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South Africa
THE LANCET
Country profile
South Africa
South Africa’s peaceful transition from the race-based apartheid system which excluded more than 80% of its citizens to a full participative democracy was marked by worldwide admiration for the nation’s achievement. The new-found pride and optimism of the “rainbow nation” led by President Nelson Mandela has been tested by the practicalities of writing a new rights-based constitution, the many acts of parliament required to undo apartheid, and the realisation that the previous government had run up a massive debt. The implementation of new dispensations for health and science has been limited by the need for fiscal discipline. In this profile of South African medicine The Lancet’s guide was Prof Ralph Kirsch.
An old health care system gives place to new Solomon R Benatar In 1994, when the Government of National Unity came into power through South Africa’s first democratic elections, health care was racially discriminatory, fragmented, and poorly coordinated. The one-fifth of the population with private insurance enjoyed good health care; but, for the poor reliant on public facilities, primary and community services were grossly inadequate. A well developed public service offered hospital-based community and tertiary care, racially segregated, to both rich and poor, but it was beginning to crumble (N Engl J Med 1991; 325: 30). How did this system come about? During the 1960s and 1970s, rapid economic growth gave rise to a strong private sector, supportive of academic medicine through part-time appointments: 40% of the country’s doctors provided private care to 20% of the population, mainly white (about 90% of whites had medical insurance). The private sector consumed nearly one-third of the 5% of gross national product (GNP) devoted to health care. The public sector, responsible for training health care professionals, was a segregated, largely hospital-based service providing a mixture of community and tertiary health care and at least some access to state-of-the-art treatment in all specialties. Not all academic institutions were at the same level, but most could offer tertiary expertise in some spheres. By the 1970s this sector was strong; 60% of the country’s doctors cared for 80% of the population. Respected by private practitioners, the public sector provided expert backup for private patients who suffered complex disorders or ran out of insurance cover. It accounted for 70% of the nation’s health expenditure—half of the sum going to academic institutions, where the bulk of public medicine was practised. The ratio of earnings of private to public doctors was about 2–3:1. During the next decade private medicine expanded and the proportion of doctors in this sector rose to 60%. Now much less supportive of academic medicine, the private sector increasingly offered tertiary medical and surgical services in a burgeoning array of private hospitals and clinics—though still only for one-fifth of the population Lancet 1997; 349: 1537–45
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(now made up of the insured 80% of white and 15% of black groups). The proportion of GNP spent on health care had risen to 8%, of which 60% was consumed by the private sector; the cost of health insurance was rising at over three times the rate of the consumer price index. Meanwhile academic medicine and the public sector were suffering under the thrust of privatisation. Medical, nursing and technological staff were being recruited into better paid jobs in lavish private institutions that were developing tertiary services with equipment unaffordable in the public sector. The salary ratio widened to about 3–5:1, and public medicine in rural areas and in academic institutions was further damaged by emigration.
Health care reform in the new South Africa The wide disparities in health in South Africa at the close of the apartheid era are illustrated in panel 1. Clearly the social challenges of transformation would be daunting. Although the 1980s had been characterised by much debate on a national health service it became obvious that the private sector would be beyond the reach of any immediate comprehensive nationalisation process. In view of the demographics of the large deprived 1537
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Panel 1: Some health disparities in South Africa Population (millions) % urbanised Infant mortality (per 1000 births) % deaths under 5 yr Life expectancy (yr) M F Tuberculosis notification rate (per 100 000) Maternal mortality (per 100 000 births)
Yr 1994
Asian 1·0
1993 1990
96·2 15·9
35·8 48·3
1988
7·4
21·6
1995 1995 1994
65 73 43
1990
5
Black Coloured 30·8 3·4
60 67 180
58*
White 5·2
Total 40·4
83·2 28·6
91·1 7·4
48·3 40·2
20·4
2·9
60 67 726
68 75 17
22
8
62 68 205
83†
*Excludes former homelands. †World Bank estimates for South Africa.
population and the challenges of development, the Government opted for a primary care based system. District-based primary care in the public sector would offer an opportunity to move from the strictly biomedical approach to a more comprehensive strategy that acknowledged the social basis of health. With the overemphasis of hospital-based care in the past, the grossly deficient primary health care facilities, and the lack of new resources to build and staff such facilities, the decision to transfer funds from expensive academic institutions would inevitably imply reduction, withdrawal, and restructuring of public hospital services. Initially the expectation was that restructuring could be achieved without loss of excellence in teaching institutions, and with extension of excellence to the primary and community levels, but the process of reform became complicated by several factors. First, the broad nationalisation processes, which the new Government had promised, were becoming modified by an understanding of the difficulty in achieving “redistribution” in a world where economic policies were moving in the opposite direction. A country that hoped to attract investment from the industrialised world had to confine its reforms to the public sector. Second, economic growth did not meet expectations, and continuing population growth was compounded by illegal immigration from the rest of Africa. With Government income 35% of GNP and expenditure 40%, redistribution policies had to be reconciled with “fiscal discipline”. The term employed was rationalisation, and politicians avoided public acknowledgment that this meant reduced public expenditure on health, education, and welfare. The four major principles of reform towards equity became: (i) reallocation of budgets strictly in line with the populations of each of the nine provinces, (ii) reshaping of the racial and gender composition of the public sector, (iii) a change in ideology toward the primary care approach, and (iv) a shift of the investigative thrust towards “essential national health research”. The increased access to affordable and effective health care envisaged through these mechanisms is clearly desirable, but difficulties arise from the pace of change and its short and long term implications for sustaining public medicine 1538
beyond primary care. Let me give an example from my own territory. Because the Western Cape has two medical schools and a smaller population than the previous Cape Province, its academic facilities have been threatened. Their budgets, reduced by about 15% over recent years, will now be cut by a further 50% over the next 5 years, to expand primary services and bring per caput public health expenditure into line with that of other provinces. The danger in slashing the budgets of established institutions is that they become incapable of the clinical and development activities for which they exist.
Conclusions The notion that all medical schools should model themselves on aspirations of the past, or of much wealthier societies, is unrealistic. An alternative is either to close some schools or to restructure schools in ways that capitalise on their specific strengths, thus fostering training systems capable of meeting the country’s diverse needs. Such imaginative possibilities could stimulate essential areas of growth while saving resources and preserving fragile existing facilities that will be necessary for tertiary medical care of future generations of the poor, and for sustaining education and scholarly endeavours on a broad front. While perfect justice in health care is unattainable, health reform must at least be towards a just system. If private medicine is not coordinated with public medicine, public medicine will be reduced to the provision of primary and community care; and, should elite private medical schools be developed, inequities will be enhanced and racial apartheid will be seen to have given place to economic apartheid.
Towards an essential drugs programme Peter I Folb One of the central issues in the policy of the new Department of Health in South Africa is to establish an essential drugs programme (EDP). This will be in line with and strongly support the Government’s primary health care initiatives; if successfully implemented, it should also address the inordinately high cost of medicines in the country. As in other health sectors, the challenge will be to find a formula that encompasses the private as well as the public components of health care delivery. There is much going for the country that gives the EDP a good chance of success. Firstly, there is political will. The Ministry of Health, firmly committed to a primary health care focus, recognises that a successful drug policy is critical to the overall success of its health plans in general. There are sufficient well-trained people working in the public service to bring it about. The United Kingdom Overseas Development Administration (ODA) and the World Health Organization have brought in considerable logistical, technical, and financial support for the national drug policy. The financial resources necessary to provide essential medicines equitably to the entire population are available. Academics are supportive of an essential drugs programme in the public sector, and they have proved willing to cooperate in providing the necessary expertise. Furthermore, and significantly,
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national drug policy is underpinned in South Africa by a strong and independent national drug regulatory authority, the Medicines Control Council. Other initiatives are also in the offing. These include the introduction of traditional medicines (and healers) into the formal health structures, expansion of the nation’s vaccines production facility, a commitment to curtailing the unscrupulous charging for medicines by some dispensing doctors, uniform price controls on medicines imposed by Government, parallel importing of high quality generic medicines, and wide-scale introduction of training programmes for nurses and other primary health care workers in the rational use of medicines. With all this in place, or at least in prospect, what can go wrong? Unfortunately, a great deal. Firstly, there are some doubts about the administrative and organisational capacity of the Department of Health to coordinate and bring these programmes about, and the willingness of the Department to delegate them appropriately. There are moves afoot to reduce the autonomy of the Medicines Control Council, so that it would come more under the authority and control of the Ministry of Health. This will be an error, and we can expect broad and determined opposition to the idea. The private sector, accounting for nearly 60% of the national drug consumption in rand terms, remains a wild card, although the betting is that insurers would welcome a cost-effective and rational approach to the use of essential medicines so as to reduce their own expenditure. The locally based pharmaceutical industry will find the going increasingly hard, with its high profit margins reduced, while the international pharmaceutical industry with subsidiaries in South Africa may reconsider its position, already threatened by inefficiency and overcapacity. There is large scale, although not quantified, theft of pharmaceuticals in public hospitals and clinics, and introduction of counterfeit medicines manufactured in the country and abroad; the country lacks the police force and the control systems necessary to deal with these. And we do not yet know whether the traditional healers will cooperate with a health plan that does not fully meet their expectations. Yet, as people from the World Health Organization have commented, if South Africa does not succeed with these ideas and programmes over the next 3 to 4 years, it is unlikely that any other country in the developing world will be able to do so.
