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Draft White Paper on Population Policy

Ministry for Welfare and Population Development

20 August 1997

Background
Executive Summary
Part One: Preamble
Part Two: Population and Human Development Situation
Part Three: Population Policy Goals, Objectives and Strategies
Part Four: Institutional Frameworkd for Implementing, Monitoring and Evaluating the Policy
Glossary of Concepts Used in the White Paper
Bibliography

BACKGROUND

THE PROCESS OF DEVELOPING A NEW POPULATION POLICY FOR SOUTH AFRICA

The impetus for the reorientation of government policy arose from the change in government in 1994. This was the same year that the United Nations International Conference on Population and Development (ICPD) took place in Cairo, Egypt in September 1994. The ICPD offered a useful new international perspective on population and development issues.

The development of the new national population policy commenced in June 1994, when the South African Government of National Unity initiated a review of the population policy adopted during the apartheid era as well as the functions of the population units at national and provincial levels. This review was undertaken in a number of stages. Consultations were held with the staff of population units and with population experts in order to identify the key issues that needed to be reviewed. A core group of national consultants and a broader working group of members of the population units was set up to undertake the review and prepare a new policy.

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A public discussion document, entitled A Green Paper for Public Discussion: Population Policy for South Africa? was launched in April 1995 during the Conference on Formulating a Population Policy for South Africa, organised by the Department of Welfare. A Non-Governmental Organisation Conference Report-back on the International Conference on Population and Development and on consultation on population policy was also held in April 1995. The Green Paper was widely advertised (including advertisement on Internet) between April and September 1995. Written submissions were requested from interested parties and the general public. In addition, the population units facilitated workshops in all provinces for government and representatives of civil society to build a broad based consensus on national population problems, and the best means of addressing them.

A total of seven hundred and forty nine written submissions on the Green Paper were received from academics, community groups, government departments, the private sector and NGOs. These were analysed and a report on the major findings was prepared by the core group and submitted to the national and provincial Ministers responsible for the population function in October 1995. Proposals were also made regarding the approach the population policy should take in order to reflect the findings of the submissions on the Green Paper.

The predominant view expressed in the submissions was that a new population policy for the country was necessary, and that such a policy should -

• form an integral part of national development strategies;
• have as a major goal the provision of a broad range of social services to improve the quality of life of the entire population, instead of the achievement of demographic objectives;
• ensure the establishment of effective mechanisms for the collection, analysis and interpretation of demographic and related socio-economic data and their use in policy formulation, planning, programming, monitoring and evaluation processes in various sectors;
• lay the basis for the construction of interventions that should receive attention as part of the implementation of specific programmes in sectoral departments.

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A draft discussion document on population policy was subsequently compiled during the period December 1995 to August 1996. During the drafting of the discussion document and the subsequent reviewing thereof, extensive consultations were held with all relevant ministries and departments as well as with population and development experts within universities, NGOs and the United Nations.

The completed draft discussion document on the population policy was presented to the Minister for Welfare and Population Development in September 1996. The following month Cabinet approved that the document be gazetted and released for public comments as the first Draft White Paper for a Population Policy for South Africa. It was released as Government Gazette, Volume 376, Number 17529 of 31 October 1996.

Copies of the first Draft White Paper were widely distributed and public comments on the contents were invited until the end of February 1997. The Department of Welfare received one hundred and sixteen written submissions from the public on the draft population policy. The submissions were scrutinised in March 1997. A number of substantive policy issues were identified, noted and then discussed; firstly, with a reference group of multi-disciplinary local and international experts on population and development, and secondly, with the Provincial Ministers and the relevant senior officials responsible for the population function in the nine provinces. These discussions provided guidelines for finalising the draft population policy.

The final draft of the White Paper was submitted to the Cabinet Committee for Social and Administrative Affairs early in August 1997. The Portfolio Committee for Welfare and Population Development also arranged public hearings in August 1997 to offer the public an opportunity to air their views on the new population policy. The White Paper was tabled in Parliament in September 1997.

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EXECUTIVE SUMMARY

A number of major population issues need to be addressed as part of the overall socio-economic development strategy of the country, as reflected in the Reconstruction and Development Programme (RDP) and the Growth, Employment and Redistribution (GEAR) strategy of the Government of South Africa. These population issues have been identified as limiting the attainment of sustainable development objectives. They constitute obstacles to improving the quality of life of the people of South Africa.

The population policy described in this White Paper is designed to provide a comprehensive and multi-sectoral framework for addressing population issues that are currently considered not commensurate with achieving sustainable socio-economic and environmental development. A basic tenet of this policy approach is that the population concerns are considered as multi-faceted and intersectoral. Consequently, efforts to address them within the context of national development strategies are also portrayed as multi-sectoral. The policy conforms with the Bill of Rights contained in the Constitution of the Republic of South Africa. It forms an integral component of national strategies for reducing past inequities, while substantially enhancing the quality of life of the entire population.

The policy places emphasis on the shift to a sustainable human development paradigm which places population at the centre of all development strategies and regards population as the driving force and ultimate beneficiary of development. The role of population in development is encapsulated in the Programme of Action of the International Conference on Population and Development (ICPD), agreed upon by the international community in Cairo in 1994. South Africa endorses the Programme of Action and thus the strategy for development that emphasizes the reciprocal relationships between population, development and the environment.

The population policy has been designed and conceived as integral to development policies and strategies, not as a substitute for them. Given an improved understanding of the interrelationships between population, development and the environment, it calls upon Government to take these relationships into account when designing, implementing and monitoring development programmes. This call is made against the background that past policies aimed at addressing population issues in South Africa focussed on fertility reduction, restricted population movement and controlled settlement patterns.

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This population policy clearly articulates the Government's position on the relationship between population and development. Sustainable human development is the central theme and organizing principle of this policy. Therefore, the development challenge is viewed in terms of meeting the needs of the present generation and improving their quality of life without destroying the environment or depleting non-renewable natural resources, in order to avoid compromising the ability of future generations to meet their own needs. Accordingly, the policy is rooted in an approach which recognizes the three demographic processes of fertility, mortality and migration as critical indicators of factors influencing the attainment of sustainable development.

The population policy described in this document has been developed within the framework of the Constitution. The policy is based on a set of twelve guiding principles, which provide the ethical context for a human rights approach to integrating population concerns into development planning, implementation and monitoring. These guiding principles provide the fundamental points of departure which guide the contents of the population policy.

