At the level of words and policies South Africa’€™s health system is broadly on track towards a more effective and equitable service, but implementation and delivery still have a long way to go.

This is the diagnosis of the 1999 South African Health Review, an annual report produced by the Health Systems Trust, which assesses the state of the nation’€™s health services.

The review notes that the National Health Bill, necessary to replace the 1977 Health Act and to provide a broad enabling legal framework for current policies, is still awaited. It also points out that the standard of health care in some parts of South Africa is lower than in other poorer African countries.

Preventable deaths such as infant mortality and women dying in childbirth are still high. In the Eastern Cape, the rate of infant mortality (61,2 deaths per 1 000 births) is double that of the Western Cape (30,2).

Wide variations also exist in levels of immunisation. The Northern Cape has achieved 80 percent immunisation coverage, but only half the population of Kwa-Zulu-Natal and Eastern Cape is being inoculated.

Sharp inequities also exist. Speaking at the release of the report at Parliament yesterday (Wednesday) the author of the chapter on the distribution of human resources, Dingie van Rensburg, said 40 percent of all pharmacists in the country worked in the private sector in Gauteng.

“This is four times the number of pharmacists in the public sector in all the provinces combined,” he said. The serious problems caused by the shortage of pharmacists in the public sector, especially in district hospitals, will hopefully be alleviated to some extent by the introduction of community service for pharmacists from January 2001.

Examining the relationship between the public and private medical sectors, the review says better monitoring of the private sector is needed. It notes that there is “plenty of evidence” to suggest that some care in the private sector Is of poor quality and influenced by commercial considerations. One example cited was that as many as 63 percent of all visits for sexually transmitted diseases (STDs) were to private doctors, but at the most, only 30 percent of those doctors were giving effective treatment for STDs.

The review says “the idea that a free service is an inferior service needs to be challenged”. It says that if the South African public were more health literate they would be in a better position to make choices about if and when to seek private care.

A major stumbling block to the effective restructuring of the South African health system has been the slow progress towards implementing the District Health System.

This system is the foundation for how primary and public health care services are to be delivered to the South African population.

The review says a confusion of roles between national and provincial health departments and district-level responsibilities, as well as continued uncertainty over local government boundaries are the main problems hampering the development of an effective District Health System.

The introduction of the essential drugs’€™ list seems to have assisted to rationalise drug use and improve the availability of key drugs. However, The review notes that there has been progress in the implementation of the national TB control programme, but warns that the close link between TB and HIV/AIDS must lead to better co-ordinated programmes between the two diseases.

In the face of the “catastrophically high” levels of HIV infection, especially amongst teenage women, the SA Health Review says urgent action in the form of strong national and provincial AIDS programmes is needed. It notes that Gauteng stands out as a good example of a developing provincial programme.

Commenting on the first year of community service for doctors, the review says it enjoyed partial success. However, less than a quarter of community service doctors were placed in rural hospitals where the need was greatest. More than half went to regional, tertiary and specialised hospitals.

Finally, the review notes that the termination of pregnancy is still out of the reach of many women, as this service is not widely offered in many provinces. ‘€“ Health-e news service.