Undergraduate medical education J P de V van Niekerk Medical education in South Africa is the oldest and best developed in Africa south of the Sahara. The first South African medical school, that of the University of Cape Town, produced its first graduates in 1922. There are currently eight medical schools producing just over 1000 doctors a year (see panel 2) for a population of just over 40 million people. 28 479 doctors are registered with the Interim National Medical and Dental Council, of whom 7744 are specialists. Like the whole of South African society, medical education was shaped and skewed by apartheid. The medical schools were divided by language and by colour,
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with consequent maldistribution of their educational facilities. There are three medical schools in the Gauteng Province and two in the Western Cape Province. Three of the eight medical schools—those attached to the Universities of Pretoria, Stellenbosch, and Free State— are Afrikaans. The Universities of Cape Town and the Witwatersrand tried to be racially mixed but until recently were largely prevented from accepting black students. The University of Natal’s medical school was designated for black students as was the Medical University of South Africa (MEDUNSA) which is situated roughly 30 kilometres from Pretoria. The most recent addition, the University of the Transkei (Unitra), founded by the government of the “independent” Transkei homeland, is situated in Umtata and is relatively inaccessible to most inhabitants of the Eastern Cape Province which it serves. Medical education is based on the traditional British model. After twelve years of schooling successful candidates enter a six-year undergraduate programme. This is still largely divided into three preclinical years and three years of clinical training. The quality of South Africa’s medical graduates has been acknowledged as being very good. Alas, one consequence of this high reputation is that they are sought after by foreign countries where they easily overcome the hurdles of entry and rapidly achieve prominence in their chosen specialties. Nevertheless, many pressures resulting from much-needed, but hardly ideally managed, changes are threatening standards of health care and of medical education. Firstly, there is concern about the level of education at the schools. The legacy of apartheid, which deliberately downgraded education for black pupils, will persist for many years. Secondly, all medical schools have recognised the need for their student body to be more representative of the population mix of the country. The medical schools have grappled with the problems of identifying “excellence” in poorly prepared candidates and in designing methods that will allow educationally disadvantaged students to achieve their potential; these efforts have met with variable success. Thirdly, the shift of resources from privileged to less privileged provinces to develop primary health care facilities has resulted in financial cuts to teaching hospitals. These massive sociological changes will take their toll on the financial and human resources of universities. In such circumstances there is a tendency to present slogans as solutions—instead of careful thought, analysis, and planning. There are thus cries for radical changes in admissions and the suggestion that a five-year curriculum would be better suited to South Africa’s needs. This despite the absence of evidence of inadequacy of our medical graduates for practice in South Africa and much to support the view that they hold their own with the best Panel 2: Current student enrolment at the eight South African medical faculties University Cape Town Witwatersrand Pretoria Natal Stellenbosch Free State MEDUNSA Unitra
Founded 1912 1919 1943 1947 1956 1969 1976 1985
MB/yr* 180 179 195 108 170 109 137 20
Registrars 355 610 278 284 251 210 200
MD/PhD† 129 69 24 45 33 27 22
*No of medical graduates. †No of students registered.
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produced elsewhere. There has, however, been much wanting in the health care systems of the country and local facilities remain the most powerful determinants of how and where good graduates practise. Medical education in Africa is ailing. Many African colleagues believe that South Africa has the potential to influence medical education powerfully for the good of education in the entire continent. South Africa will be best served by ensuring that it has effective medical schools of good quality. Thereby it can also best serve Africa.
Postgraduate vocational training Thomas H Bothwell An announcement by the Interim National Medical and Dental Council (INMDC) concerning compulsory postgraduate vocational training has evoked a strong reaction from junior doctors. Currently a medical practitioner must have completed six years of undergraduate training followed by one year’s internship before being registrable for independent practice. These requirements are about to change. From Jan 1, 1998, new graduates will have to undergo a further two years of postgraduate training in the public sector as a prerequisite for entry into the private sector. Since the original announcement, a task group set up by the INMDC has produced preliminary details on how the system will work within the guidelines that have been laid down by the INMDC. According to these guidelines the vocational training must take place under proper supervision, in hospital facilities approved for this purpose by the INMDC. The task group’s report was “based on the premise that the main objective of postgraduate vocational training was to provide trainees with opportunities to develop knowledge, skills, behaviour patterns and professional thinking to equip themselves to function in a primary health approach”. To this end a structured though flexible training period is envisaged to ensure a progression of training and experience involving a standardised pattern of rotation through specific disciplines and hospitals, with some choice during the second and third year of training. The overall aim is to provide a broad spectrum of options that will lead the trainee towards the sphere in which he or she ultimately wishes to practise (eg, specialist practice, family medicine, general medical practice including hospital practice). For the scheme to succeed, the hospitals and other facilities must be adequate and appropriate supervision must be available. Thus, the task group has recommended that only hospitals currently accredited for internship training be initially included in the scheme and that each of them be visited by the INMDC’s newly appointed inspectors of internship training over the next few months. In addition, the universities are to be directly involved via their outreach programmes, to ensure that training and supervision are adequate in the hospitals within their spheres of influence. The College of Medicine has also been approached to become actively involved in the scheme, since trainees will be encouraged to acquire one or more of the diplomas it offers during their training period. 1540
In recognising that a doctor is not yet ready to practise independently and without supervision after one year as an intern the new regulations are in line with long established practice in the United Kingdom and other countries with broadly comparable medical standards. At the same time, many of the concerns raised by the Junior Doctors’ Association of South Africa (JUDASA) are valid. The first relates to the perception that the new scheme is compulsory community service under a new guise. In 1989 the previous Medical Council did, in fact, approve in principle the introduction of “national community service”, whereby recently qualified doctors would have been sent to underserved rural areas. However, the proposal was found not to be feasible and was abandoned. The present proposals are very different, with the emphasis on structured training in approved facilities. It is unfortunate that these two separate issues have become entangled. A second concern relates to the need for this sudden and unheralded change, since South African graduates already have an international reputation for clinical competence, with the majority electing on their own initiative to spend another year or two in public hospitals after completion of their internships. On this basis, JUDASA questions the need for such a precipitate change and recommends rather an incremental approach, in which undergraduate and postgraduate training are considered as a whole. This is an important point, since the extension period of postgraduate vocational training obviously has implications for the undergraduate curriculum. The issue has already been addressed by the task group set up by the INMDC, which recommends an urgent review of existing curricula, including the possibility of reduction from six to five years. The ultimate success of the proposed scheme for postgraduate vocational training will almost surely depend on bread-and-butter issues. Young doctors will have to feel they have some choice in where they are sent and will be particularly concerned with working conditions and standards of supervision. The burden of service must be light enough to allow time for reading, attending lectures and courses, and preparing for diplomas. Training programmes must be tailored to individual needs and there must be mechanisms for formal feedback on performance by supervisors. Accommodation must also be adequate, including library and recreational facilities. Although there have been substantial increases in pay packages for junior medical personnel, most students incur large debts during their undergraduate years and assistance with repayment of loans also merits urgent attention. These are but some of the issues that must be addressed before the new scheme is introduced. If the starting date is to be Jan 1, 1998, there is a lot of work still to be done.
Population control? Bah, humbug! Daniel J Ncayiyana In the preface to his book The World’s Population: Problem of Growth (1972), Dr Quentin Stanford asserted that “the current rate of world population growth . . . constitutes a serious threat to the future of all mankind”. This concern, so popular during the apartheid years, persists even in the new South Africa. I say “bah, humbug” to that. There is
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not a shred of evidence to support the existence of an absolute threshold beyond which further population growth will blow Planet Earth and Homo sapiens into oblivion. Stanford was not the first to predict such a threshold. In his Republic, Plato advocated an optimum population size of 5040 citizens, who would then be required to practise rigid birth control. Since Plato’s time, thresholds have been proposed and exceeded without the skies falling down. Robert Thomas Malthus, a clergyman who lived between 1766 and 1834, is renowned for his thesis that “population, when unchecked, increases in a geometric ratio, whereas agricultural production increases in an arithmetical ratio”. Now, it is a principle of mathematics that any geometric progression, however slow, must eventually overtake any arithmetic progression, however rapid. Yet even the most rabid advocate of population control will concede that per caput food production (and consumption) has consistently exceeded world population growth, and that the world is enjoying the lowest food prices in centuries. World food stocks are higher than ever before in human history—so high that some developed countries unabashedly pay their farmers not to produce, or purchase the surplus so as to destroy it. In more recent times, it was the American Paul Ehrlich who fanned the fires of population phobia with his book The Population Bomb (1968). A collection of myths and scientifically unsupported speculation, the book sowed panic across the world and spawned a sense of impending doom. Among his many predictions was that the world would run out of lead by 1983, zinc by 1985, and oil by 2000. The inaccuracy of these predictions has not stopped Ehrlich from continuing his campaign to save the world. There is no historical evidence linking prosperity to population reduction. On the contrary, historical evidence points to sharp population increases having preceded the onset of prosperity, a sine qua non for the levelling-off of population growth. In this sense, the biblical injunction to “be fruitful and multiply, and populate the earth” remains the only demographic principle to be vindicated by history in terms of prosperity, wealth creation, and human progress. About 10 000 years ago, world population growth of 5–10 million ushered in the Agricultural Revolution. In the 1750s, the Industrial Revolution followed growth of the world population to 800 million. Historically, population size has often been used by the rich and powerful to blame the poor for the ills of society. Malthus’ theories reflected his deep prejudice against the indigent Irish. In apartheid South Africa, population control was conceived as a tool to limit the size of the black population for purposes of political containment. In his book entitled The Population Explosion in Southern Africa (1972) Van Rensburg bluntly identifies the growth of the black South African population as a threat to the survival of white heritage, asserting that “the Negro differs fundamentally from the Caucasian and Mongolian branches of the human race... not just [in terms of] the superficial, easily recognizable physical differences of skin colour, nose, lips, body-build etc, but also differences in intellectual and mental capabilities.” The truth is that a decline in the fertility rate is a function of economic prosperity and social upliftment. In Europe, the onset of the levelling off and decline in
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fertility (the so-called demographic transition) occurred after World War I in response to growing industrialisation, urbanisation, universal literacy, an improved social status for women, and an unmistakable decline in infant mortality. In South Africa, the demographic transition is already in evidence. According to our demographers, the South African population growth curve has peaked and is in plateau. Soweto, with its plummeting birth rate, is a prime example of how socioeconomic upliftment (no matter how modest) and greater empowerment for women can quietly achieve what eluded Indira Gandhi’s India and has required draconian measures in China. In this context, South Africa’s options are clear: grow the economy, educate the people, and eliminate the social subordination of women. Then population will take care of itself.