The policy vision emphasizes the attainment of a high and equitable quality of life for all South Africans, as well as the balance between population trends, sustainable socio-economic development and the environment. The goal of the policy states that changes in the determinants of the country's population trends must be brought about to promote sustainable human development.

The policy objectives reflect the two main pillars on which the policy rests. One pillar is the systematic integration of population factors into all policies, plans, programmes and strategies aimed at enhancing the quality of life of the people at all levels and within all sectors and institutions of government. The other pillar is a co-ordinated, multi-sectoral, interdisciplinary and integrated approach in designing and implementing programmes and interventions that effect major national population concerns. Underpinning these two pillars is the need for reliable and up-to-date information on population and human development to inform policy making and programme design, implementation, monitoring and evaluation.

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A number of major population concerns have been identified as a result of analysing the human development and demographic situation in the country. These concerns cover a full range of population, development and environmental challenges, such as:

• growth and structural dynamics of the population relative to the growth and capacity of the economy to cope with backlogs in employment, education, housing, health and other social services to meet the needs and aspirations of the people;
• pressure of the interaction of population, production and consumption patterns on the environment; and
• the high incidence and severity of poverty in both rural and urban areas;
• inequities in access to resources, infrastructure and social services, particularly in rural areas, and the implications for redistribution and growth and the alleviation of poverty.
• reduced human development potential influenced by a high incidence of unplanned and unwanted pregnancies and of teenage pregnancies;
• high rates of infant and maternal mortality, linked to high-risk child bearing;
• high rates of premature mortality attributable to preventable causes;
• the rising incidence of sexually transmitted diseases, especially HIV/AIDS, and the projected socio-economic impact of AIDS;
• marked gender inequalities in development indicators, including access to productive resources, that reflect the low status of women;
• the poor knowledge base on population and population-development relationships;
• limited systematic use of population data in formulating and implementing, monitoring and evaluating development plans and programmes for the entire population.

A number of strategies are outlined, which comply with the multi-sectoral nature of the population policy. They link with the major population concerns and are expected to be operationalised to achieve the objectives of the policy. The twenty-four strategies cover ten broad areas, namely:

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• coordination and capacity building for integrating population and development planning;
• advocacy and population information, education and communication (IEC);
• poverty reduction;
• environmental sustainability;
• health, mortality and fertility;
• gender, women, youth and children;
• education;
• employment;
• migration and urbanisation; and
• data collection and research.

The multi-sectoral strategies in these areas are envisaged to lay the basis for multi-sectoral programmes that will be designed and implemented by a variety of government departments and supported by the private sector and organisations within civil society. In addition, the strategies form the basis to orient and, where necessary, to reorient intersectoral and sectoral policies and programmes towards the achievement of the objectives of this policy. The implementation of the policy will be the responsibility of the entire government, the private sector, civil society and all South Africans. Sectoral ministries and departments, especially those in the social, economic and environmental sectors, will have the responsibility for implementing the policy by designing and implementing interventions aimed at the achievement of the policy objectives. Interdepartmental liaison and co-ordination will be necessary to ensure effective policy implementation, such as the development of shared goals, targets and indicators to evaluate progress and impact.

Population units at national and provincial levels attached to the welfare departments will be restructured to facilitate and support the implementation of the policy. Their functions will include:

• promoting advocacy for population and related development issues;
• assisting government departments to interpret the population policy in relation to their areas of responsibility;
• analysing and interpreting population dynamics;
• commissioning research on the reciprocal relationships between population and development;
• disseminating information to inform policy design and programming; and
• monitoring and evaluating population policy implementation.

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The Cabinet, Parliament and legislatures will play an essential role of ensuring the successful implementation of the policy. The President as Head of State will report on progress with the implementation of the policy as part of an annual national development report. The Cabinet Committee for Social and Administrative Affairs will also oversee the implementation, monitoring and evaluation of the policy as part of the national development strategy. All parliamentary and provincial legislature portfolio committees whose areas of responsibility relate to population and development issues, are expected to ensure that all legislation is consistent with the goal and objectives of the policy. They are called upon to monitor the implementation of the policy as it pertains to their respective sectors. This will ensure that legislation that supports the achievement of the policy objectives is enacted and that legislation that militates against it is identified and repealed.

Civil society will have a critical role in achieving the policy objectives. To this end, government departments will involve community structures in decision making and the implementation of programmes. Existing consultative structures will also incorporate issues addressed in the population policy in their deliberations. Non-governmental organisations that already implement programmes related to strategies identified in this population policy, will continue to monitor and critique the policy and its implementation.

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PART ONE

PREAMBLE

1.1 WHY SOUTH AFRICA NEEDS AN EXPLICIT POPULATION POLICY

An analysis of the population and human development situation in South Africa reveals that there are a number of major population issues that need to be dealt with as part of the numerous development programmes and strategies in the country. Some of these concerns constitute serious obstacles to redressing inequalities and improving the quality of life of the population. They therefore need to be resolved within the framework of an explicit, comprehensive and multi-sectoral population policy, which is an integral component of national strategies for reducing past inequities based on race, while substantially enhancing the quality of life of the entire population. This policy should address current population trends that are not considered commensurate with sustainable socio-economic and environmental development. It should aim at bringing about changes in population trends, at removing flaws in past policies, and filling in gaps in the national social and economic development strategy.

The Reconstruction and Development Programme (RDP) and the Growth, Employment and Redistribution (GEAR) strategy currently constitute the overall planning framework for South Africa. The RDP is an integrated, coherent socio-economic policy that sets out various interconnected programmes for the many social and economic problems facing the country. The central objective of the RDP is to improve the quality of life of all South Africans. Its major programmes focus on meeting basic needs, developing human resources, democratising the state and society, and building the economy. The need for population data to formulate and implement pragmatic and realistic interventions for achieving the objectives of the RDP, and for their continuous monitoring and evaluation, is recognized. These data, however, require further elaboration to make the RDP a more effective instrument for achieving the Government’s objectives in the post-apartheid era.

