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UNHS is a commonly practised approach to early detection in developed countries, with well-established, standardised programmes, and dedicated screeners outside of the profession of speech pathology and audiology. While these developed countries have established NHS programmes and are concerned with the diagnostic follow-up and intervention aspects, South Africa appears to be in the early stages of implementation of NHS services and programmes (Kanji, 2016). Research and conceptual papers related to EHDI in South Africa have acknowledged the impracticalities of attempting to implement developed world models of NHS in developing countries (Moodley & Störbeck, 2015; Swanepoel, Delport, & Swart, 2004; Swanepoel, Hugo, & Louw, 2005).

Both approaches to NHS have been explored in the South African context. Studies involving UNHS have looked at different health care contexts – private and primary health care, secondary level hospitals and midwife obstetric units (MOUs) – in the public sector in two provinces (Bezuidenhout, Khoza-Shangase, De Maayer, & Strehlau, 2018; De Kock, Swanepoel, & Hall, 2016; Khoza-Shangase & Harbinson, 2015; Swanepoel, Ebrahim, Joseph, & Friedland, 2007).

A UNHS study conducted over a four-year period at a private hospital revealed a 75 percent coverage rate within the first 22 months when hearing screening was included in the hospital birthing package. However, the efficiency of the programme decreased to a 20 percent coverage rate during the following 26 months, when parents were responsible for payment of the NHS service (Swanepoel et al., 2007). Of the two studies conducted in the public health care sector, the study at a secondary level hospital included screening of 121 neonates out of a possible 2 704 births during the study period. Challenges to the implementation of UNHS included noise interference; vernix in the external auditory canal of neonates; human resource challenges due to a high patient-to-audiologist ratio, resulting in limited coverage; technical and equipment challenges; as well as early discharge of well babies (Bezuidenhout et al., 2018).

MOUs have been reported to serve as a useful platform for UNHS and follow-up with postnatal visits (De Kock et al., 2016). A study conducted over a 16-month period at three MOUs in the Western Cape revealed initial follow-up return rates to be high, with a decline for additional screening or diagnostic appointments (De Kock et al., 2016). The employment of dedicated non-professional screeners was reported to have positively influenced screening services, with quality training and regular supervision being vital to programme efficiency. While the HPCSA guidelines are geared toward UNHS and serve as the gold standard that audiologists in South Africa should aim to achieve, they are not necessarily applicable as the starting point in all health care sectors in the country.

Studies related to TNHS have been less frequently conducted in the South African context. However, findings from one study suggest the need to establish more context-specific risk factors in order to ensure effective implementation of TNHS programmes (Kanji, 2016). Results from this study indicate that the case history factors in the sample of high-risk neonates were not all present on the HRRs by the JCIH (2007) and HPCSA (2018). These differences in findings, along with those in Australian studies by Beswick, Driscoll, and Kei (2012), as well as Beswick, Driscoll, Kei, Khan, and Glennon (2013), highlight the need to specifically tailor risk factors to context. Kanji and Khoza-Shangase (2019) further highlight the importance of context itself as a risk indicator. These authors propose the concept of a quadruple influence on risk, which takes cognisance of the influence of the burden of disease, medical advancements, technological advancements and human advancements. The use of appropriate risk factors is further explored in chapter 6 of this book. It has also been suggested that TNHS be considered in contexts where UNHS is not yet feasible, particularly in hospital settings in the public health care sector, where high-risk neonates would be more likely to undergo follow-up and monitoring by paediatricians.

The South African health care sector consists of a large public sector on which over 80 percent of the population is dependent (Naidoo, 2012). The Department of Health (DoH) focuses on other health priorities and specific health-related goals, such as the eradication of extreme hunger and poverty, the promotion of gender equality, reduction of child mortality, improvement in maternal health, and combating of HIV/AIDS, malaria and other major diseases (DoH, 2012).

Considering South Africas' health care context, and the importance of early detection of hearing impairment in newborns and infants, there is a need to seriously consider how early detection services may be adapted to better meet these realities (Kanji, 2018). A number of factors need to be considered when deciding on the most suitable approach to NHS, whether interim or long term (see Table 3.1). Khoza-Shangase explores the challenges and realities confronting the implementation of early detection services in South Africa in chapter 5.

Table 3.1 Factors to consider when weighing up the approach to NHS

Factor	Details
Human resources	Availability of audiologists and whether non-professional personnel are available to conduct screening
Equipment	Availability of equipment for screening and/or diagnostic assessmentCosts associated with maintenance of equipment
Data management	Availability of an effective and efficient data management and tracking system
Costs	Clinical assessment and management costs for newborns and infants with hearing impairment