Free care for pregnant women and for children under six Marian Jacobs, David McCoy On May 24 1994, President Nelson Mandela declared that all health care for children under the age of six years and pregnant women would be free. This policy—promulgated in the 100 days that followed South Africa’s first democratic elections—was an early signal of the Government’s intention to translate the political priority accorded children and women into clear policies and programmes. It was formulated in response to recognition that infants and young children bear the burden of preventable morbidity and mortality in South Africa, with the greatest costs borne by those who are poor and have limited access to health care. Removal of user fees for this vulnerable sector of the population was perceived as one important strategy by which to improve access to health services, thereby promoting equity in a society of disparities. A year after its implementation, the policy was evaluated in terms of its impact on health service utilisation, the monetary costs (additional expenditure and loss of fee revenue), and the perceptions of users and providers. Evaluation The new policy had increased patient attendances at public sector facilities as well as the number and proportion of referrals from clinics; thus user fees, when in place, had probably been an important deterrent to service utilisation by the general population as well as those in need of referral. For the period under review, there was also a decline in the proportion of unbooked deliveries, indicating an impact on one of the key intermediate determinants of infant wellbeing. The biggest recurrent public health service expenditure item, staffing cost, was not altered by the policy. Although no direct assessment was made of drug costs, the increase in this area was estimated to be less than 1% of the total public sector health budget. Revenue from user fees was estimated to have dropped by about 30% (1·5% of the total public health budget), with most of this loss occurring at the large referral hospitals. What were the views of users and providers? In general, users supported the new policy; those living in rural areas, in informal settlements, and on white-owned farms 1541
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felt that access to health care had improved. However, there were concerns about the capacity of health services to cope with the extra workload. Of the public sector providers, most believed that the policy had helped to prevent serious illness among children and pregnant women, but the dominant opinion was that several preexisting deficiencies had been aggravated. These included poor working conditions, low morale, overcrowding, and scarcity of equipment and medicines. Users and providers agreed that one of the main reasons for the apparent inappropriate use of referral hospitals was the inadequacy of primary care facilities, and there was a general feeling that implementation of the policy, which had extensive implications for practice, should have been preceded by greater consultation and planning.
User fees Although the evaluation was retrospective and the quality of the information poor, these results have usefully highlighted areas for further inquiry and policy development. One area that has not yet been assessed is the impact on health outcomes when user fees are eliminated. This calls for a long-term analysis, in which all the other variables impacting on health outcome are carefully considered and controlled. To yield reliable results, such as a study will have to await a more accurate health information system than we now have. One thing is already clear—that fees generated at the primary level of care make a negligible contribution to the overall health budget; thus, free health care has now been extended to all users of the primary level public sector health service. The effectiveness of this policy will be contingent on concurrent strengthening of administrative infrastructures and service delivery at all levels of care, with special emphasis on primary level health care services. While reduction in user fees is important in promoting access to health care services, this is but one of the many strategies towards equity. Other important interventions concern the quality and effectiveness of care, facilitation of appropriate referrals between different levels of care, strengthening of district development and primary care, and strategies to improve the wellbeing of health care providers. Free health care for pregnant women and for children under six years has clearly improved access to health care for some, especially in underserved populations. It has also highlighted the limitations of a single intervention and the need for coordinated implementation of South Africa’s multidimensional plan for health care.
HIV and tuberculosis Salim S Abdool Karim South Africa’s HIV epidemic developed a few years after that in other countries of southern and eastern Africa. The first described cases of AIDS in South Africa were among homosexual men; retrospective HIV testing of stored sera from 1985 revealed no case of HIV infection in the general population. Since then, large-scale anonymous serosurveys in antenatal clinics have borne witness to a rapidly progressing epidemic. The prevalence of HIV infection in this sentinel group was 0·73% in 1990, 2·15% in 1992, and 7·57% in 1984; by 1995 it had 1542
risen to 10·44%. Although HIV-2 has been reported in South Africa it remains uncommon. Within the homosexual population the predominant HIV-1 subtype is B whereas in the heterosexual population it is subtype C. Community based HIV serosurveys reveal that 15–25-year-olds have the highest incidence rate of HIV infection, girls being infected at an earlier age than boys.
The spread of HIV An important factor in the spread of HIV and other sexually transmitted diseases is the apartheid-created migrant labour system, which separated millions of black workers, mainly men, from their families and resulted in a system of “oscillatory migration” between the workplace in the city and the family in the rural area. Do people appreciate the risk they run? Knowledge about HIV infection is high within the general population, although certain myths (for example, that sex with a virgin can cure AIDS) are still common. Safe sex is not widely practised by the youth of South Africa—partly because the future holds so little promise for the hundreds of thousands who are poorly educated, who see no reason to defer immediate sexual gratification for future benefit. Since 1994, the fight against AIDS has been accorded a higher profile and a larger budget. Information has been disseminated widely; and, more important, condom distribution by Government services rose from 6 million in 1994 to 97 million in 1995. The female condom is currently being introduced into Government clinics. Condoms are available free in Government health care services while private sector marketing and promotion of condoms, as well as social marketing, has grown substantially in the past four years. Sexually transmitted diseases are very common. A 1994 community-based survey in a rural district revealed an 8·8% prevalence of active syphilis, a 4·5% prevalence of gonorrhoea, a 6·1% prevalence of chlamydial infection, and a 10·5% prevalence of HIV infection. The control of sexually transmitted diseases has been neglected; but now the Government has adopted the policy of syndromic management, with extensive training of primary health care nurses. Most patients with sexually transmitted diseases still visit a traditional healer first. In South Africa, AIDs now dominates clinical practice across disciplines ranging from paediatrics to neurology. Antiretroviral drugs are not available in Government health services but can be bought in the private sector. Most private medical insurance schemes do not cover the costs of antiretroviral drugs. Many large hospitals run specific AIDS clinics in an attempt to provide better specialised care for AIDS patients. Stigmatisation and discrimination are, unfortunately, widespread. HIV counselling and testing are widely available, since they are offered by AIDS training and information centres run by local health authorities and funded by Central Government. Tuberculosis control Clinically, pulmonary tuberculosis (TB) is the main presenting illness among HIV infected persons. The incidence rate of TB in South Africa is one of the highest in the world at 341 per 100 000 per year. To illustrate the burden in the era of HIV, the incidence rate of TB in one rural district with a population of about 200 000 rose
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from 154/100 000 in 1991 to 413/100 000 in 1995. At the same time, prevalence of HIV infection among these TB patients rose from 29% to 55%. Drug resistance in TB is closely monitored. Multipledrug resistant TB has not increased as a fraction of all TB cases over the past two decades. However, the number of patients with multiple-drug resistant TB has increased concomitantly with the rise in TB in South Africa, to the extent that more than 2000 cases were registered in 1996. Directly observed therapy on an outpatient basis is the standard policy, and this strategy has been very successful in some areas; others, however, continue to have difficulty achieving high rates of treatment completion and cure. TB control in South Africa focuses on enhancing diagnostic accuracy, standardised combination drug therapy, directly observed therapy within the community, improving cure rates, and active surveillance through a register of all TB cases. The individual and joint effects of the HIV and TB epidemics give these two conditions high priority in South Africa. While positive achievements are heartening, much more concerted effort, political will, and resources are needed if they are to be effectively controlled.
What future for South African medical research? Chairperson of the Medical Research Council’s Board is Dr M W Makgoba, professor of molecular immunology at the University of Witwatersrand; the President is Dr O W Prozesky. Robin Fox interviewed them together at MRC headquarters in Tygerberg.
business—which is health research?” How was the perception of medical research at that time of transition? Makgoba: When people speak of South African science you find they are nearly always talking about medical research. Our international reputation in science derives almost entirely from the medical fraternity, which during the apartheid era was uniquely able to maintain standards. Of course, the average South African is not impressed by citation rates in international journals, and is more likely to ask “Who have you helped by this research?”. Developing countries have been encouraged to adopt a policy of “essential national medical research” (EHNR), whereby the programme is grounded in local priorities. The South African MRC, however, has invented something new called Integrated National Health Research. What is the difference? Makgoba: For much of this century, knowledge has been split. Now we find that, as in human beings themselves, systems do not function independently. Whatever we study, we should integrate the different approaches. So, for example, the molecular biologist must not think he has nothing to discuss with the epidemiologist. Prozesky : EHNR should be driven from a Ministry of Health, whose job is to make sure the essential research is done in some way by some system. At the MRC we can contribute to this research “cake” but we don’t want the whole of it; there’s room for independent university departments, charitable foundations, NGOs, and so on. So, let the whole country’s programme be EHNR. There is a tension here. Integrated research taps the skills and knowledge of excellent scientists from a wide range of disciplines, and makes no sharp distinction between fundamental and applied science. An administrator in Pretoria, wanting a quick answer on the prevalence of tuberculosis across the nation, will understandably take a short-term view. But in our philosophy the only difference between fundamental and applied research is the length of your vision. Makgoba: Curiosity-driven research is integral to what we should be doing. So the MRC remains strongly committed to the training of scientists. Prozesky : That’s right. There’s no way we can build a healthy nation without excellent scientists, and it’s only by doing both fundamental and applied research that you create such people.