The GEAR, which is complementary to the RDP, sets out an integrated economic strategy for rebuilding and restructuring the economy. The focus of the GEAR is on the overall macro-economic environment. It constitutes a framework for accelerated economic growth, while focusing on the challenges of meeting basic needs, developing human resources, increasing participation in the democratic institutions of civil society and implementing the RDP in all its facets. Specific social and sectoral policy: health and welfare services, housing, land reform and infrastructure, and their key links with economic growth, employment and redistribution, are also contained in the GEAR. The RDP and the GEAR provide the overall framework within which to integrate the population policy.

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The Bill of Rights contained in Chapter 2 of the Constitution for the Republic of South Africa also addresses social and human development issues, which affect the quality of life of people. These issues include housing, health care, food, water and social security, the situation of children, and education. Chapter 2 specifically notes the right of people to live in an environment "protected, for the benefit of present and future generations, through reasonable legislative and other measures that ... secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development". The links between these matters and population policy are clear.

1.2 PAST POLICY AND PLANNING CONTEXTS FOR POPULATION AND DEVELOPMENT

Past policies, especially with regard to the demographic processes of fertility, mortality and migration, were flawed in many respects. They were anchored in apartheid ideology and focused on:

• forced and/or restricted movement and resettlement of the population, especially blacks;
• reducing the country’s rate of population growth by reducing the fertility of the population primarily through the provision of contraceptive services, often by coercive means;
• demographic rather than human developmental targets;
• restricting the access of blacks to educational and employment opportunities.

Past policies were also based on incorrect assumptions about the nature of those factors affecting of the demographic processes, such as the belief that poverty is the consequence of a high population growth rate instead of recognizing the reciprocal relationship between the two phenomena.

Information on population and human development was often incomplete or deficient. Consequently, the knowledge base on the population, and on the interrelationship between population and development, was inadequate. Insufficient use was made of population data in the allocation of resources. Development planning and programming was seldom undertaken with the support of demographic analysis. The use of population data was further limited in scope because no overarching socio-economic development planning framework existed for the country as a whole. Although population data were used in the formulation of many development plans and programmes, it was not done systematically for the entire population. Development plans largely excluded the majority of the population.

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Institutional mechanisms, which dealt with population-related issues, were limited by their location in government, and by the technical capacity of their staff. They were also limited by the ways in which they related to other institutions, both inside and outside of government, with which they had to deal and through which their programmes could be implemented. Mechanisms for co-ordination and collaboration were either weak or ineffective. This lack of effective cooperation and coordination resulted in programme interventions being neither realistic nor pragmatic.

The population policies of the former government, apart from their racial/racist basis, reflected a population and development paradigm that is no longer accepted. Rapid population growth was regarded as the major population concern. The preferred solution to the perceived overpopulation problem was the promotion of fertility decline, to be achieved largely through an intensive family planning programme.

In 1974 a national family planning programme was established to promote access to contraceptive services in order to lower the rate of growth of the black population. At the same time the government was encouraging an increase in the white population through immigration. Static and mobile family planning clinics were established and contraceptives were provided free of charge. The clinics operated independently of other health services, which were often not accessible or free. The programme consequently came under much pressure, both for its ideological focus and the inadequacy of its services. By the mid-1980s the programme’s management distanced itself from the demographic intent of the Population Development Programme. Instead, it promoted the programme’s health benefits and started to integrate family planning into the other primary health care services.

In the early 1980s the government decided to implement a policy aimed explicitly at lowering the national population growth rate because the country's resources (especially water) could not sustain the prevailing high rate of population growth. Ironically the black population was either being denied access to well water-resourced arable land or was being removed and relocated to poor water-resourced areas. Thus the minority population owned, or was systematically taking ownership of most of the well water-resourced land in the country. This approach to population growth was based on the recommendations of the 1983 Report of the Science Committee of the President’s Council on Demographic Trends in South Africa. The Population Development Programme (PDP) was established in 1984 to implement this policy.

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The PDP set a demographic target of achieving a total fertility rate of 2,1 by the year 2010 to stabilize the population at 80 million by the year 2100. The major thrust of the PDP was fertility reduction through family planning. However, in recognition of the fact that family planning by itself would not achieve this objective, the PDP included interventions in other areas that have an impact on fertility levels, namely education, primary health care, economic development, human resource development, and housing. Although it did not concern itself directly with mortality or migration, it did consider the impact of mortality, urbanization and rural development on fertility. The recognition of the broader dimensions of population growth marked a significant shift in government attitudes to the population problem and ways of solving it. However, the PDP did not address the fundamental question of the lack of citizenship of the black population, nor the institutionalized discrimination in the very areas it sought to address.

Since the PDP was multi-sectoral, it was to be implemented through an intersectoral committee consisting of representatives of departments responsible for education, primary health care, economic development, manpower development and housing. Each of these departments was expected to give priority to meeting the relevant needs of the population in the areas under its mandate. The Chief Directorate Population Development (CDPD) was established in the Department of Health and Population Development. Population units were also set up under the CDPD in the provinces. Similar units were subsequently established in the homelands.

The implementation of the PDP was inadequate for a variety of reasons. There was no substantial shift in national funding priorities. Consequently, the intersectoral committee operated more in form than in substance. The CDPD did not have any authority to intervene in the programmes of other departments to ensure that the aims of the PDP were being pursued. In addition, there was no viable strategy or mechanism for the effective co-ordination of the multi-sectoral programme. An over-arching socio-economic development plan for the country did not exist. There was insufficient reliable demographic data and an insufficient number of appropriately trained people to analyse and interpret the data and to integrate population variables into sectoral plans and programmes. Attempts by the provincial population units to pursue the objectives of the PDP were not very successful either. Their briefs were unclear. They had no development funds.

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The PDP met with considerable political resistance. In addition, there was little if any political commitment to ensure the effective integration of population issues in overall development planning. There was also no viable strategy to support the PDP’s objectives.

As a result, the focus of the CDPD and the provincial population units shifted (from 1990) to the formulation and implementation of population information, education and communication (IEC) programmes. However, there were differences in focus, especially in the homelands, where the units concentrated on community development. The IEC programmes promoted the small family norm, stressing the relationship between poverty and large family size. The objective was to influence family size preferences and the reproductive behaviour of sub-groups with high fertility. Preference for a small family size increased during this period, especially among the Africans.

