Series www.thelancet.com Vol 374 September 19, 2009 1023 Health in South Africa 6 Achieving the health Millennium Development Goals for South Africa: challenges and priorities Mickey Chopra, Joy E Lawn, David Sanders, Peter Barron, Salim S Abdool Karim, Debbie Bradshaw, Rachel Jewkes, Quarraisha Abdool Karim, Alan J Flisher, Bongani M Mayosi, Stephen M Tollman, Gavin J Churchyard, Hoosen Coovadia, for The Lancet South Africa team* 15 years after liberation from apartheid, South Africans are facing new challenges for which the highest calibre of leadership, vision, and commitment is needed. The effect of the unprecedented HIV/AIDS epidemic has been immense. Substantial increases in mortality and morbidity are threatening to overwhelm the health system and undermine the potential of South Africa to attain the Millennium Development Goals (MDGs). However The Lancet’s Series on South Africa has identified several examples of leadership and innovation that point towards a different future scenario. We discuss the type of vision, leadership, and priority actions needed to achieve such a change. We still have time to change the health trajectory of the country, and even meet the MDGs. The South African Government, installed in April, 2009, has the mandate and potential to address the public health emergencies facing the country—will they do so or will another opportunity and many more lives be lost? Introduction Political change in South Africa since the end of apartheid has placed the country on a new trajectory of hope in which human rights are replacing racial and sexual discrimination. Institutions of the state are being built on notions of redress and equality, with parliament representing all ethnic groups instead of a white minority. In the health sector, political change has aimed to reduce inequities in health and health services, integrate the disparate homeland health-care systems into one South African health-care system, and reorientate services towards primary health care. Concurrently, the govern- ment has had to resist the vested interests of corporate companies in South Africa and worldwide that could cause harm to health, especially the tobacco and pharmaceutical industries. User fees were removed for maternal and child primary health-care services, abortion was legalised, and more than 1300 clinics were built. Government policy to remove discrimination and promote wealth redistribution has led to initiatives that include improved pensions, a burgeoning number of social grants, and a social expenditure programme to build houses, and provide clean water, sanitation, and electricity. Challenges in achieving the Millennium Development Goals In the 15 years since the first democratic election the health policies and programmes in South Africa should have led to substantial improvements in health, and achievement of the Millennium Development Goals (MDGs). Yet a review of progress towards the MDGs shows that South Africa has made some progress towards several intersectoral goals, but progress has been insufficient or even reversed for many of the health goals (figure 1). Since 1994 life expectancy has reduced by almost 20 years—mainly because of the rise in HIV-related mortality—and average life expectancy at birth is now 50 years for men and 54 years for women. 1 The proportion of the global burden of disease borne by South Africa, with a population of only 48 million, is disproportionately high (figure 2). The total disability- adjusted life-years for high burden diseases in South Africa is almost equivalent to that of Bangladesh, which has a population three times as large and living in much worse poverty. The Lancet’s Series on South Africa has shown that the country faces a convergence of several health challenges. 2–6 In addition to HIV and tuberculosis epidemics, a very high burden of morbidity and mortality results from violence and injury, chronic diseases, mental health disorders, and maternal, neonatal, and child mortality. The combination of acute and chronic diseases spanning all age-groups and socioeconomic strata imposes a massive burden on an already weak and underdeveloped public health-care delivery system, struggling to overcome poor administrative management, low morale, lack of funding, and brain drain. South Africa exemplifies a country that has undergone a protracted and polarised health transition, which is shown by the persistence of infectious diseases, high maternal and child mortality, and the rise of non- communicable diseases. 7 This confluence of several transitions (health, demographic, and epidemiological) needs to be understood in the context of the country’s development pathway; 8 South Africa has been substantially shaped by its colonial and apartheid past that divided society by race, class, and sex. 2 The end of apartheid presented demands and challenges to redistribute wealth and tackle unemployment. The neoliberal economic policies and increased integration of South Africa into international markets resulted in only modest economic growth. High unemployment has persisted, and income inequality has grown and Lancet 2009; 374:1023–31 Published Online August 25, 2009 DOI:10.1016/S0140- 6736(09)61122-3 See Online/Comment DOI:10.1016/S0140- 6736(09)61306-4 This is the sixth in a Series of six papers on health in South Africa *Members listed at end of paper Health Systems Research Unit (M Chopra PhD, J E Lawn MRCP), and Burden of Disease Unit (D Bradshaw DPhil), Medical Research Council, Cape Town, South Africa; School of Public Health, University of the Western Cape, Cape Town, South Africa (M Chopra, Prof D Sanders MRCP); Saving Newborn Lives/Save the Children, Cape Town, South Africa (J E Lawn); School of Public Health (P Barron FFCH, R Jewkes, Prof S M Tollman PhD) and Reproductive Health and HIV Research Unit (Prof H Coovadia PhD), University of the Witwatersrand, Johannesburg, South Africa; Centre for the AIDS Programme of Research in South Africa (Prof S S Abdool Karim MB ChB, Q Abdool Karim PhD) and Nelson Mandela School of Medicine (Prof H Coovadia), University of Kwazulu-Natal, Durban, South Africa; Department of Epidemiology, Columbia University, New York, NY, USA (Prof S S Abdool Karim, Q Abdool Karim); Gender and Health Research Unit, Medical Research Council, Pretoria, South Africa (R Jewkes MD); Division of Child and Adolescent Psychiatry and Adolescent Health Research Unit (Prof A J Flisher PhD) and Department of Medicine (Prof B M Mayosi DPhil), University of Cape Town, Cape Town, South Africa;