Saving the lives of South Africa's mothers, babies, and children: can the health system deliver?

Summary

South Africa is one of only 12 countries in which mortality rates for children have increased since the baseline for the Millennium Development Goals (MDGs) in 1990. Continuing poverty and the HIV/AIDS epidemic are important factors. Additionally, suboptimum implementation of high-impact interventions limits programme effectiveness; between a quarter and half of maternal, neonatal, and child deaths in national audits have an avoidable health-system factor contributing to the death. Using the LiST model, we estimate that 11 500 infants' lives could be saved by effective implementation of basic neonatal care at 95% coverage. Similar coverage of dual-therapy prevention of mother-to-child transmission with appropriate feeding choices could save 37 200 children's lives in South Africa per year in 2015 compared with 2008. These interventions would also avert many maternal deaths and stillbirths. The total cost of such a target package is US$1·5 billion per year, 24% of the public-sector health expenditure; the incremental cost is $220 million per year. Such progress would put South Africa squarely on track to meet MDG 4 and probably also MDG 5. The costs are affordable and the key gap is leadership and effective implementation at every level of the health system, including national and local accountability for service provision.

Introduction

The enormity of the HIV/AIDS epidemic and the politics surrounding this issue in South Africa have obscured the other health challenges facing the country, yet they are closely linked. There are several colliding epidemics: HIV/AIDS and tuberculosis,¹ the increasing burden of chronic diseases including obesity linked to the demographic transition,² and staggeringly high rates of interpersonal violence.³ However, behind these headline issues is a more silent epidemic of continuing excessive mortality for mothers, babies, and children, which still primarily affects the poorest families.

Apartheid was particularly harsh to black South African women and children, mostly in peripheral and extremely poorly resourced rural homelands. Under-resourced health services, environmental risks, and precarious food security characterised the lives of many during this period. By the time the government led by the African National Congress came to power in 1994, infant mortality was ten times higher in the black population than in the white population (infant mortality rate 130 vs 13 per 1000 livebirths), rates of stunting were much higher in black children than in white children (28·4% vs 1·1%), more than 19 000 cases of measles were reported each year, and large and mostly uncounted numbers of maternal deaths were occurring from septic abortions; these examples indicate some of the ways in which women and children bore the brunt of the effects of apartheid on health.4, 5

Key messages

• At the present trajectory, South Africa will fall well short of achieving Millennium Development Goals (MDGs) 4 and 5, related to reducing child and maternal mortality.

• HIV/AIDS and poor implementation of existing packages of care are the main reasons for the lack of progress towards the MDGs.

• Full coverage of key packages of interventions such as treatment and prevention of HIV infection and provision of comprehensive maternal and neonatal care would put South Africa on track to achieve MDG 4 and make substantial progress towards MDG 5.

• To achieve high coverage of priority care for mothers, neonates, and children is financially feasible, requiring a 2·4% increase in expenditure, but this money must be spent strategically.

• Strengthening of leadership, accountability mechanisms, and high quality of care interventions are also required.