1.3 THE CURRENT POPULATION AND DEVELOPMENT PARADIGM

Different development paradigms have evolved and gained currency over time, primarily due to the analysis of the failure of past approaches to development. From an international perspective, there have recently been a number of fundamental changes in the conception and role of development, with a shift in focus to sustainable human-centred development. The focus of the current paradigm is "sustainable human development", in which population is placed at the centre of all development, as the driving force and ultimate beneficiary of development.

The role of population in development within this paradigm is encapsulated in the Human Development Reports prepared annually by the United Nations Development Programme (UNDP) and the Programme of Action of the International Conference on Population and Development (ICPD) agreed upon by the international community including South Africa, in 1994. The Programme of Action endorses a new strategy on development that emphasizes the reciprocal relationships between population, development and the environment. It focuses on meeting the needs of individuals rather than on achieving demographic targets. Among its objectives and recommended actions on the interrelationships between population, sustained economic growth and sustainable development (Chapter III) are:

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• the need to fully integrate population concerns into all development strategies, planning, decision making and resource allocation, with the goal of meeting the needs and improving the quality of life of present and future generations;
• promoting social justice and eradicating poverty;
• adopting appropriate and sustainable population and development policies and programmes;
• reducing unsustainable consumption and production patterns as well as the negative impact of demographic factors on the environment;
• the periodic review of policies to ensure the full integration of population concerns into development strategies and into all aspects of development planning at all levels aimed at achieving sustainable development.

The Programme of Action also places emphasis on:

• gender equity:the equality and empowerment of women both as an important end in itself, and as essential for the achievement of sustainable development;
• improving education and health conditions;
• promoting sexual and reproductive health (including family planning) and reproductive rights;
• supporting the family as the basic unit of society and contributing to its stability;
• fostering a more balanced distribution of population and reducing the role of various factors that affect rates of migration; and
• establishing factual bases for understanding and anticipating the interrelationships of population, socio-economic and environmental variables, and for improving programme development, implementation, monitoring and evaluation.

As a result of the close interrelationships between population, development and the environment, many population variables are now used as indicators of the development status of a country or geographical area. Similarly, many development indicators reflect the population situation within a country. It is incumbent on governments to take these relationships into account when designing, implementing and monitoring development programmes. Recommendations by various international forums are also encouraged. The most recent of the documents from the international fora are the Rio Declaration on Environment and Development; the Programme of Action of the International Conference on Population and Development (Cairo, 1994); the World Summit on Social Development (Copenhagen, 1995); the Platform of Action of the Fourth World Conference on Women and Development (Beijing, 1995); the second United Nations Conference on Human Settlements (Habitat II) (Istanbul, 1996) and the Food Summit (Rome, 1996). There is consensus within these forums that "population issues should be integrated into the formulation, implementation, monitoring and evaluation of all policies and programmes relating to sustainable development". Further, it is agreed that the framework of population policies should be conceived as integral to development policies and strategies; not as a substitute for them.

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1.4 THE APPROACH OF THE SOUTH AFRICAN GOVERNMENT TO THE POPULATION POLICY

This population policy articulates the Government’s position on the population and development. The Government’s position is essentially in response to the injustices inherent in the population-related policies of the previous government, as well as to the internationally accepted paradigm shift in the population and development field. Sustainable human development is the central theme and organizing principle of this policy. "Sustainable human development" sees development as a process of enlarging people's choices. The role of government in development is the creation of an enabling environment for people to enjoy long, healthy and creative lives. The challenge is to meet the needs of the present generation and to improve their quality of life without destroying the environment or depleting non-renewable natural resources, which would compromise the ability of future generations to meet their own needs.

The three interrelated elements of population, pervasive poverty and environmental degradation are especially pertinent to sustainable human development. Thus, while the Government recognizes the critical links between population, development and the environment, the precise nature of these interrelationships must be further investigated in order to provide a solid foundation to improve the quality of life of all South Africans. The objectives, recommended actions and emphases of the ICPD Programme of Action stated earlier are thus accepted as basic points of departure for this policy and its further refinement.

The present population situation is chiefly the consequence of past and current aspects of the interaction between development, demographic and environmental variables. Development affects population and the environment. Low levels of socio-economic development (a corollary of poverty) are typically associated with high rates of fertility, mortality and population growth. Changes in various development indicators have a direct impact on population trends. For instance, increasing levels of income, education and the empowerment of women are positively associated with better health and declining fertility and mortality rates, and often with migration from rural areas. On the other hand, some patterns of economic production lower the quality of the environment while others enhance it. For example, unregulated industrial production can lead to air and water pollution. Population pressure, too, can affect the environment. For example, population pressure on ecologically fragile areas can exacerbate environmental degradation and disrupt the ecosystem.

A country's population situation also affects its development prospects and the quality of the environment. For instance, high population growth places increasing pressure on government to provide services that will not only sustain but also improve existing standards of living. If the rate of population increase should be more than a country can cope with, the quality of life will decline. This is true even where government is promoting equity in resource distribution.

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The more youthful the population, the greater the proportion of the nation's resources that will have to be invested in the provision of services (for example education and health) for the dependent population, thereby reducing the resources available for stimulating economic growth in the short term. Further, a disproportionately young population will ensure that the population will increase in the future. In areas of the country where the population is thinly distributed, it is more expensive to make social services and infrastructure accessible to all.

The interrelationships between population, development and the environment outlined above implies that national population concerns must be taken into account in terms of promoting sustainable development in the country. The full range of major population concerns to be addressed through this policy initiative is clearly identified in Part Three of this policy document, following the analysis of the human development and demographic context in Part Two.

Consultations leading up to the final approval of this White Paper have seen a strong lobby for maintaining population growth as the central focus of this policy. However, such an approach would negate the important relationship between population and development for sustainable human development. While the factors promoting population growth are recognized as legitimate population concerns they must be addressed in a balanced manner.

A similar approach applies to family planning. Family planning is regarded as an integral part of reproductive health. The promotion of reproductive and sexual health is an important issue in its own right. It aims at helping men and women to control their fertility. It also aims at contributing to the improvement of the health of men, women and children. Sensitivity about past policies and strategies should not limit policy decisions for family planning service delivery. Within sustainable human development the emphasis is on providing equal access to reproductive health care for all. Quality of care, free choice, access to information and the availability of a full range of contraceptive methods are of crucial importance.

