HIV/AIDS is reversing all the health gains that have been made in the last two decades and is affecting South Africans at every age and stage of their lives. In addition, our increasingly unhealthy lifestyles are killing us.

These are some of the findings in the 2003/4 South African Health Review (SAHR), an annual report on the state of the nation’€™s health produced by non-governmental organisation, the Health Systems Trust, and launched by the Minister of Health, Dr Manto Tshabalala-Msimang in Cape Town last night (July 28).

South Africans are most likely to die of HIV/AIDS, which was responsible for 39 percent of all deaths in 2000. Those who don’€™t die of AIDS, may fall victim to homicide and violence, which is the country’€™s second biggest killer overall (7,5 percent), followed by tuberculosis (5 percent) and road accidents (4,1 percent).

But an increasingly westernised, sedentary lifestyle is also leading to more deaths. The SAHR report found that when all categories of non-communicable diseases ‘€“ chronic non-infectious diseases usually associated with lifestyle ‘€“ are combined, they kill almost as many people as HIV/AIDS (responsible for around 37 percent of deaths).

The biggest chronic killer in South Africa is heart disease, followed by strokes, cancer, chronic obstructive pulmonary disease and diabetes.

The chances of women dying in, or as a result of, childbirth (maternal deaths) is also increasing. In 1998 in Gauteng’€™s public health sector, 67 women died in childbirth per 100 000 births, but by 2002 the number had risen to 112.

More of children under the age of five are dying, with the death rate of this age group worse in 2000 (95 per 1 000 births) than it was in 1975 (89 per 1 000).

AIDS-related illnesses were responsible for 40,3 percent of deaths of our children under five, followed by low birth weight (11,2 percent) and diarrhoea (10,2 percent).

The HIV/AIDS epidemic has effectively reversed the health gains made in child health as, by 1998, the death rate for the under fives had been reduced to 59,4 per 1 000.

The SAHR also exposes a deterioration in the quality of healthcare services for a range of reasons including a significant lack of staff.

The report revealed that the exodus of skilled health personnel for the year under review has been substantial – 600 South African doctors are registered in New Zealand while 10 percent of Canada’€™s hospital-based physicians and a staggering six percent of the total health workforce in the United Kingdom are South African.

Nationally, the percentage of vacant public sector posts was reduced from 57 percent in 2001 to 31 percent in 2003. However, during this same period, the actual number of public sector posts was reduced from 268 122 to 169 121, of which 116 547 were filled in 2003

Head of the School of Public Health at the University of the Western Cape, Professor David Saunders says that the biggest problem with the South African healthcare system is the implementation of sound policies.

‘€œThe reason why there is this huge gap (between policy and implementation) is the lack of capacity of human resources at all levels. When we say the health systems are not functioning it is because the human resources are not functioning,’€ says Professor Saunders.

The human resources factor is even more critical in the face of the AIDS epidemic. South Africa’€™s Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment will continue to come unstuck unless this crucial element of attracting health professionals is addressed.

The Department of Health has implemented community service as well as rural and scarce skills allowances in the hope of attracting staff to under-resourced areas. Community service for doctors was introduced six years ago and subsequently has been extended to dentists, pharmacists, physiotherapists, occupational and speech therapists, clinical psychologists, dieticians, radiographers and environmental health practitioners. The new Nursing Bill makes provision for the introduction of community service for nurses for a period of one year before they can be registered with the SA Nursing Council.

According to the review, community service has had limited success in increasing the supply of personnel in under-served areas. Various problems have arisen including students opting for urban in preference to rural placements where there is greatest need. The absence of supervision has also been a problem ‘€“ in some hospitals community service doctors reportedly end up as the only doctor. One study found that between 20 and 45 percent of all community service practitioners were planning on working overseas after completion of their time.

More funding has been directed to health care in the public sector, but real spending per person has not matched spending levels of the mid to late 1990s as the uninsured population grew by almost seven million in the last 10 years.

Mark Blecher, Director of the Social Sector at National Treasury and Stephen Thomas of the Health Economics Unit at University of Cape Town, caution in the review that a real growth of R3-billion in personnel expenditure has masked a reduction of 19 000 filled posts.

This is due largely to a 28 percent increase in average wages. The average wage of a health sector employee was R98 153 in 2003.

Overall the Western Cape remains the best-funded province and Limpopo the lowest funded per capita. Limpopo also has one of the largest numbers of uninsured (those not on medical aid) inhabitants while the Western Cape has one of the smallest.

The 2003/4 South African Health Review, the 9th edition published by the Health Systems Trust, consists of 24 chapters, each describing a key health concern.   Atlantic Philanthropies funded the development and printing of the 2003/4 SA Health Review. Funders of the Health Systems Trust include the Department of Health, the Department for International Development (UK), Henry J Kaiser Family Foundation (USA), Commission of the European Union, Rockefeller Foundation, Ford Foundation and WW Kellogg Foundation.