Is democracy good for people's health? A South African perspective

BMJ 2004; 329 doi: (Published 16 December 2004)
Cite this as: BMJ 2004;329:1425

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Dr Ncayiyana (1) discussed some of the successes and failures of health policies and health care in South Africa since the advent of full democracy. Progress has been made in some areas, but the statistics tell an appalling story. In 1990, at the end of the Apartheid regime, life expectancy in South Africa was approximately 63 years, among the highest in Africa. This year (2004) it was estimated to be 43 years (1). South Africa dropped from 57 in 1991, to 94 in 2001 and to 119 in 2004 in the United Nations' Human Development Index (the higher the number, the lower the level of development) (2).

If one was to apply the reasoning of Alvaro Franco et al (3), the interpretation of these shocking figures are that democracy has caused a terrible decline in the health and well being of South Africans. However, the main reason for this decline in the health of the population is the unchecked advance of HIV/AIDS. The prevalence of HIV in women attending antenatal clinics has increased from 0.8% in 1990, to as high as 37.5% in some parts of the country 2003 (4). The country now has possibly the largest population living with HIV/AIDS in the world.

The ANC government under president Thabo Mbeki is partially to blame for the current state of affairs (5). At the height of the crisis, president Mbeki denied the existence of direct link between HIV and AIDS. HIV and sex education were not pursued early and vigorously enough. Distribution of free condoms was neglected. The safe sex message, which proved to be such a lifesaver for gay communities in the USA and Europe, were not taken up by many South Africans; a direct result of the government’s ambivalence. Many South Africans still lack basic understanding of HIV/AIDS; only 20% of South African women have comprehensive knowledge of HIV (6). The South African government not only neglected to focus on sex education but also had to be forced to supply medication to AIDS sufferers through court action by the Treatment Action Campaign (TAC) and actions by activists such as Zachie Achmat. Treatment were finally started to be supplied years later than some other, poorer African countries. It came too late for hundreds of thousands of adults and children (5).

Those most prone to HIV infection are poor, black and female. They were the most disadvantaged group under apartheid. The dreadful irony for South Africa is that these are the same people abandoned to die of AIDS by the current government. This is why health inequalities in the country are now more pronounced than ever before.

1. Ncayiyana DJ. Is democracy good for people’s health? A South African perspective. BMJ 2004;329:1425-6.

2. UNDP (United Nations Development Programme). Human Development Report 2004. Available at

3. Franco A, Alvarez-Dardet, Ruiz MT. Effect of democracy on health: ecological study. BMJ 2004;329: 1421-3.

4. Department of Health (South Africa). National HIV and Syphilis Antenatal sero-prevalence survey in South Africa 2003. Available from

5. Achmat Z. HIV/AIDS and Human Rights: A new South African Struggle (2004 John Foster Lecture). Available from

6. UNICEF. (Accessed 18 December 2004)

Competing interests: None declared

Competing interests: None declared

Andre Strydom, Research Fellow

Royal Free and University College Medical School, London NW3

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