This emphasis on reproductive and sexual health does not, however, mean that these issues form the central thrust of this policy. The policy is rooted in an approach which recognizes the three demographic processes of fertility, mortality and migration as equally important. A single policy intervention, such as family planning, therefore cannot form the thrust of the policy. Similarly, strong fertility control measures are not acceptable within this policy. Fertility control measures are not reconcilable with sustainable human development and human rights.

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The Government acknowledges the reciprocal relationships between population, development and the environment. A basic tenet of the policy is that population concerns are multi-faceted and intersectoral. Efforts to address them within the context of the national development strategy should therefore be multi-sectoral and need to be realized within the framework of the RDP and the GEAR.

This population policy therefore commits the Government to resolving the national population concerns within the country’s overall development framework. This will be achieved through the implementation of intersectoral programmes that impact on major national population concerns. Population and human development information that supports the systematic integration of population factors into all policies and programmes aimed at enhancing the quality of life of the people will be harnessed to maximum effect.

The vision embodied in this policy emphasizes the attainment of a high and equitable quality of life for all South Africans. The goal and objectives of the policy focus on changes in the determinants of the country’s population trends, so that these trends are consistent with the achievement of sustainable human development. The design and implementation of interventions that will lead to the achievement of the objectives of the policy will be undertaken by all relevant government departments at all levels and in all sectors. Many of the programmes required to effectively operationalise the strategies are already being planned or implemented by various government departments at national and provincial level. However, existing and future development programmes may have to be oriented or reoriented towards achieving the objectives of the policy.

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1.5 GUIDING PRINCIPLES OF THE POLICY

This population policy is based on the following guiding principles:

1.5.1 All South Africans are born free and equal in dignity and rights. Everyone is entitled to all the rights and freedoms set forth in the Universal Declaration of Human Rights and the Bill of Rights of the Constitution of South Africa. Population policies should therefore respect human rights.

1.5.2 The right to development is a universal, inalienable and an integral part of fundamental human rights. The people are the country’s most important and valuable resource as well as the central subjects of development. The role of the Government in the development process is to facilitate people's ability to make informed choices, and to create an environment in which they can manage their lives.

1.5.3 Population, sustained economic growth and sustainable development are closely inter-related. Population policy should therefore be an integral part of an integrated system of development policies and programmes in a country. Its ultimate goal should be enhanced human development.

1.5.4 A population policy is more comprehensive than a fertility policy and includes such considerations as migration, mortality and fertility as well as their economic, social, cultural and other determinants.

1.5.5 Timely and reliable data and information are basic prerequisites for the design, monitoring and implementation of an appropriate population policy.

1.5.6 Advancing gender equality, equity and the empowerment of women, are fundamental prerequisites for sustainable human development, and thus constitute cornerstones of population and development programmes.

1.5.7 All couples and individuals have the basic right to decide freely and responsibly on the number and spacing of their children, and to have the information, education and means to do so.

1.5.8 People have the right to move freely within the boundaries of their country. Refugees may seek asylum from persecution in countries other than their own.

1.5.9 Poverty is one of the most formidable enemies of choice. Therefore, one of the most important objectives of a population policy is to contribute towards the eradication of poverty and all forms of social and economic exclusion of people.

1.5.10 People have the right to be informed about all matters relating to their daily lives. Consequently, the South African public should have access to relevant information concerning government policies, and an appropriate understanding of this information and its implications for all facets of their lives. This includes information on population and development issues.

1.5.11 The overall well being of children should be given the highest priority by government.

1.5.12 Civil society should be involved in the design and implementation of population policies and programmes.

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PART TWO

POPULATION AND HUMAN DEVELOPMENT SITUATION

2.1 DATA AND INFORMATION ON POPULATION AND HUMAN DEVELOPMENT

While a considerable amount of information is available on South Africa's population and the various indicators of human development in the country, it is unfortunately often deficient, especially with respect to its quality, reliability, coverage and completeness. Its usefulness is therefore limited, particularly with regard to accurately assessing the population and human development situation in the country, and for developing, implementing, monitoring and evaluating development plans and programmes.

Although eleven population censuses have been conducted since 1904, their coverage has been limited because some of the former homelands were not included. This is especially the case in the more recent census enumerations conducted in the pre-1994 period. Inappropriate methodologies were adopted in the enumeration of populations residing in informal settlements around major cities. The organisation of the censuses was poor in several respects and the quality of data collected varied greatly between the various racial groups and provinces. Sample surveys conducted in that period did not as a rule cover the former homelands. The sampling procedures adopted were biased against informal settlements. The coverage and completeness rates of the vital registration system have always been low. The system did not cover the entire country, nor did the registration of births take place in health institutions. Data on international migration is deficient. A significant number of people immigrate illegally into South Africa, while many people who leave the country permanently do not declare themselves as emigrants. In addition, human resource capacities for undertaking analyses of the population and related data have been very limited, especially within government institutions.

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As a result of the deficiencies mentioned above, there is no generally accepted set of reliable population and socio-economic data for the entire country. The estimates available are largely those made by national institutions and/or international agencies. There are few comprehensive or reliable analyses of demographic and socio-economic trends, or of the interrelationships between population and development phenomena in the country. Consequently, statistics used in this document, and explanations about their levels, trends and determinants, are based on the "best" available information and should be treated as indicative. The official publication of the Central Statistical Service (CSS), entitled RSA Statistics in Brief 1996, was used as a basic source of data and information in this document. Data disaggregated by race, geographical area and sex have been included where available. The limited availability of data disaggregated by sex, as well as of basic statistics on internal and international migration is striking.

It is recognized that disaggregation of data by race may be interpreted as an entrenchment of past political approaches that are no longer acceptable in the current democratic dispensation. Yet, the reality of the South African situation is that patterns of inequalities are clearly linked to race as a result of the country’s history. An adequate situation analysis of the human development and demographic contexts thus needs to reflect the racial dimensions in order to effectively highlight population and development concerns and more adequately target development programmes. It will remain essential to maintain data sets disaggregated by race for the foreseeable future in order to monitor the success of corrective action in the quest for social justice.

