Elsevier

The Lancet

Volume 380, Issue 9858, 8–14 December 2012, Pages 2029-2043
The Lancet

Review
Health in South Africa: changes and challenges since 2009

https://doi.org/10.1016/S0140-6736(12)61814-5Get rights and content

Summary

Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the world's largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.

Introduction

The 2009 Lancet Health in South Africa Series1 coincided with a crucial moment in the life of the nation. A new administration with a committed health minister had just been elected, and the democratic government that had been established 15 years previously was expected to finally jettison the unscientific health policies and disastrous mistakes of the Thabo Mbeki era (1999–2008) made in response to the HIV epidemic,2, 3, 4 and to overcome shortcomings in the delivery of health and social services. The Series clearly depicted the residual imprint of the colonial and apartheid eras, and the weight of a quadruple disease burden falling on an inequitable and inefficient health system (panel 1).5, 6, 7, 8, 9 In the final paper of the Series,10 a call for action was made to the South African Government, educational and research institutions, and civil society about measures that were necessary to strengthen the health system.

Here, we focus on themes from the 2009 Series and this report is therefore not necessarily comprehensive. Additionally, we do not mean to imply that a causal relation exists between events that have happened in the past 3 years and the 2009 Series. Nonetheless, it is evident that the Series has been highly influential. The Minster of Health Aaron Motsoaledi opened the launch of the Series in Johannesburg, South Africa, on Aug 24, 2009,11 and at subsequent public meetings, he repeatedly referred to its importance in defining of key health challenges that the country faced and the task ahead for his ministry.12 The Series is widely quoted and referenced by academics, researchers, policy commentators, and senior staff in the provincial and national Health Ministries. The language of the so-called four colliding epidemics, the substance of the analyses of health problems, and subsequent recommendations have entered the lexicon of health and social literature, complementing other important reports.13

Our goal is to assess what progress has been made since 2009, particularly in terms of the specific calls for action to achieve the Millennium Development Goals (MDGs) by 2015. In our view, four important changes have occurred and yet we recognise that four major challenges remain.

Section snippets

Change 1: Leadership as a key driver

The rapid transition from the failed stewardship of ex-President Thabo Mbeki and the disastrous policies of his health minister Mantombazana Tshabalala-Msimang to the leadership shown by the present health minister Aaron Motsoaledi and his team could not have been more striking. Barbara Hogan took the first steps, initiating several projects to deal with the disarray in the Department of Health in her short term as Minister of Health. These changes were followed by decisive actions, indicating

Overview

South Africa has experienced a complex health transition in the past two decades.18 Mortality worsened between 1990 and 2005, in virtually all age groups largely because of HIV and AIDS.19 The morbidity profile is made up of coexisting infectious diseases (including new infections such as HIV and AIDS), non-communicable diseases (NCDs), persisting child diarrhoea and malnutrition, and interpersonal violence and accidents. In the past 3 years, important changes have been made mainly by the

Change 3: Towards universal coverage with national health insurance

About seven previous attempts to introduce a health scheme with progressive features began with the Commission on Old Age Pension and National Insurance in 1928, which was followed by different committees and commissions and the present Ministerial Advisory Committee on national health insurance, which was introduced in 2009. The best known iteration was the National Health Service (or Gluckman Commission; 1942–44), which recommended a tax for funding of health services.88 The call for action

Change 4: Consensus about health research

Wieland Gevers drew attention to the parlous state of clinical research in South Africa in 2009.99 The serious decline in clinical research activity and capacity prompted the Academy of Science of South Africa to produce recommendations for revitalisation of clinical research, such as increased funding, training of a new generation of health researchers, establishment of clinical research centres, and improved regulation and planning of the health research enterprise.100 The Department of

Challenge 1: Social determinants and racial disparities

Many data show that health and wealth are mutually reinforcing and that national pro-poor policies for economic growth also contribute to health and improved health outcomes contribute to economic development.107 Countries such as Brazil have shown these changes at scale.108 The most important reasons why South Africa has not achieved social and economic development in the past two decades are poverty, unemployment, sexism, and socioeconomic inequity.13 These factors are the core elements for

Challenge 2: Integration and coordination

Integration of aspects of the South African health system—eg, the public and private sectors, vertical programmes, and community outreach—will be challenging. Coordination and partnerships between public and private sectors of health care are possible (as with national health insurance) but will have to be carefully monitored for efficacy; integration seems highly unlikely and is probably undesirable. Integration of tuberculosis and HIV services and of wide service delivery for maternal,

Challenge 3: Surveillance and information

In 2011, the National Department of Health established a Health Data Advisory and Co-ordinating Committee which has identified key indicators and data sources to be used to monitor the performance of the health ministry.119 Additionally, efforts to strengthen the information systems were supported by policies and an audit of infrastructure and resources.120 However, South Africa can be judged to be data rich but information poor, because the data systems might not provide nationally

Challenge 4: Scaling up of innovative interventions

The 2009 Series called for increased innovation in service delivery and noted that HIV/AIDS interventions have tended to be more innovative than have others.7 Innovations in maternal, neonatal, and child health were noted, such as quality-of-care mentor schemes, but few reached wide scale within a decade, apart from mortality audits.6 Initiation of national health insurance gives a potential platform for innovation at scale.95, 131 A fundamental criticism of national health insurance, however,

Conclusion

We have summarised the important changes in South Africa's health dialogue and care of its people. A determined leadership for health has contributed to major successes in the confrontation and management of some of the most serious epidemics affecting modern societies: HIV/AIDS; tuberculosis; high mortality of women and young children and their mothers; a nascent and rising threat of NCDs; and unconscionable effects of relentless and pervasive violence. In the past few years, the inexorable

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