Dr Makgoba (left) and Dr Prozesky (right)
According to the Corporate Plan published in 1995, the Medical Research Council’s vision is “Building a healthy nation through research” and its mission is “To improve the health status and quality of life of the nation through excellence in scientific research”. Did these represent a change of policy from the previous era? Prozesky : Yes. Medical research had become more of a social issue. The old vision focused on achieving the best possible outputs for research. But in 1994 we were building a new nation, and one essential for economic development was seen to be a healthy population. We asked ourselves, “What can we offer through our core
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Yet the programme does seem to have become more focused, with its twenty “research thrusts” on topics such as trauma, women’s health, burden of disease. This looks like a switch of emphasis towards applied research; and could you be taking subdivision of the enterprise too far? It seems that even health surveys will be part of the work. Prozesky : We shy away as much as possible from pure surveys. In the past they have not been well done by the Ministry of Health, and ideally the Ministry should buy them through the MRC. Having secured the information wanted by the Minister, on where the disease is and who has it, then we could set our organisation to look at the data and begin to ask how and why. As to the “thrusts”, a country in our position does need to focus its research efforts; we can’t afford the largesse for everyone to get on 1543
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Examples of MRC-funded research in South Africa Amoebiasis Entamoeba histolytica was for a long time believed to be a commensal, occasionally being activated by some unidentified trigger to cause invasive amoebiasis. Since 1980 the MRC Amoebiasis Research Programme, working closely with the London School of Hygiene and Tropical Medicine, has shown that it occurs as two distinct though morphologically identical species—E histolytica (pathogenic) and E dispar (non-pathogenic). Only E histolytica elicits a serological response, which is observed both in patients with amoebiasis and in symptomless carriers (10% of whom subsequently develop invasive disease). The species status of these two organisms is underlined by the fact that their identities are retained after axenisation. Tuberculosis Members of the MRC Unit for Inflammation and Immunity, University of Pretoria, are participating in the Glaxo-Wellcome Action TB initiative. Their primary objective is to discover novel targets on Mycobacterium tuberculosis that can be modulated directly by antimicrobial or immunotherapeutic strategies. Microbial K⫹-transporting systems have been identified as potential selective targets for antimicrobial chemotherapy. Bacterial K⫹ transporters differ structurally and functionally from their counterparts in eukaryotic cells. Several pharmacological agents (some of them novel) have proved to inhibit K⫹ transport in M tuberculosis; and decreased K⫹ transport seems to precede, and to be the cause of, microbial death. Existing agents function as membrane-perturbing factors, leading to secondary inhibition of cation uptake. The search is on for pharmacological agents that are primary and selective. Variegate porphyria South Africa has the highest incidence of variegate porphyria (VP) in the world. The VP families seem to be descended from a Dutch couple who married at the Cape of Good Hope in 1688. VP—an autosomal dominant inherited trait that results in decreased activity of the penultimate haem synthetic enzyme protoporphyrin oxidase (PPO)—is characterised clinically by photosensitive skin lesions and a propensity to develop acute neurovisceral crises. Since theses crises are usually precipitated by a porphyrinogenic drug, early diagnosis is important for prevention. The MRC Liver Research Centre, University of Cape Town, working closely with colleagues in Athens (Georgia) and Cardiff, were the first to publish on a gene defect responsible for decreased PPO activity in VP. They found an R59W substitution in the PPO gene in over 90% of South African VP families, including known descendants of the putative founder couple.
with his own thing. I favour the heterogeneous approach to a project: you pick, say, three biostatisticians, four or five geneticists, so many of this, so many of that, and make them into a team. But you still manage them as biostatisticians &c. A good example is the Glaxo Tuberculosis Project, which came to South Africa because of our unique mixture of problems and skills. The money actually goes into the universities, but the project is run from an office up here by one very good scientist manager, one secretary, and one finance person. Could you use more money? Prozesky : The Government intends to wean us from state funding, and we now obtain 20% of our money elsewhere. At present we receive 6% of the science budget—about US$15 million. We think that’s too little—but a more important obstacle than underfunding is a shortage of skilled researchers. Just throwing money at a problem is no answer. At present, the schools of public health are running on MRC manpower, and the staff are not only training researchers of the future; they are also teaching health workers to be familiar with research attitudes. They have been criticised for this emphasis—but it’s the price we exact! An exciting idea in the Corporate Plan is that the MRC could become “the driving engine of research for the rest of Africa”. Makgoba: Most of us believe that, and not just out of national pride. Under apartheid, medical research was appropriate for only some 20% of the population. Now we are presented with a unique opportunity. If we can bring in the other 80% of the people, the experience they offer will contribute new dimensions and new interpretations. By African standards we are rich; we have a strong infrastructure and culture of research; and the world, having seen us fight and win the battle for democracy, wants us to succeed. Outside the country we are now building relationships in a way that was not possible before; where we used to fly to England, we now travel to Uganda, Mozambique, Nigeria. There’s a chance to build a new ethos. As the last country in Africa 1544
to achieve independence, the choice before us is either to seize these opportunities or to go the way of our brothers who got it wrong and ended up in the doldrums. Prozesky : The vision is perfect. But I’d like to add that it can’t be achieved without awareness that the MRC is a national asset that must not be tampered with.
The future for health care Ralph Kirsch In May 1994 the new Minister of Health, Dr Nkosasana Zuma, inherited a highly fragmented health service consisting of 14 previous ministries of health, all biased towards curative care. The private sector was largely undisciplined (medical aid fees had escalated by 500% between 1975 and 1985) and used at least half of the country’s medical expenditure to provide care for at best a quarter of its citizens. Both the private and public sectors were set against a background of the gross socioeconomic inequities engendered by apartheid. Fortunately the African National Congress healthplanners had used the long period of negotiation before the elections to develop a health plan for the nation. The plan acknowledged that the health of all South Africans would be secured mainly by economic development. This would allow Government to address race-based disparities in socioeconomic status, occupation, education, and housing. The system would be healthbased and informed by the primary health care approach. Central Government would formulate policy while the provinces would coordinate and manage the provision of services at provincial, regional, and district levels. Priority would be given to maternal and child health, nutrition, the control of communicable diseases, and violence. Although no government could repair the effects of almost 50 years of institutionalised racial discrimination in 2₂ years, it is not too soon to examine some of the early successes and failures. As well as a National Health Department, we now have Provincial Health Departments, 48 health regions,
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and 157 health districts. Economic stagnation has been replaced by growth of 3% and the rate of inflation has effectively been halved. But the economy is still performing below its real potential. The recent fall in the value of the rand highlights the fragility of the progress achieved. Unemployment, difficult to assess because of a large “informal” sector, is probably about 35%. Too few jobs are being created. Indeed, the Government estimates that to create 400 000 jobs a year by the year 2000 and produce resources for the improvement of living conditions, South Africa will need a 6% growth rate by the end of the century. Between March, 1994, and November, 1996, 123 139 houses had been built or were under construction (one million promised by 1999). 186 clinics have been built and a further 217 are under construction. Roughly 4750 new primary care posts have been created. Free maternal and child care has been introduced. New legislation allows women free access to abortion up to twelve weeks of gestation. Government data indicate that 7 out of 10 children are fully immunised. A primary school nutrition programme now serves about 5·6 million children. Clean water has been provided to 1 million people. These successes have been tainted by the National Department of Health's handling of a controversial AIDS education play which cost the taxpayer the equivalent of more than US$3 million. The redistribution of funds between and within the various provinces has also been problematic. Areas that were formerly underfunded and underserved have not always used these new funds wisely. One province spent excess funds on several advanced CT scanners. Two of the new provinces, Gauteng and the Western Cape, found themselves with more than one medical school and several teaching hospitals which consumed a large portion of their budget. In Gauteng, one of these schools, at the
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University of Pretoria, had been founded to provide education in Afrikaans while another, MEDUNSA, was to educate black students. In the Western Cape the Medical Faculty of the University of Stellenbosch (Afrikaans) had been built some 25 km from that of the University of Cape Town. The shift to primary health care has resulted in severe cuts to the budgets of the teaching hospitals. In the Western Cape cuts of as much as 25% are on the cards. While both central and provincial health departments are grappling with this problem a lack of the clearcut political will required to address the plight of the teaching hospitals may leave these irrevocably damaged and thus have far reaching long-term effects on the nation’s health care. South Africa’s transition to democracy has been labelled a fragile miracle (Lancet 1995; 345: 1222–24). A better analogy may be that of a lusty baby, thriving but beset by growth pains and by occasional childhood disease.
Contributors Prof Solomon R Benatar, Head, Department of Medicine, University of Cape Town; Prof Peter Folb, Head, Department of Pharmacology, University of Cape Town, Chairman, South African Medicines Control Council, Director, World Health Organization Collaborating Centre for Drug Policy at the University of Cape Town; Prof J P de V van Niekerk, Dean, Faculty of Medicine, University of Cape Town; Prof Thomas H Bothwell, former Dean, Faculty of Medicine, University of Witwatersrand; Prof Daniel J Ncayiyana, Deputy Vice-Chancellor, University of Cape Town, Editor, South African Medical Journal; Prof Marian Jacobs, Department of Paediatrics and Child Health, University of Cape Town; Dr David McCoy, Research Fellow, Department of Paediatrics and Child Health, University of Cape Town; Dr Salim S Abdool Karim, Director, Centre for Epidemiological Research of Southern Africa, Medical Research Council of South Africa; Prof Ralph E Kirsch, Department of Medicine, University of Cape Town, Executive Director, MRC Liver Research Centre, University of Cape Town.
