Since the 2009 Lancet Health in South Africa Series, important changes have occurred
in the country, resulting in an increase in life expectancy to 60 years. Historical
injustices together with the disastrous health policies of the previous administration
are being transformed. The change in leadership of the Ministry of Health has been
key, but new momentum is inhibited by stasis within the health management bureaucracy.
Specific policy and programme changes are evident for all four of the so-called colliding
epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence;
and maternal, neonatal, and child health. South Africa now has the world's largest
programme of antiretroviral therapy, and some advances have been made in implementation
of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention
has received increased attention. Child mortality has benefited from progress in addressing
HIV. However, more attention to postnatal feeding support is needed. Many risk factors
for non-communicable diseases have increased substantially during the past two decades,
but an ambitious government policy to address lifestyle risks such as consumption
of salt and alcohol provide real potential for change. Although mortality due to injuries
seems to be decreasing, high levels of interpersonal violence and accidents persist.
An integrated strategic framework for prevention of injury and violence is in progress
but its successful implementation will need high-level commitment, support for evidence-led
prevention interventions, investment in surveillance systems and research, and improved
human-resources and management capacities. A radical system of national health insurance
and re-engineering of primary health care will be phased in for 14 years to enable
universal, equitable, and affordable health-care coverage. Finally, national consensus
has been reached about seven priorities for health research with a commitment to increase
the health research budget to 2·0% of national health spending. However, large racial
differentials exist in social determinants of health, especially housing and sanitation
for the poor and inequity between the sexes, although progress has been made in access
to basic education, electricity, piped water, and social protection. Integration of
the private and public sectors and of services for HIV, tuberculosis, and non-communicable
diseases needs to improve, as do surveillance and information systems. Additionally,
successful interventions need to be delivered widely. Transformation of the health
system into a national institution that is based on equity and merit and is built
on an effective human-resources system could still place South Africa on track to
achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its
citizens.
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