Quality of health care depends on geography

The quality of health care, including access to HIV prevention and testing services, depends to a large extent on which of South Africa's 52 districts you happen to live in.

A man living in Cape Town received an average of 55 free condoms in 2007/08, while a man living in Kgalagadi, a rural district in Northern Cape Province, received only 1.7. On average, South African men were rationed to about one condom per month, according to the latest District Health Barometer (DHB), an annual report by the Health Systems Trust, a research NGO.

In KwaZulu-Natal Province's Umzinyathi district 100 percent of pregnant women attending antenatal clinics were tested for HIV in 2007/08, but only half those in eThekwini, also in KwaZulu-Natal, were tested, despite eThekwini having an antenatal HIV-prevalence rate of 42 percent, the highest in the country.

Some of the inequities highlighted by the DHB can be traced to differences in health spending, with districts in Western Cape Province spending the most on primary health care and districts in Free State Province spending the least.

The uneven distribution of HIV infection in South Africa also influenced ratings: six out of 10 districts with the highest number of Caesarean births were in KwaZulu-Natal, the province with the highest number of HIV-infected pregnant women [HIV infection can complicate delivery].

District Extremes
	55.2 condoms per man per year in Cape Town (WC); 1.7 condoms in Kgalagadi (NC)
	100 percent of pregnant women tested for HIV in Umzinyathi (KZN); 52 percent in eThekwini (KZN)
	100 percent of pregnant HIV positive women received nevirapine in Uthukela (KZN); 12 percent in Lejweleputswa (FS)
	83 percent of TB patients cured in Overberg (WC); 37 percent in Sisonke (KZN)
	12 patients a day seen by nurses in Waterberg (LP); 44 patients a day in Fezile Dabi (FS)
	R633 (US$79) spent on primary healthcare per person in Namakwa (NC); R191 ($24) spent in Lejweleputswa (FS)
FS - Free State, KZN - KwaZulu-Natal, LP - Limpopo, NC - Northern Cape, WC - Western Cape

Writing in the DHB, Dr Tanya Doherty of South Africa's Medical Research Council attributed a lack of improvement in child and maternal mortality rates to the HIV epidemic - under-five mortality barely shifted from 60 per 1,000 births in 1990, to 59 in 2007, while maternal mortality actually increased.

Prevention of mother-to-child HIV transmission (PMTCT) is vital to reducing maternal and child mortality and combating HIV, but health authorities have failed to properly monitor PMTCT interventions. "This is indicative of management neglect of the programme from national to facility level," Doherty wrote.

Although HIV testing of pregnant women has risen in most of the country, Doherty warned that the national average of 80 percent for 2007/08 might be an overestimate, due to errors in recording the data.

Figures on the percentage of pregnant HIV-positive women who received a dose of nevirapine to reduce transmission were even more unreliable, partly because women could receive their dose in either an antenatal clinic or a labour ward, but the two facilities often failed to combine their data.

Based on the available information, the national average for nevirapine coverage was 76 percent, but five districts in Free State achieved less than 40 percent.

Fuelled by the HIV epidemic, tuberculosis (TB) infections have increased rapidly, with Cacadu in Eastern Cape Province recording the highest incidence: 673 new TB cases per 100,000 people, compared to a national average of 283 cases per 100,000.

Although TB cure rates are still far from the WHO target of 85 percent they have steadily improved, reaching 65 percent in 2006. Three districts saw declines, which the authors described as "an indictment of management at all levels".

This edition of the DHB is the fifth since 2005. It not only highlights inequities in health provision and outcomes, but also reveals South Africa's progress towards achieving the UN Millennium Development Goals and the targets set in the National Strategic Plan for HIV and AIDS.

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