The data situation is expected to be substantially improved in the immediate future since the Government, through the CSS, has already set in motion measures aimed at correcting past errors in the mechanisms for data collection, analysis, and dissemination. A system of integrated household surveys to be conducted annually (the October Household Survey series) started in 1993. A new Demographic and Health Survey (DHS) will be conducted in 1998 and is expected to be repeated at five-year intervals. The first post-apartheid population census to cover the entire country was done in 1996. Preliminary estimates of the 1996 census have been published by the CSS in June 1997. The only results included in the preliminary estimates are population size per Province, population distribution by sex, and urban/non-urban population distribution. The preliminary estimates indicate that there were 37,9 million people in South Africa at the time of the census. However, the CSS has indicated that detailed data from the 1996 census will only be released by April 1998. This data will be used to further elaborate on the nature of major population concerns for policy implementation.

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2.2 THE HUMAN DEVELOPMENT SITUATION

2.2.1 THE ECONOMIC SITUATION

South Africa’s GDP (at 1990 market prices) was R287 233 million in 1995. Real GDP increased at an annual average rate of only 0,7 per cent during the last decade, even with the stronger economic performance since 1994. With an annual population growth rate of more than two percent, real per capita output has declined significantly. However, recent economic growth rates have increased to 2,7 per cent in 1994 and 3,3 per cent in 1995.

The Consumer Price Index (CPI), which reflects the cost of living, was 12,4 per cent for the period 1970-1995. The value of the rand, based on the CPI, has been decreasing dramatically since the eighties, while the average level of consumer prices has increased constantly. With an inflation rate of just under 10 per cent, it is evident that South African consumers are currently worse off than they were two or three decades ago.

These figures indicate declines instead of improvements in the standard of living in the recent past. With existing inequities in access to resources, these declines are likely to have been more acutely felt among the disadvantaged sub-groups, which constitute the majority of the population.

South Africa is classified as an upper-middle income country with a medium level human development. However, the level of human development for the majority of the population is low. The Human Development Index (HDI), the level of development of a country’s population calculated on the bases of life expectancy, education and income, was 0,716 in 1994. National level figures mask huge differentials in the quality of life of the various sub-groups of the population, especially those identified by race and sex, and in the various geographical regions. In reality, the relative levels of human development are much lower for the majority of South Africans than is reflected by the above national aggregate indicators. For example, the HDI for Africans is 0,500; 0,663 for Coloureds; 0,836 for Asians; and 0,897 for whites; it also ranges from 0,470 for Northern Province to 0,826 for Western Province.

South Africa’s history is characterised by colonialism, racism, apartheid, sexism and repressive laws. This history has created a divided society whose divisions have been reinforced and sustained by a system of separate and unequal development and segregation in virtually all spheres of social, economic, political and cultural life. One section of society is characterised by extreme wealth, with high levels of consumption, human development and the enjoyment of fundamental human rights. However, the major part of society is characterised by abject poverty, squalor, and minimal access to basic social and economic services. Fundamental human rights, including the enjoyment of full citizenship, were granted to the majority of the population only in 1994.

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The country has one of the most skewed income distribution profiles in the world (as is reflected by a Gini Coefficient of 0,65). On average, Africans earn 13 per cent of the income earned by whites, while Asians and coloureds earn 40 per cent and 27 per cent respectively. An estimated 45 per cent of the population live in poverty. Almost all of the poor are Africans who live in either rural areas or urban slums/squatter settlements. These differentials are primarily a legacy of the apartheid system.

2.2.2 THE SITUATION OF WOMEN AND GENDER DISPARITIES

Gender disparities exist in many indicators of human development. These disparities reflect the generally lower status of women compared with men. Enrolment rates at primary, secondary and tertiary educational levels are estimated to be slightly higher for females (79,6 per cent) than for males (77,1 per cent), and adult literacy rates are almost equal for females and males. However, a high dropout rate is recorded for young women due to teenage pregnancies. Moreover, women are enrolled at tertiary level of education mainly in traditionally female sectors such as teaching and nursing.

The income share of females is only 30,5 per cent of total income. This figure reflects the lower labour force participation rate of women and indicates that they are employed largely in low-wage jobs. A detailed breakdown of the economically active population by occupation and sex shows that women are bunched in traditional female occupations, which are relatively low-paid. Women are under-represented in the decision-making structures of both government and the private sector. They hold only 23,7 per cent of seats in Parliament, and constitute only 17,4 per cent of administrators and managers. The maternal mortality rate of 230 per 100 000 deliveries reflects their poor reproductive health status. The incidence of violence against women is high, with an estimated average of one rape every 83 seconds. Although the Constitution guarantees equality between the sexes in all aspects of life, many administrative and cultural practices still discriminate against them. In addition, women cannot as a rule take advantage of such life enhancing opportunities as politics, education, community involvement or leisure, because of their heavy domestic and work burdens. Female-headed households are particularly disadvantaged; their average income is about half that of male-headed households (R1 141 and R2 089 respectively). Consequently, a larger proportion of female rather than male-headed households lives in poverty.

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Within the family, women assume the primary responsibility for the care of children, especially very young children. In South Africa, for the majority of African families, the extent to which women can fulfil this responsibility had been severely compromised by the socio-political situation of the past. The burden on women to take on domestic as well as economic responsibilities leaves little time for childcare or feeding. At the same time, the provision of affordable, organised, early childhood education and care is completely inadequate or lacking. This need is probably greatest in urban and peri-urban areas. In rural areas, where families tend to be larger and employment rates lower, there is more likelihood of finding adults at home who can provide children with the necessary care and stimulation for development. Moreover, many families are female-headed with fathers absent or working elsewhere. Single parents do not have the time to undertake the double role of looking after their children and earning an income. This is particularly true of single mothers of small children.

The social-cultural context of gender issues in South Africa is not clearly understood. One of the reasons may be that the racial inequalities caused by apartheid policies have tended to mask the cultural aspects. Research on cultural perceptions of gender issues is needed to improve understanding of gender issues. Such research will provide a basis for developing appropriate illustrations of the real benefits of emancipating women and providing opportunities for children as part of policy implementation.

2.2.3 THE ENVIRONMENT AND NATURAL RESOURCES

Economic development and population settlement under apartheid policies could not be sustained. Industrial production has created air and water pollution. The reliance of 1,5 million households on agricultural production, together with forced removals to the homelands, has resulted in severe pressure on the land and environmental degradation. Overgrazing, overcrowding, and erosion occurred in many areas which were already characterised by poor quality of land and low rainfall. Environmental degradation has also been exacerbated by deforestation. The lack of sanitation and refuse removal services in many rural and urban areas has added a further pressure on the environment.

