• [Show abstract] [Hide abstract]
    ABSTRACT: Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the world's largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.
    The Lancet 12/2012; 380(9858):2029-2043. DOI:10.1016/S0140-6736(12)61814-5 · 45.22 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To analyse trends in under-five mortality rate in South Africa (1990-2011), particularly the contribution of AIDS deaths. Three nationally-used models for estimating AIDS deaths in children were systematically reviewed. The model outputs were compared with under-five mortality rate estimates for South Africa from two global estimation models. All estimates were compared with available empirical data. Differences between the models resulted in varying point estimates for under-five mortality but the trends were similar, with mortality increasing to a peak around 2005. The three models showing the contribution of AIDS suggest a maximum of 37-39% of child deaths were due to AIDS in 2004-2005 which has since declined. While the rate of progress from 1990 is not the 4.4% needed to meet Millennium Development Goal 4 for child survival, South Africa's average annual rate of under-five mortality decline between 2006 and 2011 was between 6.3%-10.2%. In 2005, South Africa was one of only four countries globally with an under-five mortality rate higher than the 1990 Millennium Development Goal baseline. Over the past five years the country has achieved a rate of child mortality reduction exceeded by only three other countries. This rapid turnaround is likely due to scale up of prevention of mother-to-child transmission of HIV, and to a lesser degree, the expanded roll-out of antiretroviral therapy. Emphasis on these programmes must continue, but failure to address other aspects of care including integrated high quality maternal and neonatal care means that the decline in child mortality could stall.
    AIDS (London, England) 07/2013; DOI:10.1097/01.aids.0000432987.53271.40 · 6.56 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Resuscitation with bag and mask is a high-impact intervention that can reduce neonatal deaths in resource-poor countries. This study assessed the capacity to perform newborn resuscitation at facilities offering comprehensive emergency obstetric and newborn care (EmONC) in Afghanistan, as well as individual and facility characteristics associated with providers' knowledge and clinical skills. Assessors interviewed 82 doctors and 142 midwives at 78 facilities on their knowledge of newborn resuscitation and observed them perform the procedure on an anatomical model. Supplies, equipment, and infrastructure were assessed at each facility. Descriptive statistics and simple and multivariate regression analyses were performed using STATA 11.2 and SAS 9.1.3. Over 90% of facilities had essential equipment for newborn resuscitation, including a mucus extractor, bag, and mask. More than 80% of providers had been trained on newborn resuscitation, but midwives were more likely than doctors to receive such training as part of pre-service education (59% and 35%, respectively, p < 0.001). No significant differences were found between doctors and midwives on knowledge, clinical skills, or confidence in performing newborn resuscitation. Doctors and midwives scored 71% and 66%, respectively, on knowledge questions and 66% and 71% on the skills assessment; 75% of doctors and 83% of midwives felt very confident in their ability to perform newborn resuscitation. Training was associated with greater knowledge (p < 0.001) and clinical skills (p < 0.05) in a multivariable model that adjusted for facility type, provider type, and years of experience offering EmONC services. Lack of equipment and training do not pose major barriers to newborn resuscitation in Afghanistan, but providers' knowledge and skills need strengthening in some areas. Midwives proved to be as capable as doctors of performing newborn resuscitation, which validates the major investment made in midwifery education. Competency-based pre-service and in-service training, complemented by supportive supervision, is an effective way to build providers' capacity to perform newborn resuscitation. This kind of training could also help skilled birth attendants based in the community, at private clinics, or at primary care facilities save the lives of newborns.
    BMC Pediatrics 09/2013; 13(1):140. DOI:10.1186/1471-2431-13-140 · 1.92 Impact Factor