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Detection of hearing impairment is not considered high on the priority list in South Africa due to the governments' other health care priorities. South Africa faces a quadruple burden of disease with the health system struggling to cope with four major health issues: NCDs which are chronic diseases; communicable diseases, particularly HIV and TB; maternal and child health (morbidity and mortality rates); and death from injury and violence (DoH, 2014; Naidoo, 2012). The South African government is focused on health promotion aimed at combating diseases or reducing mortality rates, while increasing life expectancy and health system effectiveness (DoH, 2014). Specific challenges in the private health care sector include aspects related to NHS services not forming part of the birthing package or institutional policy. Early detection programmes in this sector have also not been supported by medical aid schemes (Meyer & Swanepoel, 2011), although Discovery, one of the largest schemes, started showing an interest in 2019 in funding screening programmes.

Programmes for early detection of hearing impairment in South Africa have not been standardised nationally, with documented differences existing between provinces as well as between the public and private health care sectors (Meyer & Swanepoel, 2011; Theunissen & Swanepoel, 2008). Overall, results from NHS studies in South Africa have revealed poor coverage rates and limited implementation of universal newborn hearing screening (UNHS) due to a number of context-specific challenges (Table 2.1).

The number of UNHS programmes implemented in the private health care sector has been limited. A UNHS programme conducted over a four-year period at a private health care hospital in South Africa reported a 75 percent coverage rate within the first 22 months when hearing screening was included in the hospital birthing package. This coverage rate decreased to 20 percent when parents were financially responsible for the NHS services (Swanepoel, Ebrahim, Joseph, & Friedland, 2007). A national survey conducted in the private health care sector in South Africa indicated that only 14 percent of obstetric units offer true UNHS (Meyer & Swanepoel, 2011). A significant 47 percent of the private health care units included in the survey reported not performing NHS. Although risk-based or targeted newborn hearing screening (TNHS) may yield a greater coverage rate, more units (18 percent) reported conducting screening on request or referral in comparison to TNHS (Meyer & Swanepoel, 2011). This lack of UNHS programmes has also been documented in the public health care sector (Theunissen & Swanepoel, 2008).

Findings from an earlier national survey among public sector hospitals in eight of the nine South African provinces indicated that an estimated 7.5 percent of public sector hospitals provide some form of NHS, and less than 1 percent provide UNHS (Theunissen & Swanepoel, 2008). As a result, PHC clinics and MOUs were proposed as a platform for UNHS with the rationale that the PHC level provides an opportunity for improved coverage and follow-up return rates (HPCSA, 2007; Swanepoel, Hugo, & Louw, 2006). PHC has also been viewed as having a set of values and principles that support universal health care access and address the social determinants of health (Mash et al., 2018; Scott et al., 2017). A few studies in South Africa have explored or piloted early hearing detection programmes at different levels of service delivery (Bezuidenhout, Khoza-Shangase, De Maayer, & Strehlau, 2018; De Kock et al., 2016; Kanji, Khoza-Shangase, Petrocchi-Bartal, & Harbinson, 2018; Khoza-Shangase & Harbinson, 2015). Table 2.1 details findings from these studies.

Table 2.1 Summary of findings from studies related to early hearing detection in South Africa

Context	Province	Coverage rates	Age of identification of hearing impairment	Pros and cons	Study
MOUs	Western Cape	Not documented	Mean age at initial screening documented as 6.1 days	Well-trained and -managed screeners can be used successfullyGood follow-up return rates for screeningLoss to follow-up when referred for diagnostic assessmentVariability in diagnostic assessment protocols	De Kock, Swanepoel, & Hall, 2016
MOUs	Gauteng	38 percent at initial screening	Not documented	Screening at the three-day MOU assessment clinic was more practicalTime of discharge did not always coincide with audiologists' working hoursLack of staffing, equipment and resourcesNoise levels at the clinic were not ideal	Kanji, Khoza-Shangase, Petrocchi-Bartal, & Harbinson, 2018; Khoza-Shangase & Harbinson, 2015
Hospital	Gauteng	17 percent over a two-year period	Not documented	Technical difficulties and/or equipment failureHigh patient-to-assessor ratio resulting in limited coverageEarly discharge of neonates born without complications	Bezuidenhout, Khoza-Shangase, De Maayer, & Strehlau, 2018

Despite the various programmes piloted in different health care contexts in a few provinces in South Africa, early hearing detection programmes have not yet been implemented at a national level. There is a great need for resources in terms of staffing and equipment for screening and diagnostic assessment to ensure timely detection and diagnosis of hearing impairment. In chapter 4, Petrocchi-Bartal, Khoza-Shangase and Kanji explore the feasibility of implementing early detection programmes at various levels of service delivery in the South African context.