1545
Country profile
South Africa
South Africa’s peaceful transition from the race-based apartheid system which excluded more than 80% of its citizens to a full participative democracy was marked by worldwide admiration for the nation’s achievement. The new-found pride and optimism of the “rainbow nation” led by President Nelson Mandela has been tested by the practicalities of writing a new rights-based constitution, the many acts of parliament required to undo apartheid, and the realisation that the previous government had run up a massive debt. The implementation of new dispensations for health and science has been limited by the need for fiscal discipline. In this profile of South African medicine The Lancet’s guide was Prof Ralph Kirsch.
An old health care system gives place to new Solomon R Benatar In 1994, when the Government of National Unity came into power through South Africa’s first democratic elections, health care was racially discriminatory, fragmented, and poorly coordinated. The one-fifth of the population with private insurance enjoyed good health care; but, for the poor reliant on public facilities, primary and community services were grossly inadequate. A well developed public service offered hospital-based community and tertiary care, racially segregated, to both rich and poor, but it was beginning to crumble (N Engl J Med 1991; 325: 30). How did this system come about? During the 1960s and 1970s, rapid economic growth gave rise to a strong private sector, supportive of academic medicine through part-time appointments: 40% of the country’s doctors provided private care to 20% of the population, mainly white (about 90% of whites had medical insurance). The private sector consumed nearly one-third of the 5% of gross national product (GNP) devoted to health care. The public sector, responsible for training health care professionals, was a segregated, largely hospital-based service providing a mixture of community and tertiary health care and at least some access to state-of-the-art treatment in all specialties. Not all academic institutions were at the same level, but most could offer tertiary expertise in some spheres. By the 1970s this sector was strong; 60% of the country’s doctors cared for 80% of the population. Respected by private practitioners, the public sector provided expert backup for private patients who suffered complex disorders or ran out of insurance cover. It accounted for 70% of the nation’s health expenditure—half of the sum going to academic institutions, where the bulk of public medicine was practised. The ratio of earnings of private to public doctors was about 2–3:1. During the next decade private medicine expanded and the proportion of doctors in this sector rose to 60%. Now much less supportive of academic medicine, the private sector increasingly offered tertiary medical and surgical services in a burgeoning array of private hospitals and clinics—though still only for one-fifth of the population Lancet 1997; 349: 1537–45
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(now made up of the insured 80% of white and 15% of black groups). The proportion of GNP spent on health care had risen to 8%, of which 60% was consumed by the private sector; the cost of health insurance was rising at over three times the rate of the consumer price index. Meanwhile academic medicine and the public sector were suffering under the thrust of privatisation. Medical, nursing and technological staff were being recruited into better paid jobs in lavish private institutions that were developing tertiary services with equipment unaffordable in the public sector. The salary ratio widened to about 3–5:1, and public medicine in rural areas and in academic institutions was further damaged by emigration.
Health care reform in the new South Africa The wide disparities in health in South Africa at the close of the apartheid era are illustrated in panel 1. Clearly the social challenges of transformation would be daunting. Although the 1980s had been characterised by much debate on a national health service it became obvious that the private sector would be beyond the reach of any immediate comprehensive nationalisation process. In view of the demographics of the large deprived 1537
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Panel 1: Some health disparities in South Africa Population (millions) % urbanised Infant mortality (per 1000 births) % deaths under 5 yr Life expectancy (yr) M F Tuberculosis notification rate (per 100 000) Maternal mortality (per 100 000 births)
Yr 1994
Asian 1·0
1993 1990
96·2 15·9
35·8 48·3
1988
7·4
21·6
1995 1995 1994
65 73 43
1990
5
Black Coloured 30·8 3·4
60 67 180
58*
White 5·2
Total 40·4
83·2 28·6
91·1 7·4
48·3 40·2
20·4
2·9
60 67 726
68 75 17
22
8
62 68 205
83†
*Excludes former homelands. †World Bank estimates for South Africa.
population and the challenges of development, the Government opted for a primary care based system. District-based primary care in the public sector would offer an opportunity to move from the strictly biomedical approach to a more comprehensive strategy that acknowledged the social basis of health. With the overemphasis of hospital-based care in the past, the grossly deficient primary health care facilities, and the lack of new resources to build and staff such facilities, the decision to transfer funds from expensive academic institutions would inevitably imply reduction, withdrawal, and restructuring of public hospital services. Initially the expectation was that restructuring could be achieved without loss of excellence in teaching institutions, and with extension of excellence to the primary and community levels, but the process of reform became complicated by several factors. First, the broad nationalisation processes, which the new Government had promised, were becoming modified by an understanding of the difficulty in achieving “redistribution” in a world where economic policies were moving in the opposite direction. A country that hoped to attract investment from the industrialised world had to confine its reforms to the public sector. Second, economic growth did not meet expectations, and continuing population growth was compounded by illegal immigration from the rest of Africa. With Government income 35% of GNP and expenditure 40%, redistribution policies had to be reconciled with “fiscal discipline”. The term employed was rationalisation, and politicians avoided public acknowledgment that this meant reduced public expenditure on health, education, and welfare. The four major principles of reform towards equity became: (i) reallocation of budgets strictly in line with the populations of each of the nine provinces, (ii) reshaping of the racial and gender composition of the public sector, (iii) a change in ideology toward the primary care approach, and (iv) a shift of the investigative thrust towards “essential national health research”. The increased access to affordable and effective health care envisaged through these mechanisms is clearly desirable, but difficulties arise from the pace of change and its short and long term implications for sustaining public medicine 1538
beyond primary care. Let me give an example from my own territory. Because the Western Cape has two medical schools and a smaller population than the previous Cape Province, its academic facilities have been threatened. Their budgets, reduced by about 15% over recent years, will now be cut by a further 50% over the next 5 years, to expand primary services and bring per caput public health expenditure into line with that of other provinces. The danger in slashing the budgets of established institutions is that they become incapable of the clinical and development activities for which they exist.
Conclusions The notion that all medical schools should model themselves on aspirations of the past, or of much wealthier societies, is unrealistic. An alternative is either to close some schools or to restructure schools in ways that capitalise on their specific strengths, thus fostering training systems capable of meeting the country’s diverse needs. Such imaginative possibilities could stimulate essential areas of growth while saving resources and preserving fragile existing facilities that will be necessary for tertiary medical care of future generations of the poor, and for sustaining education and scholarly endeavours on a broad front. While perfect justice in health care is unattainable, health reform must at least be towards a just system. If private medicine is not coordinated with public medicine, public medicine will be reduced to the provision of primary and community care; and, should elite private medical schools be developed, inequities will be enhanced and racial apartheid will be seen to have given place to economic apartheid.
Towards an essential drugs programme Peter I Folb One of the central issues in the policy of the new Department of Health in South Africa is to establish an essential drugs programme (EDP). This will be in line with and strongly support the Government’s primary health care initiatives; if successfully implemented, it should also address the inordinately high cost of medicines in the country. As in other health sectors, the challenge will be to find a formula that encompasses the private as well as the public components of health care delivery. There is much going for the country that gives the EDP a good chance of success. Firstly, there is political will. The Ministry of Health, firmly committed to a primary health care focus, recognises that a successful drug policy is critical to the overall success of its health plans in general. There are sufficient well-trained people working in the public service to bring it about. The United Kingdom Overseas Development Administration (ODA) and the World Health Organization have brought in considerable logistical, technical, and financial support for the national drug policy. The financial resources necessary to provide essential medicines equitably to the entire population are available. Academics are supportive of an essential drugs programme in the public sector, and they have proved willing to cooperate in providing the necessary expertise. Furthermore, and significantly,
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national drug policy is underpinned in South Africa by a strong and independent national drug regulatory authority, the Medicines Control Council. Other initiatives are also in the offing. These include the introduction of traditional medicines (and healers) into the formal health structures, expansion of the nation’s vaccines production facility, a commitment to curtailing the unscrupulous charging for medicines by some dispensing doctors, uniform price controls on medicines imposed by Government, parallel importing of high quality generic medicines, and wide-scale introduction of training programmes for nurses and other primary health care workers in the rational use of medicines. With all this in place, or at least in prospect, what can go wrong? Unfortunately, a great deal. Firstly, there are some doubts about the administrative and organisational capacity of the Department of Health to coordinate and bring these programmes about, and the willingness of the Department to delegate them appropriately. There are moves afoot to reduce the autonomy of the Medicines Control Council, so that it would come more under the authority and control of the Ministry of Health. This will be an error, and we can expect broad and determined opposition to the idea. The private sector, accounting for nearly 60% of the national drug consumption in rand terms, remains a wild card, although the betting is that insurers would welcome a cost-effective and rational approach to the use of essential medicines so as to reduce their own expenditure. The locally based pharmaceutical industry will find the going increasingly hard, with its high profit margins reduced, while the international pharmaceutical industry with subsidiaries in South Africa may reconsider its position, already threatened by inefficiency and overcapacity. There is large scale, although not quantified, theft of pharmaceuticals in public hospitals and clinics, and introduction of counterfeit medicines manufactured in the country and abroad; the country lacks the police force and the control systems necessary to deal with these. And we do not yet know whether the traditional healers will cooperate with a health plan that does not fully meet their expectations. Yet, as people from the World Health Organization have commented, if South Africa does not succeed with these ideas and programmes over the next 3 to 4 years, it is unlikely that any other country in the developing world will be able to do so.
