ReviewHealth in South Africa: changes and challenges since 2009
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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