Integrated Regional Information Networks - August 26, 2009

This is the picture that emerges from "Health in South Africa", a new series released on Tuesday by UK-based medical journal, The Lancet, written by some of the country's leading researchers, doctors and public health specialists.

Six papers and six commentaries detail the roots of South Africa's health system challenges, its neglected epidemics of HIV and TB, persistently high rates of maternal and newborn deaths, a rising tide of non-communicable diseases such as diabetes, cancer and heart disease, and a burden of violence and injury which together form the country's second leading cause of death.

"Although South Africa is considered a middle-income country in terms of its economy, it has health outcomes that are worse than those in many lower-income countries," noted Prof Hoosen Coovadia of the University of Witwatersrand, and others, in the introductory paper of the series.

Little progress has been made towards achieving the health Millennium Development Goals (MDGs), the HIV/AIDS epidemic has not slowed, and progress has even been reversed in eradicating poverty and hunger, and reducing child mortality; South Africa is one of only 12 countries where child deaths have actually increased since 1990, partly due to HIV/AIDS.

Although the diagnosis for the health system is largely gloomy, the prognosis is upbeat - the authors felt that with strong leadership South Africa has the potential to overcome its high disease burden and huge health care inequities, and save hundreds of thousands of lives.

"The health predicaments facing South Africa are some of the country's greatest threats since apartheid," said Richard Horton, editor of The Lancet, at the launch of the series in Johannesburg on 24 August.

South Africa's strong research base, active civil society and newly elected government, which has already made a commitment to major health care reform, put the country in a strong position to improve health outcomes and lead the way for the rest of the continent.

Leadership crucial

A recurring theme in the series is the paradox of poor health outcomes in the context of sound policies and relatively high spending. But poor leadership and a lack of accountability mean many policies have not been properly implemented, particularly at provincial and district levels, where there has been a persistent scarcity of management skills.

"In the most striking example of poor stewardship, the national HIV/AIDS epidemic was allowed to spread, with relentless and massive yearly increases in prevalence," Coovadia wrote.

Former President Thabo Mbeki's "bizarre and seemingly unshakable belief that HIV did not cause AIDS" resulted in the loss of hundreds of thousands of lives and placed a calamitous burden on the health sector.

President Jacob Zuma's administration has the mandate and potential to address these public health emergencies, but "Will they do so or will another opportunity and many more lives be lost?" The Lancet writers asked.

Where to from here?

Health Minister Aaron Motsoaledi, who took office in May 2009, agreed with the often harsh findings in the reports: "Clearly, in health we have arrived at the diagnosis; there can't be any argument. The problem is what do we do from there?"

He noted that many of the recommendations in the series coincided with the ministry's 10-point action plan, and said there was still time to meet the MDGs if "we work together and have the will to succeed".

In contrast to the combative style of previous health minister Manto Tshabalala-Msimang, Motsoaledi pledged to "extend our partnerships with all stakeholders".

"It is critical that civil society, organized business and labour, researchers and academics in our country work with us to turn our health system around."

The to-do list is long, but both Motsoaledi and The Lancet authors prioritized implementing a national health insurance system, developing more effective and accountable managers, and adopting a more decentralized primary health care approach to bring services to communities.

Scaling up HIV and TB treatment and prevention, in particular the unacceptably high levels of mother-to-child HIV transmission, were also highlighted, with the caveat that the HIV/AIDS emergency not overshadow other urgent health priorities, such as the rising prevalence of non-communicable diseases.

Antiretroviral treatment means HIV-positive people will live longer and have a greater likelihood of developing diseases like diabetes and hypertension, said Prof Bongani Mayosi, head of the University of Cape Town's Department of Medicine. "We need to think of innovative ways to achieve a totally integrated system for infectious and non-communicable diseases."

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