Undergraduate medical education J P de V van Niekerk Medical education in South Africa is the oldest and best developed in Africa south of the Sahara. The first South African medical school, that of the University of Cape Town, produced its first graduates in 1922. There are currently eight medical schools producing just over 1000 doctors a year (see panel 2) for a population of just over 40 million people. 28 479 doctors are registered with the Interim National Medical and Dental Council, of whom 7744 are specialists. Like the whole of South African society, medical education was shaped and skewed by apartheid. The medical schools were divided by language and by colour,
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with consequent maldistribution of their educational facilities. There are three medical schools in the Gauteng Province and two in the Western Cape Province. Three of the eight medical schools—those attached to the Universities of Pretoria, Stellenbosch, and Free State— are Afrikaans. The Universities of Cape Town and the Witwatersrand tried to be racially mixed but until recently were largely prevented from accepting black students. The University of Natal’s medical school was designated for black students as was the Medical University of South Africa (MEDUNSA) which is situated roughly 30 kilometres from Pretoria. The most recent addition, the University of the Transkei (Unitra), founded by the government of the “independent” Transkei homeland, is situated in Umtata and is relatively inaccessible to most inhabitants of the Eastern Cape Province which it serves. Medical education is based on the traditional British model. After twelve years of schooling successful candidates enter a six-year undergraduate programme. This is still largely divided into three preclinical years and three years of clinical training. The quality of South Africa’s medical graduates has been acknowledged as being very good. Alas, one consequence of this high reputation is that they are sought after by foreign countries where they easily overcome the hurdles of entry and rapidly achieve prominence in their chosen specialties. Nevertheless, many pressures resulting from much-needed, but hardly ideally managed, changes are threatening standards of health care and of medical education. Firstly, there is concern about the level of education at the schools. The legacy of apartheid, which deliberately downgraded education for black pupils, will persist for many years. Secondly, all medical schools have recognised the need for their student body to be more representative of the population mix of the country. The medical schools have grappled with the problems of identifying “excellence” in poorly prepared candidates and in designing methods that will allow educationally disadvantaged students to achieve their potential; these efforts have met with variable success. Thirdly, the shift of resources from privileged to less privileged provinces to develop primary health care facilities has resulted in financial cuts to teaching hospitals. These massive sociological changes will take their toll on the financial and human resources of universities. In such circumstances there is a tendency to present slogans as solutions—instead of careful thought, analysis, and planning. There are thus cries for radical changes in admissions and the suggestion that a five-year curriculum would be better suited to South Africa’s needs. This despite the absence of evidence of inadequacy of our medical graduates for practice in South Africa and much to support the view that they hold their own with the best Panel 2: Current student enrolment at the eight South African medical faculties University Cape Town Witwatersrand Pretoria Natal Stellenbosch Free State MEDUNSA Unitra
Founded 1912 1919 1943 1947 1956 1969 1976 1985
MB/yr* 180 179 195 108 170 109 137 20
Registrars 355 610 278 284 251 210 200
MD/PhD† 129 69 24 45 33 27 22
*No of medical graduates. †No of students registered.
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produced elsewhere. There has, however, been much wanting in the health care systems of the country and local facilities remain the most powerful determinants of how and where good graduates practise. Medical education in Africa is ailing. Many African colleagues believe that South Africa has the potential to influence medical education powerfully for the good of education in the entire continent. South Africa will be best served by ensuring that it has effective medical schools of good quality. Thereby it can also best serve Africa.
Postgraduate vocational training Thomas H Bothwell An announcement by the Interim National Medical and Dental Council (INMDC) concerning compulsory postgraduate vocational training has evoked a strong reaction from junior doctors. Currently a medical practitioner must have completed six years of undergraduate training followed by one year’s internship before being registrable for independent practice. These requirements are about to change. From Jan 1, 1998, new graduates will have to undergo a further two years of postgraduate training in the public sector as a prerequisite for entry into the private sector. Since the original announcement, a task group set up by the INMDC has produced preliminary details on how the system will work within the guidelines that have been laid down by the INMDC. According to these guidelines the vocational training must take place under proper supervision, in hospital facilities approved for this purpose by the INMDC. The task group’s report was “based on the premise that the main objective of postgraduate vocational training was to provide trainees with opportunities to develop knowledge, skills, behaviour patterns and professional thinking to equip themselves to function in a primary health approach”. To this end a structured though flexible training period is envisaged to ensure a progression of training and experience involving a standardised pattern of rotation through specific disciplines and hospitals, with some choice during the second and third year of training. The overall aim is to provide a broad spectrum of options that will lead the trainee towards the sphere in which he or she ultimately wishes to practise (eg, specialist practice, family medicine, general medical practice including hospital practice). For the scheme to succeed, the hospitals and other facilities must be adequate and appropriate supervision must be available. Thus, the task group has recommended that only hospitals currently accredited for internship training be initially included in the scheme and that each of them be visited by the INMDC’s newly appointed inspectors of internship training over the next few months. In addition, the universities are to be directly involved via their outreach programmes, to ensure that training and supervision are adequate in the hospitals within their spheres of influence. The College of Medicine has also been approached to become actively involved in the scheme, since trainees will be encouraged to acquire one or more of the diplomas it offers during their training period. 1540
In recognising that a doctor is not yet ready to practise independently and without supervision after one year as an intern the new regulations are in line with long established practice in the United Kingdom and other countries with broadly comparable medical standards. At the same time, many of the concerns raised by the Junior Doctors’ Association of South Africa (JUDASA) are valid. The first relates to the perception that the new scheme is compulsory community service under a new guise. In 1989 the previous Medical Council did, in fact, approve in principle the introduction of “national community service”, whereby recently qualified doctors would have been sent to underserved rural areas. However, the proposal was found not to be feasible and was abandoned. The present proposals are very different, with the emphasis on structured training in approved facilities. It is unfortunate that these two separate issues have become entangled. A second concern relates to the need for this sudden and unheralded change, since South African graduates already have an international reputation for clinical competence, with the majority electing on their own initiative to spend another year or two in public hospitals after completion of their internships. On this basis, JUDASA questions the need for such a precipitate change and recommends rather an incremental approach, in which undergraduate and postgraduate training are considered as a whole. This is an important point, since the extension period of postgraduate vocational training obviously has implications for the undergraduate curriculum. The issue has already been addressed by the task group set up by the INMDC, which recommends an urgent review of existing curricula, including the possibility of reduction from six to five years. The ultimate success of the proposed scheme for postgraduate vocational training will almost surely depend on bread-and-butter issues. Young doctors will have to feel they have some choice in where they are sent and will be particularly concerned with working conditions and standards of supervision. The burden of service must be light enough to allow time for reading, attending lectures and courses, and preparing for diplomas. Training programmes must be tailored to individual needs and there must be mechanisms for formal feedback on performance by supervisors. Accommodation must also be adequate, including library and recreational facilities. Although there have been substantial increases in pay packages for junior medical personnel, most students incur large debts during their undergraduate years and assistance with repayment of loans also merits urgent attention. These are but some of the issues that must be addressed before the new scheme is introduced. If the starting date is to be Jan 1, 1998, there is a lot of work still to be done.
Population control? Bah, humbug! Daniel J Ncayiyana In the preface to his book The World’s Population: Problem of Growth (1972), Dr Quentin Stanford asserted that “the current rate of world population growth . . . constitutes a serious threat to the future of all mankind”. This concern, so popular during the apartheid years, persists even in the new South Africa. I say “bah, humbug” to that. There is
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not a shred of evidence to support the existence of an absolute threshold beyond which further population growth will blow Planet Earth and Homo sapiens into oblivion. Stanford was not the first to predict such a threshold. In his Republic, Plato advocated an optimum population size of 5040 citizens, who would then be required to practise rigid birth control. Since Plato’s time, thresholds have been proposed and exceeded without the skies falling down. Robert Thomas Malthus, a clergyman who lived between 1766 and 1834, is renowned for his thesis that “population, when unchecked, increases in a geometric ratio, whereas agricultural production increases in an arithmetical ratio”. Now, it is a principle of mathematics that any geometric progression, however slow, must eventually overtake any arithmetic progression, however rapid. Yet even the most rabid advocate of population control will concede that per caput food production (and consumption) has consistently exceeded world population growth, and that the world is enjoying the lowest food prices in centuries. World food stocks are higher than ever before in human history—so high that some developed countries unabashedly pay their farmers not to produce, or purchase the surplus so as to destroy it. In more recent times, it was the American Paul Ehrlich who fanned the fires of population phobia with his book The Population Bomb (1968). A collection of myths and scientifically unsupported speculation, the book sowed panic across the world and spawned a sense of impending doom. Among his many predictions was that the world would run out of lead by 1983, zinc by 1985, and oil by 2000. The inaccuracy of these predictions has not stopped Ehrlich from continuing his campaign to save the world. There is no historical evidence linking prosperity to population reduction. On the contrary, historical evidence points to sharp population increases having preceded the onset of prosperity, a sine qua non for the levelling-off of population growth. In this sense, the biblical injunction to “be fruitful and multiply, and populate the earth” remains the only demographic principle to be vindicated by history in terms of prosperity, wealth creation, and human progress. About 10 000 years ago, world population growth of 5–10 million ushered in the Agricultural Revolution. In the 1750s, the Industrial Revolution followed growth of the world population to 800 million. Historically, population size has often been used by the rich and powerful to blame the poor for the ills of society. Malthus’ theories reflected his deep prejudice against the indigent Irish. In apartheid South Africa, population control was conceived as a tool to limit the size of the black population for purposes of political containment. In his book entitled The Population Explosion in Southern Africa (1972) Van Rensburg bluntly identifies the growth of the black South African population as a threat to the survival of white heritage, asserting that “the Negro differs fundamentally from the Caucasian and Mongolian branches of the human race... not just [in terms of] the superficial, easily recognizable physical differences of skin colour, nose, lips, body-build etc, but also differences in intellectual and mental capabilities.” The truth is that a decline in the fertility rate is a function of economic prosperity and social upliftment. In Europe, the onset of the levelling off and decline in
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fertility (the so-called demographic transition) occurred after World War I in response to growing industrialisation, urbanisation, universal literacy, an improved social status for women, and an unmistakable decline in infant mortality. In South Africa, the demographic transition is already in evidence. According to our demographers, the South African population growth curve has peaked and is in plateau. Soweto, with its plummeting birth rate, is a prime example of how socioeconomic upliftment (no matter how modest) and greater empowerment for women can quietly achieve what eluded Indira Gandhi’s India and has required draconian measures in China. In this context, South Africa’s options are clear: grow the economy, educate the people, and eliminate the social subordination of women. Then population will take care of itself.
