On the way down

It is a truth universally acknowledged, that a country in possession of economic growth will find the health of its citizens improving. But almost uniquely, South Africa’s growing financial strength has been accompanied by a fall in key indicators of health.

The tie between health and wealth has held true for most of the world, and for as long as there appear to have been economists to notice it. Wealthier countries tend to be healthier at least until they start to encounter the diseases of affluence such as obesity.

In South Africa, and some other surrounding countries, this link has broken.

South Africa’s Gross Domestic Product per capita has increased by an average of 3% per year for the last decade. Yet the most obvious indicators of health are falling.

The easiest way to get snapshot of a nation’s health is to look at key indicators: life expectancy at birth, maternal mortality and infant mortality. These are such fundamental markers that they were written into the Millennium Development Goals (MDGs), which South Africa signed in 2000.

MDG 4 is to reduce child deaths by two-thirds, MDG 5 to cut maternal deaths by three-quarters.

Signatories to the MDGs were required to achieve the goals within 15 years. As a middle-income country undergoing steady economic growth, South Africa should be on its way.

Yet all three indicators are going the wrong way life expectancy is falling, and the maternal and child death rates are rising. Since 1997, while deaths from non-natural causes such as car crashes and violence have remained roughly on a plateau, overall mortality has escalated. Most of these increased deaths were among young adults, and young children.

Birth and death
In 2001 Statistics South Africa estimated that average life expectancy for both men and women was 54,6 years. As is normal, life expectancy for women was higher (57,2 years) than for men (52,1 years). However by 2007, overall life expectancy had fallen to just 50 years. Women still have a higher life expectancy at birth (51,6 years) compared to men (48,4), but the gap is closing.

South Africa has a population of about 48-million people, and slightly more than a million babies are born each year. According to the Child Healthcare Problem Identification Programme (PiP) study Every Death Counts: Saving the Lives of Mothers, Babies and Children in South Africa, at least 260 mothers, babies and children die each day in South Africa. The national rate of infant morality of 60/1 000 births represents an infant dying every eight minutes.

An estimated 75 000 children under the age of five, 1 600 mothers, and 22 000 newborn infants die every year in South Africa. Another 20 000 babies are stillborn.

HIV and Aids, neonatal causes and childhood infections such as pneumonia and diarrhoea account for roughly a third of deaths. One estimate is that just over 9% of deaths are due to unsafe water and sanitation, which contribute to the diarrhoea.

But as Rob Dorrington, professor of actuarial science at UCT, points out, national reporting on “vital registration” (births and deaths) is erratic. While demographers are fairly confident about adult mortality data, they are less so about child mortality, especially in rural areas.

According to the study Every Death Counts, approximately 38% of all maternal deaths are due to infections unrelated to the pregnancy primarily HIV, TB and pneumonia. But according to the Department of Health’s 2003 Confidential Enquiry into Maternal Deaths the role of HIV may be under-represented: only 54% of women who died had been tested for the virus, and of those 78% were HIV-positive.

A report by the University of Pretoria and the Medical Research Council in 2007 into child deaths between 2003 and 2005 found that 46% of children in the study who died were not tested for HIV. Of those who were, 35% died from HIV-related causes. Pregnancy-related mortality based on 2001 census data estimated pregnancy-related mortality at between 650 and 820 per 100 000.

The deaths of mothers, babies and children are linked, both directly and indirectly. Research by Dorrington suggests that infected mothers are more likely to die and not be able to report on the deaths or survival of their children, who in turn experience higher than average mortality.

Aids and HIV
The most obvious indeed the almost automatic answer as to why the health-wealth link appears broken in South Africa is HIV/Aids. In acknowledgement of the magnitude of the crisis this epidemic has created, MDG 6 aims to halt and begin to reverse the spread of HIV and Aids.

Dorrington has long been involved in modelling the demographic impacts of the disease. He points out that, even with the weaknesses in the data collected on births and deaths in South Africa, there has been a clear change in the profile of the population. There has been a disproportionate number of adult deaths, especially among young women and older men. Almost all are due to HIV and its associated illnesses.

According to the department of health’s annual survey in antenatal clinics, approximately one in three pregnant women attending public health facilities are infected with HIV. This figure ostensibly appears to have reached a plateau, although many experts question some of the statistical procedures and assumptions lying behind this, the closest to good news in HIV/Aids statistics.

HIV not only affects life expectancy but has a major impact on two other health indicators maternal and infant deaths. Every Death Counts puts HIV and Aids among the “Big Five” causes of maternal and child mortality in South Africa and the disease has wider-ranging impacts.

So while the devastation being wrought by HIV and Aids is undeniable, are these epidemics being made at least in part the scapegoats for other healthcare problems in South Africa?

Epidemics, like famines are largely made and not just borne in isolation. HIV is not only a cause of declining health in South Africa, but is also the result of a failed healthcare system.

Failure of health systems
In 1997 there were about 251 000 staff members in the public health system. This had declined by about 36 000 people by 2002, but has since risen to 251 000 in 2007/8.

So over a decade, despite a greatly increased burden of disease, and an increasing population, there has been no real increase in staff levels. One estimate is that if staff levels were adjusted to account for population growth there is a shortfall of over 64 000 medical workers.

Reductions in staffing levels lead to decreased staff morale and quality of service, as well as encouraging other healthcare workers to leave.

Malnutrition and childhood infections, including HIV, are the biggest killers of children, according to the Medical Research Council.

