Western Cape Department of Health

Injuries cause 6 million deaths and 40 million disabilities annually. Over 90% of deaths occur in low-and-middle-income-countries (LMICs), and nearly half are preventable. This Commentary examines the possibilities and limitations of data to support injury care in LMIC settings. We frame injury care as a wicked problem with complex causality, contested goals, unintended consequences, and an incomplete evidence base. We use critical realism (CR) to address conceptual complexity and data scarcity using depth ontology and retroduction. Using exemplars (drug-related admissions, intimate-partner violence, and ambulance delays), we apply a pragmatic approach to: (1) describe patterns/distributions; (2) identify who/what may be missing or misrepresented; (3) triangulate with frontline/community intelligence to infer mechanisms and constraints, translating interpretations into feasible actions and accountabilities. CR broadens interpretation to include institutional and structural drivers (e.g. mistrust, referral fragmentation, gender norms). Routine data are indispensable but are partial. Used uncritically, they can reproduce disparities, leaving health systems to manage complex demands with limited insight. CR supports holistic analysis of how interventions interact with actors, interests, institutions, and political-economic conditions. Focusing on why disparities persist and linking routine metrics to triangulation and dialogue, CR readings can guide service adaptation and wider structural reform.

Reliance on purely face-to-face in-service training for primary healthcare workers in low-and middle-income countries is increasingly unsustainable. The COVID-19 pandemic accelerated the transition of the University of Cape Town Knowledge Translation Unit's Practical Approach to Care Kit programme from a facility-based cascade model to online and blended learning formats. This paper analyses the implementation of this transition across 29 courses between 2020 and 2023 in South Africa. Using the Health System Process Goals framework, we reflect on the challenges and enablers of e-learning, shifting the focus from digital training as a standalone technical solution to a systemic enabler of health system strengthening. While e-learning expanded access and standardised content, successful implementation relied on addressing systemic barriers. Key learnings include the necessity of subsidised ('reverse-billed') data to ensure equitable access; the superiority of a'blended' pedagogical model that combines digital content with peer interaction and in-person technical support and the value of automated reporting for workforce management. The systemic barriers included the lack of protected time for learners, which risks placing an inequitable burden on the workforce and reliance on donor funding, challenging long-term institutionalisation. For e-learning to effectively strengthen the health system, it must be integrated into administrative workflows and budget lines. We provide actionable recommendations for Ministries of Health, funders and implementers, advocating for a transition to government-owned platforms, accredited blended learning models and policy that mandates protected time for capacity development.

Youth reintegrating into society following incarceration, commonly referred to as reentry youth or youth who reenter, face major challenges to achieving successful, healthy developmental trajectories when transitioning back to their families and communities. Family-based interventions focusing on family strengths and psychoeducational skills help reduce risky behaviors and assist youth who reenter transition back into their families and healthy trajectories into adulthood. Research on family-based interventions for youth who reenter and barriers to treatment engagement however, is limited. The qualitative findings reported in this paper draw from a larger randomized control trial of a family-based intervention for youth who reenter and their families. Youth who reenter and their guardians were queried about their motivation to participate in family-based interventions and their desired content for these interventions. Analyses revealed themes reflecting these families’ needs and suggested strategies for researchers and practitioners to consider that may increase families’ participation when developing and implementing family-based interventions. These findings are essential for fostering engagement in these interventions, promoting treatment adherence, and ultimately improving outcomes of youth who reenter when transitioning back to their families and communities. Implications, limitations, and future directions are discussed.

Covid-19 demanded new ways of working. In this paper, we present the experience of the Vaxi Taxi, a community-orientated model of care developed when Emergency Medical Services (EMS) pivoted in response to the Covid-19 pandemic, converting its ambulances into mobile vaccination units in the Western Cape, South Africa. Using a five-year long embedded research approach, we drew on traditions of organizational ethnography and critical action research. Data collection included documenting observations and reflections in a research diary during implementation. In addition, in-depth conversational interviews, group discussions and a series of sensemaking discussions with academic research team members were done. Our analysis draws on the Everyday Health Systems Resilience framework (EHSR) which understands resilience as an emergent process underpinned by system capacities (cognitive, behavioral and contextual) that can be nurtured through response to stress and shock. Responses take the form of absorptive, adaptive or transformative strategies. We consider the Vaxi Taxi as adaptive resilience strategy that nurtured system capacities which may have transformative potential in future. For health practitioners, it highlights the value of creative problem-solving to generate ‘slack in the system’ and creating ‘spaces of unlearning’ in supporting adaptive strategies. However, the experience also highlighted that the relational work to support meaningful community relationships that enable trust take time. Routine EMS operations don’t support this trust building, and this requires alternative approaches. Finally, the paper represents a rare empirical example of an adaptive response to crisis tracked over time, and thus offers globally relevant lessons to the still-small EHSR literature.

We reviewed Corynebacterium spp. infection cases reported in South Africa during 2015-2023. We analyzed 84 isolates from 83 patients with C. diphtheriae, as well as 1 C. belfantii and 3 C. ulcerans isolates. Among C. diphtheriae cases, we observed respiratory diphtheria (26/83 patients [31%]), endocarditis (14/83 [17%]), cutaneous diphtheria (22/83 [27%]), nonspecific respiratory illnesses (5/83 [6%]), and asymptomatic carriage (16/83 [19%]). The median patient age was 19 (range 0-88) years. Diphtheria-tetanus-pertussis vaccination was incomplete for 26% (5/19) or unknown for 68% (13/19) of children 0-9 years of age. C. diphtheriae was intermediately resistant to penicillin (82/84 [98%] isolates; MIC90 0.5 μg/mL) but susceptible to erythromycin (83/84 [99%] isolates; MIC90 0.25 μg/mL). Eighteen unique sequence types were identified, corroborating C. diphtheriae heterogeneity. Toxin-producing strains were detected among cutaneous and respiratory diphtheria cases, indicating all forms of disease require monitoring and prompt public health action to curb transmission.