Free care for pregnant women and for children under six Marian Jacobs, David McCoy On May 24 1994, President Nelson Mandela declared that all health care for children under the age of six years and pregnant women would be free. This policy—promulgated in the 100 days that followed South Africa’s first democratic elections—was an early signal of the Government’s intention to translate the political priority accorded children and women into clear policies and programmes. It was formulated in response to recognition that infants and young children bear the burden of preventable morbidity and mortality in South Africa, with the greatest costs borne by those who are poor and have limited access to health care. Removal of user fees for this vulnerable sector of the population was perceived as one important strategy by which to improve access to health services, thereby promoting equity in a society of disparities. A year after its implementation, the policy was evaluated in terms of its impact on health service utilisation, the monetary costs (additional expenditure and loss of fee revenue), and the perceptions of users and providers. Evaluation The new policy had increased patient attendances at public sector facilities as well as the number and proportion of referrals from clinics; thus user fees, when in place, had probably been an important deterrent to service utilisation by the general population as well as those in need of referral. For the period under review, there was also a decline in the proportion of unbooked deliveries, indicating an impact on one of the key intermediate determinants of infant wellbeing. The biggest recurrent public health service expenditure item, staffing cost, was not altered by the policy. Although no direct assessment was made of drug costs, the increase in this area was estimated to be less than 1% of the total public sector health budget. Revenue from user fees was estimated to have dropped by about 30% (1·5% of the total public health budget), with most of this loss occurring at the large referral hospitals. What were the views of users and providers? In general, users supported the new policy; those living in rural areas, in informal settlements, and on white-owned farms 1541
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felt that access to health care had improved. However, there were concerns about the capacity of health services to cope with the extra workload. Of the public sector providers, most believed that the policy had helped to prevent serious illness among children and pregnant women, but the dominant opinion was that several preexisting deficiencies had been aggravated. These included poor working conditions, low morale, overcrowding, and scarcity of equipment and medicines. Users and providers agreed that one of the main reasons for the apparent inappropriate use of referral hospitals was the inadequacy of primary care facilities, and there was a general feeling that implementation of the policy, which had extensive implications for practice, should have been preceded by greater consultation and planning.
User fees Although the evaluation was retrospective and the quality of the information poor, these results have usefully highlighted areas for further inquiry and policy development. One area that has not yet been assessed is the impact on health outcomes when user fees are eliminated. This calls for a long-term analysis, in which all the other variables impacting on health outcome are carefully considered and controlled. To yield reliable results, such as a study will have to await a more accurate health information system than we now have. One thing is already clear—that fees generated at the primary level of care make a negligible contribution to the overall health budget; thus, free health care has now been extended to all users of the primary level public sector health service. The effectiveness of this policy will be contingent on concurrent strengthening of administrative infrastructures and service delivery at all levels of care, with special emphasis on primary level health care services. While reduction in user fees is important in promoting access to health care services, this is but one of the many strategies towards equity. Other important interventions concern the quality and effectiveness of care, facilitation of appropriate referrals between different levels of care, strengthening of district development and primary care, and strategies to improve the wellbeing of health care providers. Free health care for pregnant women and for children under six years has clearly improved access to health care for some, especially in underserved populations. It has also highlighted the limitations of a single intervention and the need for coordinated implementation of South Africa’s multidimensional plan for health care.
HIV and tuberculosis Salim S Abdool Karim South Africa’s HIV epidemic developed a few years after that in other countries of southern and eastern Africa. The first described cases of AIDS in South Africa were among homosexual men; retrospective HIV testing of stored sera from 1985 revealed no case of HIV infection in the general population. Since then, large-scale anonymous serosurveys in antenatal clinics have borne witness to a rapidly progressing epidemic. The prevalence of HIV infection in this sentinel group was 0·73% in 1990, 2·15% in 1992, and 7·57% in 1984; by 1995 it had 1542
risen to 10·44%. Although HIV-2 has been reported in South Africa it remains uncommon. Within the homosexual population the predominant HIV-1 subtype is B whereas in the heterosexual population it is subtype C. Community based HIV serosurveys reveal that 15–25-year-olds have the highest incidence rate of HIV infection, girls being infected at an earlier age than boys.
The spread of HIV An important factor in the spread of HIV and other sexually transmitted diseases is the apartheid-created migrant labour system, which separated millions of black workers, mainly men, from their families and resulted in a system of “oscillatory migration” between the workplace in the city and the family in the rural area. Do people appreciate the risk they run? Knowledge about HIV infection is high within the general population, although certain myths (for example, that sex with a virgin can cure AIDS) are still common. Safe sex is not widely practised by the youth of South Africa—partly because the future holds so little promise for the hundreds of thousands who are poorly educated, who see no reason to defer immediate sexual gratification for future benefit. Since 1994, the fight against AIDS has been accorded a higher profile and a larger budget. Information has been disseminated widely; and, more important, condom distribution by Government services rose from 6 million in 1994 to 97 million in 1995. The female condom is currently being introduced into Government clinics. Condoms are available free in Government health care services while private sector marketing and promotion of condoms, as well as social marketing, has grown substantially in the past four years. Sexually transmitted diseases are very common. A 1994 community-based survey in a rural district revealed an 8·8% prevalence of active syphilis, a 4·5% prevalence of gonorrhoea, a 6·1% prevalence of chlamydial infection, and a 10·5% prevalence of HIV infection. The control of sexually transmitted diseases has been neglected; but now the Government has adopted the policy of syndromic management, with extensive training of primary health care nurses. Most patients with sexually transmitted diseases still visit a traditional healer first. In South Africa, AIDs now dominates clinical practice across disciplines ranging from paediatrics to neurology. Antiretroviral drugs are not available in Government health services but can be bought in the private sector. Most private medical insurance schemes do not cover the costs of antiretroviral drugs. Many large hospitals run specific AIDS clinics in an attempt to provide better specialised care for AIDS patients. Stigmatisation and discrimination are, unfortunately, widespread. HIV counselling and testing are widely available, since they are offered by AIDS training and information centres run by local health authorities and funded by Central Government. Tuberculosis control Clinically, pulmonary tuberculosis (TB) is the main presenting illness among HIV infected persons. The incidence rate of TB in South Africa is one of the highest in the world at 341 per 100 000 per year. To illustrate the burden in the era of HIV, the incidence rate of TB in one rural district with a population of about 200 000 rose
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from 154/100 000 in 1991 to 413/100 000 in 1995. At the same time, prevalence of HIV infection among these TB patients rose from 29% to 55%. Drug resistance in TB is closely monitored. Multipledrug resistant TB has not increased as a fraction of all TB cases over the past two decades. However, the number of patients with multiple-drug resistant TB has increased concomitantly with the rise in TB in South Africa, to the extent that more than 2000 cases were registered in 1996. Directly observed therapy on an outpatient basis is the standard policy, and this strategy has been very successful in some areas; others, however, continue to have difficulty achieving high rates of treatment completion and cure. TB control in South Africa focuses on enhancing diagnostic accuracy, standardised combination drug therapy, directly observed therapy within the community, improving cure rates, and active surveillance through a register of all TB cases. The individual and joint effects of the HIV and TB epidemics give these two conditions high priority in South Africa. While positive achievements are heartening, much more concerted effort, political will, and resources are needed if they are to be effectively controlled.
What future for South African medical research? Chairperson of the Medical Research Council’s Board is Dr M W Makgoba, professor of molecular immunology at the University of Witwatersrand; the President is Dr O W Prozesky. Robin Fox interviewed them together at MRC headquarters in Tygerberg.
business—which is health research?” How was the perception of medical research at that time of transition? Makgoba: When people speak of South African science you find they are nearly always talking about medical research. Our international reputation in science derives almost entirely from the medical fraternity, which during the apartheid era was uniquely able to maintain standards. Of course, the average South African is not impressed by citation rates in international journals, and is more likely to ask “Who have you helped by this research?”. Developing countries have been encouraged to adopt a policy of “essential national medical research” (EHNR), whereby the programme is grounded in local priorities. The South African MRC, however, has invented something new called Integrated National Health Research. What is the difference? Makgoba: For much of this century, knowledge has been split. Now we find that, as in human beings themselves, systems do not function independently. Whatever we study, we should integrate the different approaches. So, for example, the molecular biologist must not think he has nothing to discuss with the epidemiologist. Prozesky : EHNR should be driven from a Ministry of Health, whose job is to make sure the essential research is done in some way by some system. At the MRC we can contribute to this research “cake” but we don’t want the whole of it; there’s room for independent university departments, charitable foundations, NGOs, and so on. So, let the whole country’s programme be EHNR. There is a tension here. Integrated research taps the skills and knowledge of excellent scientists from a wide range of disciplines, and makes no sharp distinction between fundamental and applied science. An administrator in Pretoria, wanting a quick answer on the prevalence of tuberculosis across the nation, will understandably take a short-term view. But in our philosophy the only difference between fundamental and applied research is the length of your vision. Makgoba: Curiosity-driven research is integral to what we should be doing. So the MRC remains strongly committed to the training of scientists. Prozesky : That’s right. There’s no way we can build a healthy nation without excellent scientists, and it’s only by doing both fundamental and applied research that you create such people.
