South Africa's history is permeated with discrimination based on race and gender. The country's infrastructure was moulded by the violent subjugation of indigenous people, appropriation of their land and resources, and the use of unjust laws, to force black people to work for low wages to generate wealth for the white minority. South Africa is also a country of political resistance; after 82 years, the organised multiracial struggle against unjust rule finally won democracy in 1994, along with a constitution that establishes the foundation for democratic institutions and upholds wide-ranging human rights. The history of South Africa has had a pronounced effect on the health of its people and the health policy and services of the present day. Before 1994, political, economic, and land restriction policies structured society according to race, gender, and age-based hierarchies, which greatly influenced the organisation of social life, access to basic resources for health, and health services. Modern South Africa is a multiracial democracy, where the black African majority (79·2% of the population), sits alongside minority groups that are white (9·2%), coloured (9·0%), and Indian (2·6%; the terms used for the different races are consistent with those in common use and employed by the national census, and do not imply acceptance of racial attributes of any kind).1 After 15 years, South Africa is still grappling with the legacy of apartheid and the challenges of transforming institutions and promoting equity in development.
South Africa has four concurrent epidemics, a health profile found only in the Southern African Development Community region.1 Poverty-related illnesses (table), such as infectious diseases, maternal death, and malnutrition, remain widespread, and there is a growing burden of non-communicable diseases.2 HIV/AIDS accounts for 31% of the total disability-adjusted life years of the South African population, with violence and injuries constituting a further cause of premature deaths and disability. Although South Africa is considered a middle-income country in terms of its economy, it has health outcomes that are worse than those in many lower income countries. South Africa is one of only 12 countries where child mortality has increased, rather than declined, since the Millennium Development Goals baseline was set in 1990.3 With 69 deaths under the age of 5 years per 100 000 live births, the country's mortality rate is far in excess of that, for example, of Peru (25 deaths per 100 000 live births), Egypt (35), Morocco (37), and Nepal (59).3
Key messages
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Freely elected governments are the minimum condition for effective health policies. The health and social consequences of despotic, unelected, or poorly functioning elected governments can be longlasting.
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The will of the people, expressed through resistance to oppression or mobilisation against failed policies in democracies, is the best investment for a healthy future.
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Programmes that directly address social determinants of health and development, such as discrimination and stigma, subordination of women, poverty and inequality, violence and traditional practices, are essential for promoting health and reducing disease.
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Macroeconomic policies that promote growth alone are insufficient; an economic architecture should allow the development of programmes that reduce poverty, unemployment, and inequities.
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Good leadership, stewardship, and management of health and related services are crucial to achieving health for all people.
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Innovative approaches to health service delivery are needed in developing countries that are affected by both communicable and non-communicable diseases.
This report examines the historical roots of the determinants of health in South Africa and the development of the health system through colonialism and apartheid to the current post-apartheid period. We present historical dimensions of current problems of gender inequity and violence, and those related to sexuality and the family, as well as the macroeconomic and socioeconomic contexts of health. We also discuss some of the failures in health system governance of the post-apartheid period that have delayed progress in addressing this historical inheritance (figure 1 and figure 2). These failings are key to the health problems currently facing the country and thus set the scene for the debates presented in the five subsequent reports in this Series, which focus on maternal and child health,20 HIV/AIDS and tuberculosis,21 non-communicable diseases,22 violence and injury,23 and finally the way forward to improve health in the country.24