South Africa: a nation killing itself

2009-08-28 00:00

A SPECIAL series of The Lancet focusing on South Africa spells out in painful detail how many of our health indicators are the worst in the world. But while our health system is littered with lost opportunities, the Jacob Zuma government brings the possibility of real progress, argue the series’ authors.

South Africa has a “cocktail of epidemics” — HIV/Aids, tuberculosis, violence, poor maternal and child health, and increasing chronic diseases.

This is according to a special edition of The Lancet, the respected United kingdom-based medical journal, focusing on health in South Africa, which was released on Tuesday.

The Lancet makes depressing reading. Some of our statistics, such as for HIV, TB and interpersonal violence, are among the worst in the world. We are beset by racial and gender inequity ingrained by decades of colonialism and apartheid.

“Racial and gender discrimination, income inequalities, migrant labour, the destruction of family life and persistent violence spanning many centuries but consolidated by apartheid in the 20th century” are to blame for the current health problems, according to Professor Hoosen Coovadia and others, who wrote the introductory chapter.

The poorest 10% of households (mostly black) have an average annual income of R4 314 (mostly from grants), while the richest 10% get over 90 times this — some R405 646.

Health indicators are still badly racially skewed. In 2002, the infant mortality rate among whites was seven per 1 000 babies born. For African babies, it was 67 per 1 000.

There are also inequities between provinces. Western Cape children under five have a mortality rate of 46 per 1 000 in comparison with KwaZulu-Natal’s 116 per 1 000.

Sexual entitlement of boys is ingrained, with almost 40% of girls reporting that they were sexually abused before the age of 18.

Teen pregnancy is widespread, and half of all South African women have had at least one child by the age of 21.

The role of alcohol abuse is raised over and over throughout all the six chapters. It plays a major role in violence, including murder and rape, road accidents and unsafe sex.

“Rudeness, arbitrary acts of unkindness, physical assault and neglect by nurses have been widely reported” during the post 1994-era, according to the authors.

Aside from rudeness, there is also a shortage of skilled health staff. Thanks to the ill-conceived decision to close a number of nursing colleges to save money during former president Thabo Mbeki’s era, and migration, the rate of skilled professional nurses has dropped from 149 per 100 000 people in 1998 to 110 per 100 000 in 2007.

“As many as 40% of nurses are due to retire in five to 10 years and nursing remains the most crucial area for urgent policy intervention,” note the authors.

Poor leadership and stewardship (taking responsibility) also run like a ruinous cancer through the public health system.

Post-1994, many inexperienced managers were placed in positions of seniority and they have struggled to deal with major challenges, particularly human resource management.

Unfortunately, “incompetence within the public sector is widespread” and the government has lacked the “political will and leadership to manage underperformance in the public sector”. Loyalty rather than the ability to deliver has been rewarded.

There is no personal accountability. Leaders and managers have not been held accountable when mistakes have been made.

“Without concerted efforts to change national thinking on accountability, South Africa will become a country that is not just a product of its past but one that is continually unable to either address the health problems of the present or to prepare for the future,” assert Coovadia and others.

Mbeki’s “belief that HIV did not cause Aids” resulted in hundreds of thousands of lives lost and a substantial burden of ill-health.

While “the public health system has been transformed into an integrated, comprehensive national service”, the “ failures in leadership and stewardship, and weak management have led to inadequate implementation of what are often good policies”, conclude the authors.

Lancet UK editors Dr Richard Horton and Dr Sabine Kleinert conclude: “The South African people have shown extraordinary resilience during difficult times. The current leaders have survived apartheid, and often imprisonment, to fight for the future of their country. Civil society, with its strong voice, has brought about many important changes in health.

“South Africa is a young democracy with pride and hope, and above all with high expectations for a fair, equitable, and peaceful society. Its people deserve a healthy future.”

— Health-e News.

• Professor Hoosen Coovadia, Rachel Jewkes, Peter Barron, David Saunders and Di McIntyre wrote Chapter one, tracing the roots of current health challenges.

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