During the 1980 s many South Africans spent the greater part of their weekends at funerals. As we move into the first decade of the 21st Century this pattern is re-emerging, although for entirely different reasons. Every South African is becoming increasingly intimate with the effects of the HIV/AIDS epidemic, and, as with most preventable diseases, it is the most vulnerable and poorest communities whose lives are most adversely affected. The attention given to HIV/AIDS by many chapters in the 2000 South African Health Review reflects the seriousness of the disease and the widespread impact that the epidemic is already having.
Previous South African Health Reviews have highlighted that in most areas of our health system excellent policies are now in place, and the challenge is to ensure implementation. In contrast, what is disturbing in relation to HIV, is that in some critical areas including Mother to Child Transmission and HIV and breastfeeding, there are not even clear policy guidelines.
In important areas of health care progress has been achieved, and in particular the development of detailed guidelines for a number of areas of specialty bear testament to improved policy implementation. For example 84% of districts have clinics offering tuberculosis treatment based on the principles of the DOTS strategy. Integrated Management of Childhood Illnesses (IMCI) has been adopted as a national programme to address acute childhood illnesses and a Vitamin A supplementation policy has been developed and approved. The Tobacco Products Control Amendment Act, an example of our model legislation, will serve to reinforce the declining prevalence of smoking, down from 34% in 1992 to 24% in 1998.
Unfortunately the benefits in terms of health status that could be expected to accrue from improved care are already being compromised by both the HIV/AIDS epidemic and by funding. There have been declines in per capita funding of the public health sector, and even declines in per capita funding of primary health care(PHC). This is cause for concern when the availability of various types of laboratory tests performed as part of PHC is unsatisfactory; when HIV testing in clinics is low with only six out of every ten fixed clinics offering this test; when essential PHC equipment is unavailable at some fixed clinics; when one quarter of fixed and satellite clinics have no ambulance available and when one third of mobile clinic workers believe that the vehicles they use are unsuitable for the roads they travel.
Promotion of equity is a cherished ideal of key policy documents relating to health care. It is regrettable that in respect of the most basic prerequisite for equity in the public sector, financing, the trend towards increased equity which took place during the first few years of democratic government appears to have been reversed as a result of changes in mechanisms of funding. Resource distribution between the public and private sectors remains the site of greatest inequity. The introduction of Social Health Insurance as it is presently construed will have only limited impact on this gap, and there is a need for re-examination of the objectives and design of existing policy. The 1998 re-regulation of medical schemes also aims to contribute to promoting equity through encouraging risk pooling and avoiding “dumping” of private patients on the public sector. Attention to the process, and to effectively involving stakeholders is crucial to the future of both Social Health Insurance and to the effective implementation of the Medical Schemes Act.
Transformation is ongoing in a number of critical areas. The transformation of Local Government heralds the opportunity for successful establishment of the District Health System, with the potential to improve the quality of life of many poor South Africans. A number of complex issues have to be addressed as part of this process and without a clearly articulated strategic plan there is the possibility that devolution of PHC will result in increased inequity.
Inherent in a Review of this type is the fact that a number of authors refer to the same issue, and this is especially so in the context of the HIV/AIDS epidemic. An overarching chapter on Health Status and Determinants provides an overview of mortality and morbidity data, and more detail is provided in chapters concentrating on programmatic issues such as Tuberculosis and Child Health. There are a few examples where small differences appear in data that is presented. These result from authors and researchers drawing upon different databases and sources of information.
As always, the Review does not expect to provide an exhaustive analysis of every facet of health services in the country. Rather it aims to examine and report on the general degree to which government is succeeding in achieving its aims in the stated health reform policies and objectives. In doing so attention is focused on critical elements that are being addressed in the system during the year in question. This year marks the beginning of a new millennium and the end of the first five years of new administration in the new South Africa. The report card demonstrates a mixed picture and the comments highlight areas of concern for trends into the future.