South Africa may be on track to achieve five of its eight Millennium Development Goals (MDGs) by 2015, but serious problems in health and education, if not attended to soon, may hold the country back from becoming a more prosperous society. Stephen Timm reports.
The goals that South Africa looks likely to meet are eradicating extreme poverty and hunger, achieving universal access to primary education, empowering women, ensuring environmental sustainability and developing a global partnership for development.
South Africa is falling behind emerging countries such as Malaysia and Brazil, which have already achieved six and four of their MDGs respectively.
The United Nations Development Programme (UNDP) says South Africa faces key challenges in health and education, which together with its high unemployment rate and high level of inequality, threaten to diminish gains made in poverty reduction and other areas.
On health, the country may have boosted child immunisation, lowered malaria deaths and got more people connected to better drinking water, but child mortality rates remain high, maternal deaths have sky-rocketed and life expectancy has fallen.
Much of the high mortality rate can be attributed to the prevalence of HIV and AIDS, which despite stabilising in recent years, remains high. This is despite condom use having increased and access to antiretrovirals (ARVs) having widened, according to the UNDP in a report last year of the country's achievements in meeting the MDGs.
The UNDP is so concerned about the country's massive increase in maternal deaths - from 150 to 625 deaths per 100 000 live births between 1998 and 2007 - that it has set up a national task team, comprising various officials, including Members of Parliament (MPs), to tackle this problem.
The UNDP believes that lowering the ratio of maternal deaths will also result in more children living beyond their fifth birthday and reduce the numbers of mothers who die from HIV/AIDS.
This is despite the fact that globally only very few countries are expected to cut maternal deaths and meet MDG 5, according to Duane Blaauw and Loveday Penn-Kekanai, from the University of the Witwatersrand's (Wits) Centre for Health Policy.
Writing in the 2010 South African Health Review, they pointed out that the average global annual reduction in the Maternal Mortality Rate between 1990 and 2005 was less than one per cent.
But there are already signs that things are looking up.
Eckhart Buchmann, Head of the Department of Obstetrics and Gynaecology at Chris Hani Baragwanath Academic Hospital, and Chair of the Priorities in Perinatal Care Association of South Africa, believes that the number of maternal deaths could come down, with recent developments.
Writing on the Public Health Association of South Africa's website in August, in an article called Maternal mortality and morbidity - still not right, Buchmann says the nationwide roll-out of antiretroviral treatment and upscaling of a training programme targeting interns and junior doctors may show a decline in maternal deaths when the 2008 - 2010 Saving Mothers report is released.
Kathy Dennil of Kedibone Health System Consultants is also confident that things will improve, with a new AIDS policy from the Government and funds from the United States through the President's Emergency Plan for AIDS Relief (Pepfar) and USAid.
"The Government's HIV counselling and testing strategy had led to over 13 million people being tested for HIV over the last 18 months to two years," she says. However, she is concerned that testing and health policy changes haven't resulted in an increase in those with CD-4 counts above 350 attending HIV wellness clinics, as the average person only seeks help when they have a CD-4 count of 87.
Added to this, says Dennil, antenatal care and tuberculosis management have traditionally been nurse-led programmes, but that these had not been doing well.
Yet, she remains positive that the new public healthcare policy being driven by the Minister of Health, Dr Aaron Motsoaledi, may address some of these problems with community-based health through the implementation of Brazil's successful district health model in South Africa. The model is based on teams of specialists where available in all parts of the country to support doctors.
A UN report - Levels and Trends in Child Mortality - released in September, revealed that while globally the under-five mortality rate dropped between 1990 and 2010 by more than one-third, from 88 deaths per 1 000 live births, to 57; in South Africa, the number of deaths per 1 000 live births among under-fives in South Africa in 1990 was 60. In 2010, it was 57. The country's MDG target for 2015 is 20. Last year, 58 000 children in South Africa died before their fifth birthday.