Additional stress on the environment results from widely differing consumption patterns within the total population. A major challenge faces water resource management strategies for the supply of safe and accessible water. The growing population and the great consumption differentials will place an increasing demand on already limited water resources.

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Rainfall is highly variable in the southern African region. Sixty-five per cent of South Africa receives less than 500 millimetres of rain per year (i.e. 60 per cent of the world average). Much of the rainfall is concentrated along the eastern and southern parts of the country, while the interior and the west are generally semi-arid or arid. Ground water is limited. Extensive investments have been made in large inter-basin transfer schemes and regional water supply schemes to meet the needs of large scale industry and commercial farming interests. International agreements on water transfers have been concluded with neighbouring countries. The demand for water for agricultural irrigation, municipal and domestic use, forestry, industry, power generation and nature conservation is increasing rapidly.

2.2.4 HOUSING, ELECTRICITY SUPPLY, WATER AND SANITATION

Although major strides have been made by government in water and electricity supply, far too many South Africans still live in shacks, without safe water, sanitation or electricity. In non-urban areas people generally rely on pit latrines, only 20 per cent of which have been improved to an acceptable, hygienic standard. Nineteen per cent of non-urban dwellings have no toilet at all.

About one quarter of South Africa’s housing stock consists of traditional dwellings and shacks, nearly all of which are located in non-urban areas. The high proportion of shacks in urban and peri-urban areas is the result of limited housing stock and increased rural-urban migration since the1980s.

The 1993 World Bank sponsored Project for Statistics on Living Standards and Development (PSLSD) survey showed a strong correlation between income and housing. Some 36 per cent of the very poor live in shacks or traditional dwellings. Very poor households are crowded with 2,3 persons per room. Africans and coloureds have an average of 0,8 rooms per person while the average for whites is 1,9. Only 15 per cent of very poor households have electricity, and 57 per cent of African households do not have access to piped water (i.e. internal household or yard taps).

Conditions are particularly bad for rural poor households. In rural areas 17 per cent of households fetch water from more than one kilometre away. Only 19 per cent have piped water, while only 11 per cent have a flush toilet or improved latrine. Very poor households use mostly wood for cooking which must also be fetched over long distances. Those household tasks performed by women and children are very time consuming. African women living in households which do not have their own water supply typically spend more than three hours a day fetching water.

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Poor housing, unclean water and lack of sanitation are major underlying causes of high mortality and morbidity, especially among children from poor families. Diarrhoeal diseases and respiratory infections are rife. A major benefit from improved water supply will be a general improvement in health. In addition, mothers and children will be released from the burden of fetching water. This will enable women to devote more time to their families, and perhaps earn income. The major benefit to children of improved sanitation will be a reduction in the incidence of disease. The health of other family members may also be improved.

2.2.5 THE SITUATION OF CHILDREN

Levels of child malnutrition and mortality are high, which indicate the plight of children. Immediate causes of malnutrition and mortality include poor dietary intake, disease and psychosocial stress and trauma. Underlying causes include poor household food security, inadequate childcare provision, lack of education and information, inadequate health services and an unhealthy living environment. These factors in turn reflect the basic economic and socio-political inequalities in the country. The need to focus on the eradication of poverty and increased access to basic services such as primary health care, clean water and sanitation and education is a priority.

Localised anthropometric studies suggest that about two and a half million South African children are undernourished and that 87 per cent of these are Africans. Sixteen per cent of African children under five surveyed in 1993 were underweight and between 20 and 30 per cent were stunted. The highest incidences of malnutrition are found in the rural areas of the former homelands and in the peri-urban informal settlements.

There is a strong correlation between poverty and malnutrition. However, the cause of malnutrition in young South African children seems to be poor feeding practices rather than actual lack of food and can be eradicated by functional nutritional education. Malnutrition and nutritional deficiencies can be detrimental to a child’s intellectual and psychometric development. Malnutrition is also associated with infections and lower immunities, exposing children not only to the increased likelihood of contracting diseases but affecting also the severity and duration of diseases. The result is not only increased mortality among children, but also the increased use of curative rather than preventive health services, thus increasing the health system’s operational costs. The situation is further affected by the lack of clean water, poor hygiene and the insanitary environment for the majority of households living in poverty. Access to primary health care facilities is a major factor in the prevention of malnutrition.

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2.2.6 HEALTH SERVICES

South Africa has a relatively well financed health service. The health budget accounts for 8,5 per cent of the GDP. Skilled employment in the health sector accounts for about four per cent of total employment. State expenditure on health services in the 1995/96 financial year amounted to R15 688 million, that is, ten per cent of the total State budget expenditure.

Expenditure in the health sector is concentrated very heavily in tertiary institutions, which benefit 20 per cent of the population who are members of medical aid schemes. More than half of South Africa’s doctors serves only 25 percent of the population. Primary health care, on the other hand, accounts for only about 12 per cent of public spending on health and is not readily accessible to a major section of the population. This is mainly due to a lack of facilities, lack of transport to reach the existing facilities, and barriers at the facilities themselves.

2.2.7 EDUCATION

As with the health sector, government spending on education has been high but inequitably distributed. Expenditure on the education system accounts for seven per cent of the GDP and the staff complement is six per cent of the formal sector workforce.

Very few South Africans under the age of six attend any form of school. In 1991 only nine per cent participated in pre-school programmes of any kind.

Enrolment rates in South African primary schools are high and there is little gender disparity. The pupil/teacher ratio is an indicator of inequality in teacher provision. The number of pupils per teacher varies considerably by province, with the largest classes in Northern Province and the smallest in Western Cape. The national average for the pupil/teacher ratio in South Africa was 41:1 in 1991. Many districts in all provinces other than the Western and Northern Cape, however, have ratios of over 37 pupils per teacher, which is considered as the norm, and there are many districts in KwaZulu/Natal and the Eastern Cape with ratios of more than 46:1. There are also great variations by race in the pupil/teacher ratio, as well as great geographical variations within race groups. These variations are partly attributed to discrimination in the allocation of resources for teacher training and teacher salaries by race in the former dispensation.

