Dan J Ncayiyana, vice chancellor, Durban Institute of Technology
What is democracy? There are probably as many versions of this elastic concept as there are countries and nations that claim to be its adherents (and there is nary a country that does not)something that is bound to confound attempts to tackle the question that constitutes the subject of this essay. Both Plato and Aristotle were contemptuous of the idea of democracy meaning direct rule by the populace or the mob as in Athens they favoured instead the idea of rule by the bestthe aristocracy (aristos is Greek for best).
The Aristotelian model underpins modern representative governance. The governed are afforded the opportunity periodically to elect the best, who will rule over them. Once elected, the ruling elite makes decisions about war and peace, the quality of the environment, the allocation of the nation's resources, and other critical matters, all of which have profound implications for the health of the peopledecisions that do not always reflect what the people regard as best for their health.
Another semantic ambiguity is the concept of people's health. The World Health Organization's definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity casts a very wide net, leaving the epidemiologists scrambling to formulate health indicators to measure the effectiveness of health systems.
South Africa became a representative democracy on 7 April 1994, the historic day when citizens of every colour and persuasion flocked to the polls to elect the first unitary non-racial government, with Nelson Mandela as the first president. Cynics have averred that with the change, an Aristotelian aristocracy characterised by struggle credentials now came to replace the white oligarchy, albeit with overwhelming popular support. The new government inherited 14 independent health departments: one for each of the 10 black homelands one each for the white, brown (mixed descent) and Asian communities and one for black Africans living and working in so called white South Africa.
Health resources used to be unabashedly skewed in favour of services for the white community. Separation between black and white services was so absolute that an empty ambulance for white South Africans happening upon a serious road crash would blithely drive by if the casualties were black.1 Chief among the priorities of the new government was to merge these separate bureaucracies and operational systems to create a single, deracialised national health system, something the rulers were able to achieve with remarkable success.
The South African Bill of Rights, one of the most comprehensive in the world, declares that everyone has the right to have access to health care services. Accordingly, access and equity constitute the cornerstones of the government's new health policy, with primary care at centre stage. To achieve this goal, funding has been redistributed between and within provinces, and from tertiary to primary care, bringing health care closer, particularly to rural poor South Africans. Ironically, the reallocation has virtually decimated academic hospitals and accelerated the flight of academic staff from the public service. Public sector user fees were abolished, and an essential drugs list was introduced that greatly improved the availability and accessibility of medicines. More district health clinics were established, and more of them were connected to electricity and running water.
Has the health of the people improved in the decade since democracy? Not according to the health indicators, such as maternal, infant, and perinatal mortality child nutrition tuberculosis prevalence and life expectancy (see table on bmj.com).2 In certain instances, the reverse is evident. Unemployment and poverty (identified by WHO as the foremost threat to health) have increased despite a relatively robust economy.3 And while the proportion of economically successful black South Africans has grown substantially, the gap between the haves and the have-nots has widened. HIV/AIDS has worsened (something for which the government is taking a lot of knocks) and is largely responsible for the regression in health indices such as infant and child mortality, tuberculosis and life expectancy.
Until and unless South Africa is able to deal with the twin evils of poverty and HIV/AIDS, the future of the health of the people will remain bleak, and the newly won democracy will seem like a pyrrhic victory in so far as people's health is concerned. (Source: BMJ 2004329:1425-1426 18 December)
A table showing rates for health indicators over the past decade is on bmj.com at
Baldwin-Ragaven L, de Gruchy J, London L. An ambulance of the wrong colour. Cape Town: UCT Press, 1999.
Ijumba P, Day C, Ntuli A, eds. South African health review 2003/04. Durban: Health Systems Trust, 2004.
Poverty and Inequality in South Africa. Report prepared for the Office of the Executive Deputy President and the Inter-Ministerial Committee for Poverty and Inequality. May 1998. www.polity.org.za/html/govdocs/reports/poverty.html (accessed 8 Dec 2004).