Dr Makgoba (left) and Dr Prozesky (right)
According to the Corporate Plan published in 1995, the Medical Research Council’s vision is “Building a healthy nation through research” and its mission is “To improve the health status and quality of life of the nation through excellence in scientific research”. Did these represent a change of policy from the previous era? Prozesky : Yes. Medical research had become more of a social issue. The old vision focused on achieving the best possible outputs for research. But in 1994 we were building a new nation, and one essential for economic development was seen to be a healthy population. We asked ourselves, “What can we offer through our core
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Yet the programme does seem to have become more focused, with its twenty “research thrusts” on topics such as trauma, women’s health, burden of disease. This looks like a switch of emphasis towards applied research; and could you be taking subdivision of the enterprise too far? It seems that even health surveys will be part of the work. Prozesky : We shy away as much as possible from pure surveys. In the past they have not been well done by the Ministry of Health, and ideally the Ministry should buy them through the MRC. Having secured the information wanted by the Minister, on where the disease is and who has it, then we could set our organisation to look at the data and begin to ask how and why. As to the “thrusts”, a country in our position does need to focus its research efforts; we can’t afford the largesse for everyone to get on 1543
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Examples of MRC-funded research in South Africa Amoebiasis Entamoeba histolytica was for a long time believed to be a commensal, occasionally being activated by some unidentified trigger to cause invasive amoebiasis. Since 1980 the MRC Amoebiasis Research Programme, working closely with the London School of Hygiene and Tropical Medicine, has shown that it occurs as two distinct though morphologically identical species—E histolytica (pathogenic) and E dispar (non-pathogenic). Only E histolytica elicits a serological response, which is observed both in patients with amoebiasis and in symptomless carriers (10% of whom subsequently develop invasive disease). The species status of these two organisms is underlined by the fact that their identities are retained after axenisation. Tuberculosis Members of the MRC Unit for Inflammation and Immunity, University of Pretoria, are participating in the Glaxo-Wellcome Action TB initiative. Their primary objective is to discover novel targets on Mycobacterium tuberculosis that can be modulated directly by antimicrobial or immunotherapeutic strategies. Microbial K⫹-transporting systems have been identified as potential selective targets for antimicrobial chemotherapy. Bacterial K⫹ transporters differ structurally and functionally from their counterparts in eukaryotic cells. Several pharmacological agents (some of them novel) have proved to inhibit K⫹ transport in M tuberculosis; and decreased K⫹ transport seems to precede, and to be the cause of, microbial death. Existing agents function as membrane-perturbing factors, leading to secondary inhibition of cation uptake. The search is on for pharmacological agents that are primary and selective. Variegate porphyria South Africa has the highest incidence of variegate porphyria (VP) in the world. The VP families seem to be descended from a Dutch couple who married at the Cape of Good Hope in 1688. VP—an autosomal dominant inherited trait that results in decreased activity of the penultimate haem synthetic enzyme protoporphyrin oxidase (PPO)—is characterised clinically by photosensitive skin lesions and a propensity to develop acute neurovisceral crises. Since theses crises are usually precipitated by a porphyrinogenic drug, early diagnosis is important for prevention. The MRC Liver Research Centre, University of Cape Town, working closely with colleagues in Athens (Georgia) and Cardiff, were the first to publish on a gene defect responsible for decreased PPO activity in VP. They found an R59W substitution in the PPO gene in over 90% of South African VP families, including known descendants of the putative founder couple.
with his own thing. I favour the heterogeneous approach to a project: you pick, say, three biostatisticians, four or five geneticists, so many of this, so many of that, and make them into a team. But you still manage them as biostatisticians &c. A good example is the Glaxo Tuberculosis Project, which came to South Africa because of our unique mixture of problems and skills. The money actually goes into the universities, but the project is run from an office up here by one very good scientist manager, one secretary, and one finance person. Could you use more money? Prozesky : The Government intends to wean us from state funding, and we now obtain 20% of our money elsewhere. At present we receive 6% of the science budget—about US$15 million. We think that’s too little—but a more important obstacle than underfunding is a shortage of skilled researchers. Just throwing money at a problem is no answer. At present, the schools of public health are running on MRC manpower, and the staff are not only training researchers of the future; they are also teaching health workers to be familiar with research attitudes. They have been criticised for this emphasis—but it’s the price we exact! An exciting idea in the Corporate Plan is that the MRC could become “the driving engine of research for the rest of Africa”. Makgoba: Most of us believe that, and not just out of national pride. Under apartheid, medical research was appropriate for only some 20% of the population. Now we are presented with a unique opportunity. If we can bring in the other 80% of the people, the experience they offer will contribute new dimensions and new interpretations. By African standards we are rich; we have a strong infrastructure and culture of research; and the world, having seen us fight and win the battle for democracy, wants us to succeed. Outside the country we are now building relationships in a way that was not possible before; where we used to fly to England, we now travel to Uganda, Mozambique, Nigeria. There’s a chance to build a new ethos. As the last country in Africa 1544
to achieve independence, the choice before us is either to seize these opportunities or to go the way of our brothers who got it wrong and ended up in the doldrums. Prozesky : The vision is perfect. But I’d like to add that it can’t be achieved without awareness that the MRC is a national asset that must not be tampered with.
The future for health care Ralph Kirsch In May 1994 the new Minister of Health, Dr Nkosasana Zuma, inherited a highly fragmented health service consisting of 14 previous ministries of health, all biased towards curative care. The private sector was largely undisciplined (medical aid fees had escalated by 500% between 1975 and 1985) and used at least half of the country’s medical expenditure to provide care for at best a quarter of its citizens. Both the private and public sectors were set against a background of the gross socioeconomic inequities engendered by apartheid. Fortunately the African National Congress healthplanners had used the long period of negotiation before the elections to develop a health plan for the nation. The plan acknowledged that the health of all South Africans would be secured mainly by economic development. This would allow Government to address race-based disparities in socioeconomic status, occupation, education, and housing. The system would be healthbased and informed by the primary health care approach. Central Government would formulate policy while the provinces would coordinate and manage the provision of services at provincial, regional, and district levels. Priority would be given to maternal and child health, nutrition, the control of communicable diseases, and violence. Although no government could repair the effects of almost 50 years of institutionalised racial discrimination in 2₂ years, it is not too soon to examine some of the early successes and failures. As well as a National Health Department, we now have Provincial Health Departments, 48 health regions,
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and 157 health districts. Economic stagnation has been replaced by growth of 3% and the rate of inflation has effectively been halved. But the economy is still performing below its real potential. The recent fall in the value of the rand highlights the fragility of the progress achieved. Unemployment, difficult to assess because of a large “informal” sector, is probably about 35%. Too few jobs are being created. Indeed, the Government estimates that to create 400 000 jobs a year by the year 2000 and produce resources for the improvement of living conditions, South Africa will need a 6% growth rate by the end of the century. Between March, 1994, and November, 1996, 123 139 houses had been built or were under construction (one million promised by 1999). 186 clinics have been built and a further 217 are under construction. Roughly 4750 new primary care posts have been created. Free maternal and child care has been introduced. New legislation allows women free access to abortion up to twelve weeks of gestation. Government data indicate that 7 out of 10 children are fully immunised. A primary school nutrition programme now serves about 5·6 million children. Clean water has been provided to 1 million people. These successes have been tainted by the National Department of Health's handling of a controversial AIDS education play which cost the taxpayer the equivalent of more than US$3 million. The redistribution of funds between and within the various provinces has also been problematic. Areas that were formerly underfunded and underserved have not always used these new funds wisely. One province spent excess funds on several advanced CT scanners. Two of the new provinces, Gauteng and the Western Cape, found themselves with more than one medical school and several teaching hospitals which consumed a large portion of their budget. In Gauteng, one of these schools, at the
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University of Pretoria, had been founded to provide education in Afrikaans while another, MEDUNSA, was to educate black students. In the Western Cape the Medical Faculty of the University of Stellenbosch (Afrikaans) had been built some 25 km from that of the University of Cape Town. The shift to primary health care has resulted in severe cuts to the budgets of the teaching hospitals. In the Western Cape cuts of as much as 25% are on the cards. While both central and provincial health departments are grappling with this problem a lack of the clearcut political will required to address the plight of the teaching hospitals may leave these irrevocably damaged and thus have far reaching long-term effects on the nation’s health care. South Africa’s transition to democracy has been labelled a fragile miracle (Lancet 1995; 345: 1222–24). A better analogy may be that of a lusty baby, thriving but beset by growth pains and by occasional childhood disease.
Contributors Prof Solomon R Benatar, Head, Department of Medicine, University of Cape Town; Prof Peter Folb, Head, Department of Pharmacology, University of Cape Town, Chairman, South African Medicines Control Council, Director, World Health Organization Collaborating Centre for Drug Policy at the University of Cape Town; Prof J P de V van Niekerk, Dean, Faculty of Medicine, University of Cape Town; Prof Thomas H Bothwell, former Dean, Faculty of Medicine, University of Witwatersrand; Prof Daniel J Ncayiyana, Deputy Vice-Chancellor, University of Cape Town, Editor, South African Medical Journal; Prof Marian Jacobs, Department of Paediatrics and Child Health, University of Cape Town; Dr David McCoy, Research Fellow, Department of Paediatrics and Child Health, University of Cape Town; Dr Salim S Abdool Karim, Director, Centre for Epidemiological Research of Southern Africa, Medical Research Council of South Africa; Prof Ralph E Kirsch, Department of Medicine, University of Cape Town, Executive Director, MRC Liver Research Centre, University of Cape Town.
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