The United Nations Children's Fund and World Health Organisation says that in South Africa, progress in reducing childhood mortality had been hampered by HIV and AIDS, and poor implementation of healthcare. However, Heather Zar, Head of the Department of Paediatrics and Child Health at the University of Cape Town and Red Cross Children's Hospital, believes government has made important interventions in the past few years, which she expects will help South Africa to tackle its high child mortality rate.
Last year, the Health Department mandated that antiretroviral treatment start in children as soon as they were diagnosed. Zar says the introduction of two important childhood vaccines that would help to lower the onset of pneumonia and diarrhoea by 20% and 30% respectively was also important, as these are the leading causes of death for children younger than five.
Professor Haroon Saloojee, Head of the Division of Community Paediatrics at (Wits), says there is already anecdotal evidence that the two vaccines are reducing pneumonia and diarrhoea in at least KwaZulu-Natal and Gauteng. He also backs the move to emulate Brazil's district health model, saying healthcare facilities are too focused on hospitals and not enough on outlying communities in South Africa: "I think it's the right priority - it's spot on."
Saloojee says that the district teams, along with government's bid to boost school health and train lay-community members to give simple health tips to fellow community members is a step forward. He also singles out the Children Problem Identification Programme, which is being run in 100 of the country's 400 hospitals and has been effective in reducing child deaths by improving simple interventions at home or at hospitals or for example by improving transport to health facilities.
According to Saloojee, child deaths started to fall again since 2006, and he attributes this to the Government tackling HIV and AIDS more effectively. He says a recent costing exercise has revealed that in Gauteng alone, the use of R4 billion in existing and new funds over five years, could help halve child deaths in the province.
Then there's the country's education system. In September, the Minister in The Presidency responsible for Planning, Trevor Manuel, referred to the state of South Africa's education as "abysmal", saying it was the root cause of many of the country's problems, including poor health, unemployment, crime and a tolerance for corrupt practices.
Briefing MPs at a meeting in Parliament on the MDGs in September, Manuel said the country might have met the MDG goal for universal access to primary education, but that results from the 2011 Annual National Assessments of numeracy and literacy skills results, released in July, showed that South Africa had little to celebrate when it came to education.
The results showed, for example, that the average percentage score of grade three pupils in literacy was 35% and in numeracy 28%. Grade six pupils scored an average of 28% for languages and 30% for maths.
Graeme Block, Professor Extraordinaire at Wits University's Public and Development Management School, explains that while government has taken steps to improve the education system - by developing workbooks, improving teaching training and doing away with Outcomes Based Education - it still lacks the necessary implementation when it came to tackling the problem.
The Department of Basic Education, however, hopes that its Action Plan to 2014: Towards the Realisation of Schooling 2025, released last year, which lists 27 goals to improve educational performance, will make a difference. The department's Director of Research Coordination, Monitoring and Evaluation, Hersheela Narsee, says it is the first time that the country has such a plan for the schooling sector and points out that the quality of learning outcomes is the country's biggest challenge when it comes to improving the education system.
African National Congress MP and editor of New Agenda, Ben Turok, says though the MDGs are useful and have helped raise awareness of poverty, they are not that effective because they conceal structural problems. Echoing what Manuel said at the September meeting with MPs - that simply "ticking boxes" would not solve the country's challenges - Turok says government officials have to be "more sophisticated" when tackling the country's problems and not just concentrate on meeting statistics.
He gives the example of the Government's focus on RDP houses, which while leading to millions of homes being built, have resulted in many of these being unsound. Similarly affirmative action, which though well intentioned has many a time resulted in the appointment of staff that can't do the job, says Turok.
Likewise, Joel Netshitenzhe, Executive Director of the Mapungubwe Institute for Strategic Reflection, believes government has the right calibre of civil servants needed to improve health and education, but that it needs better monitoring and evaluating systems: "We've done well in widening access, but now the challenge is to meet the quality."
