIDS and TB, but is not applicable to the case of
research into injuries.
Conclusion and
Recommendations
The proportion of health systems research studies relating
to PHC has increased significantly since 1994. The focus
of these and disease-orientated studies reflects to a large
extent the health research priorities as articulated in the
ENHR conferences of 1996 and 2006. Health systems research
has to date neglected some of the fundamental aspects of
PHC, namely accessibility of health care, equity of health
care distribution and the empowerment of individuals and
communities. More attention should be paid to these factors
in future health systems research in South Africa.
Health systems research is conducted primarily in provinces
with well-established medical schools, further entrenching
the existing health inequalities in this country. Future
research should include provinces that, to date, have been
relatively neglected by researchers.
219
14
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