The impact of HIV/AIDS on all aspects of South African society is hampering even the best efforts to improve the health status of the country and overall the country’€™s health status remains poor.

This is the assessment of the annual South African Health Review (SAHR) released by the Health Systems Trust today (Thursday 1/3) which places South Africa’€™s health status below that of other middle income countries.

The authors note that even without the impact of HIV/AIDS on the society, South Africa would remain lowly ranked due to the “triple burden” on its health system created by poverty-related diseases, various emerging chronic diseases and injuries.

However, the 500-page long report card also acknowledges areas of health care in which progress has been made. These include an “excellent” set of overall policies, the fact that more than 80% of clinics are able to offer the DOTS (directly observerd treatment strategy) for TB treatment, and an integrated management approach to address acute childhood illnesses.

The SAHR notes that the new law controlling the advertising and use of tobacco products serves to reinforce the government’€™s commitment to improved public health and the already declining prevalence of smoking, down from 34% in 1992 to 24% in 1998. The challenge with this and other aspects of the health policy framework is to ensure implementation.

Similar restrictions on alcohol advertising are recommended in the review as a means to address the impact of substance abuse ‘€“ estimated to cost the country about 2%of its GDP (R12 billion a year) or R270 for every man, woman and child.

However, in chapter after chapter, the authors warn that what few gains have been made in South African healthcare are likely to be eroded in the face of the AIDS pandemic and new pressures imposed on health and other social services.

The stark levels of poverty in the society ‘€“ in which an average of 22% of South African households are reported to go hungry each day ‘€“ only serve to exacerbate the impact of a disease that attacks the body’€™s immune system.

Statistics South Africa estimates that the life expectancy in 1996 was 52 years for men and 61,6 for women. The Medical Research Council estimates that as a result of the AIDS epidemic, life expectancy has dropped from 63 in 1990, to 57 in 2000. Projections estimate that by 2010, life expectancy will be 40 years ‘€“ among the lowest in the world.

It is estimated that 6 million South Africans will die from AIDS related diseases in the next 10 years. But the authors of the SAHR argue that this need not be the case. Even at this late stage of the epidemic, they say there is room to limit the impact of this bleak forecast.

A change in sexual behaviour, improved management of sexually transmitted diseases and the prevention of mother to child HIV transmission would all reduce the impact of the epidemic. In addition, affordable anti-retroviral drugs and the development of appropriate guidelines to treat opportunistic infections are essential if the worst case scenario is to be avoided.

When compared to other medium development countries, South African health expenditure is high in relative and absolute terms, but it is very skewed by the high spending in the private sector that serves a minority of the population.

In a chapter on public sector financing, health economists warn that funding of this sector has reached a “critical juncture”. Initial efforts after the democratic elections of 1994 helped to improve equity in public health care, but this trend appears to have been reversed in recent years.

Since 1997 there have been declines in public health funding and growing inequity in provincial resource allocation.

In recent years there has been a real increase in funding for public hospitals (which absorb almost two thirds of public health expenditure) but this has not resulted in increased staffing or outputs. The extra money is likely to have been spent on increased salaries and benefits.

The authors of this section of the review warn that capital infrastructure and equipment are deteriorating at faster than existing spending on rehabilitation, maintenance and replacement.

For a closer look at aspects of the South African Health Review see the following stories:

HIV threatens progress in TB control

Drug Prices

Sharp rise but malaria battle is being won