However, failure of healthcare plays a significant role: Most of the estimated 4 500 births resulting from birth asphyxia could be prevented with better care around birth. While the cause of a third of stillbirths is known, intrapartum asphyxia suffocation during birth and birth trauma account for about 2 800 dead babies being delivered each year. Approximately four out of 10 babies stillborn died during birth. Almost half maternal deaths, and between one third and one half of newborn deaths occur are on the first day of life.

These statistics indicate that better care during childbirth could have a significant impact on saving the lives of women and children. And these preventable deaths are one clear indication that the public health system is a disaster, even while medical tourists come to experience South Africa’s private healthcare.

Anecdotal reports of a collapsing public healthcare system abound. Doctors report stock-outs of drugs, medicines and other essential healthcare items. According to a doctor at one major hospital, renal dialysis patients have been known to be sent home because of shortages of not only the tubes needed to connect them to the machines, but even of the water needed for the process. Asked what happened he said, “They go home, and the worst thing is that they don’t seem surprised.” Doctors’ discussion forums abound with tales of equipment or staff missing.

The announcement by Free State province that it was unable to add new patients to its antiretroviral programme, and would run out of antiretroviral drugs by next year, led to a steady of stream of information and disinformation about the under budgeting of healthcare in South Africa.

Over the last few years expenditure on healthcare has risen, but this has failed to compensate for the previous 10 years during which the system ran down. South Africa’s public health system is decrepit, but money is only part of the reason.

South Africa spends slightly over 10% of national budget or 3% of GDP on healthcare, compared to an international mean of 11,4%. Out of the 30 countries with similar income levels, South Africa is the only one with a worsening of infant mortality, maternal and child mortality between 1990 and 2006.

Equally important has been the lack of management, leadership and institutionalised accountability. With no clear lines of responsibility, tragedy after tragedy occurs where no one is held responsible, and too often whistleblowers have been punished.

One trend has been the attempt to control media access to healthcare workers and facilities. While patient privacy should be respected, in some provinces doctors are too scared to talk to journalists for fear of being punished, either overtly or covertly. Attempts to get information from different departments of health are often unsuccessful, and information given is often conflicting. This makes it even harder for the sunlight of publicity to help sanitise the health system.

Poverty and inequality
In the 1880s, doctor and medical innovator Rudolph Virchow said, “Do we not always find the disease of the populace traceable to defects in society?”

Health generally is affected by income, which means it is inevitably integrated into wide issues of social development. It came to be seen as a human right after World War II and the creation of the World Health Organisation.

HIV is affected by the dynamics of poverty, and particularly social change and income inequalities.

Although estimates of child, infant and maternal mortality vary, one thing is agreed—South Africa is highly unlikely to meet MDGs 4 and 5. One estimate is that while some countries that had similar mortality and gross national income in 1990, such as Brazil, have halved the under five mortality, South Africa would have to achieve an average 14% cut in child mortality in year.

About 30% of child deaths occur in the first month of life, mainly due to poverty and inequity which reduce the health of mothers and thus children, and reduce their access to healthcare.

Children from poor families are at four times the risk of early death compared to those from wealthier families. According to the PiP, approximately 15% of newborn babies in South Africa weigh less than 2,5kg at birth, one-third of children are severely malnourished, and almost two-thirds are underweight for their age.

This is particularly true for HIV-positive children, whose need for nutrients and nutrition simply for growth is increased by the need of the body to cope with the demand the virus puts on the child’s immune system.

For children who survive their first few weeks, another risk period arrives when weaning begins. A mother’s milk may not be optimal if she herself is malnourished or extremely sick, but weaning can result in a child being given inadequate solid food that may stop it crying from hunger but fail to provide its body with the resources it needs for development.

The impacts of hunger and malnutrition can be seen in the levels of stunting that are seen. The 2003 South African Demographic and Health Survey found that 12% of children under five were underweight, and 27% were stunted.

According to the department of social development about 28-million people were living in poverty in 2005, of whom 14-million were children. One estimate is that in 2005 20% of children were stunted 10% were underweight, the same amount overweight, and 4% obese.

A survey at eight healthcare facilities found that of 755 child who died between September 2003 and February 2004, 695 were either underweight or severely malnourished.

Lack of nutrition damages the most energy-hungry and most sensitive part of the human body—the brain. Poor nutrition and high levels of infections can contribute to children failing to achieve their potential both physically and mentally. A tragedy for the individuals concerned, it should also be seen as a disaster for the family and for wider society. Children are the human capital of the future, crucial for families to rise above (and stay above) poverty, and in turn they affect the human capital of society and so economic development.

While absolute levels of poverty have lifted slightly, inequality has continued to rise. The Gini Coefficient is a measure of income inequality, ranging from 0 (no inequality) to 1 (complete inequality). In 1993 the Gini coefficient was estimated to be 0,672, but by 2006 had risen to 0,685. Different Gini estimates are available depending on the assumptions made. This increasing inequality comes despite a background of a massive expansion in social grants.

In 2007 3,2% of GDP was spent on social grants. In that year, 12-million people were benefiting from social assistance support grants, compared to just over 2,5-million in 1999. The most rapid growth has been in child support grants, which have grown from just under 35 000 beneficiaries in 1999 to 7,8-million in 2007
Alleviating poverty has been one of the key strategies of the South African government. There have been some successes—for example, real per capital income (in constant 2000 rand terms) for the poorest 10% of the population was R534, while by 2006 it had risen to R734.

But while real income had increased for the poorest, there had been effectively no change in the proportion of total income accruing to the poorest and richest 10% of the population between 1993 and 2006. In 1993 the poorest 10% of the population received 0,6% of total income and the richest 10% 54,8%. By 2006 the proportion of income had stayed the same for the poorest 10% and had risen slightly to 55,9% for the richest 10%.

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