Under-provision of classrooms is a further disadvantage caused by the past African education system. In the most deprived of the former homelands and independent states, as well as in some areas in former "white" South Africa, the pupil/classroom ratio varies between 48:1 and 100:1. As might be expected, there is a high correlation between pupil/teacher ratios and pupil/classroom ratios: where there are high numbers of pupils per teacher, there are also generally high numbers of pupils per classroom.

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The proportion of the school-age population receiving post-primary education is the best single index of educational progress in a developing country and a useful indicator of the level of education facilities in an area. In 1994 the Education Foundation indicated that, for South Africa as a whole, 27 per cent of all African pupils were in the secondary phase. This figure varies from region to region. This is low compared to whites and Asians with 40 per cent and 39 per cent respectively, of which virtually all pupils complete school. Only 26 per cent of coloured pupils are in the secondary phase - the lowest percentage of any race group. In some areas this figure is even lower. It is high in urban areas and in many former homelands, but lower than 15 per cent in many other parts. Throughout the western parts of the country, where coloured populations are concentrated, the secondary enrolment largely falls between one and 25 per cent, as in the western section of the Eastern Cape.

In 1991, census figures recorded 490 051 children aged 7 to 14 years as being out of school. This number excluded children of this age group in the former independent states. Whereas 11 per cent of African children in this age group were out of school, the percentage for whites and Asians was 2,5 per cent and for coloureds 4,5 per cent. This represented an overall out of school percentage of nine per cent for seven to 14 year olds. The inclusion of the former independent states and of older children would greatly increase the figure for out of school children. There are large areas in the country where 25 to 74 per cent of African children are out of school. In areas where population density is high, even low percentages of out of school children represent high actual numbers of children.

The problem of children out of school is not confined to the homeland areas but is also widespread in densely populated rural areas of the previously "white" South Africa where farm schools predominate. Children of school going age - those between seven and 14 - are likely to be out of school when access to education is constrained by poverty, when children are required for domestic or farm work, or when children drop out of school. Language also plays a crucial role in access to education for children. Among those aged 15 to 19, girls tend to drop out of school earlier than boys. Young people in rural areas tend to drop out earlier than those in urban schools.

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Despite a generally high rate of educational participation, Africans still lag behind in educational achievement. In 1994, 23 per cent of Africans aged 15-19 had not passed standard four. Moreover, among individuals aged 16 and over, two thirds of the members of the poorest households have only primary education or less. Younger people are in general better educated than older people. A majority of members of very poor households aged 45 and over have no formal education at all, whereas only eight per cent aged 18-29 completely lack formal education.

Although most children of school-going age do attend school, many perform poorly, and eventually drop out after years of failure. This predicament applies especially to Africans and coloureds. High repetition rates among African primary school children occur especially in rural areas. In some places African repetition rates reach 20 to 46 per cent. In other words, more than one child in every five is repeating a grade. However, repetition rates do not reflect the percentage of pupils who have repeated a grade at some other point in their school career. Much failure is due to disadvantages outside the school that relate to general poverty. This is compounded by inherited inequalities of the education system and prevailing resource constraints. The quality of education, with poorly qualified and trained teachers, as well as the disadvantages due to poverty and studying in a second language, all contribute to Africans (especially) making slower progress through the education system.

The implementation of an integrated education system and a new system of appraisal which have been developed in South Africa during recent years should contribute to the improvement of the quality of education and school performance.

2.2.8 LITERACY

The adult literacy rate, that is, the proportion of the population who can read, write and speak their home language, was estimated at 82,2 per cent for the country as a whole in 1991. The corresponding figures for the different race groups are as follows: Africans 76,6 per cent; coloureds 91,1 per cent; Asians 95,5 per cent; and whites 99,5 per cent.

The percentage of literate adults is much higher in metropolitan areas (52 per cent) than in either former homelands (42 per cent) or rural "white" South Africa (28 per cent). The corresponding adult literacy rate for coloured adults is 56 per cent, while the figures for whites and Asians are 97 per cent and 79 per cent respectively. The literacy levels of African adults are considerably lower than for other race groups. Moreover, the difference between African literacy levels in metropolitan areas, former homelands and rural "white" South Africa is very marked compared with other races.

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Only eight per cent of all African adults in the 25 to 64 age group have passed matric. Corresponding figures for the other population groups are: whites 61 per cent, Asians 27 per cent and coloureds 10 per cent. The figure for Africans is higher in the metropolitan and former homeland areas (ten per cent) than it is in rural areas of former "white" South Africa (four per cent). While urban areas have a higher percentage of matriculants than do surrounding rural areas, most former "white" South African rural areas have the lowest percentage of matriculants. The level of African matriculants is low in all provinces.

2.2.9 EMPLOYMENT

According to the Central Statistical Service, the economically active section of the population represented 35,2 per cent of the South African population in 1994. This figure ranged from 50,1 per cent in Gauteng to 23,1 in Northern Province. The unemployment rate (according to the October Household Survey done in 1994) was 32,6 per cent. The figures for males and females were 26,2 and 40,6 per cent respectively. The unemployment rate also varied considerably among the nine provinces. It ranged from 47 per cent in Northern Province to 17,3 per cent in Western Province.

There has been a steady increase in the number of economically active people between 1991 and 1995, particularly among Africans. The official figure for 1995 for the economically active population was 14 497 000. This figure represents 35 per cent of the population. The gender participation rate of the economically active population is 64,3 per cent for males and 47,6 per cent for females. The average annual growth rate for the economically active population in the period 1991 to 1995 was estimated at 1,99 per cent.

The 1994 unemployment rate was 33 per cent, or 4,7 million people. The corresponding figures for males and females were 26,2 and 40,6 per cent respectively. The October 1994 Household Survey revealed that the highest unemployment rate was for Africans, namely 41,1 per cent. The corresponding figure obtained from the October 1995 Household Survey was 36,9, which reflected a slight improvement since the previous year.

The South African economy provides 9,6 million jobs annually for an adult population (15+) of 25,6 million. This translates into a job holding rate of 37,5 per cent. With a labour force participation rate of 56 per cent, and an unemployment rate of 33 per cent, to attain full employment South Africa requires at least 50 per cent more jobs than it currently has. It is estimated that about 400 000 job seekers enter the labour market annually. The increase of 20 900 jobs in the whole economy in 1995 should at least be twenty times higher if South Africa wants to stabilise its unemployment problem.

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The situation for women is particularly acute with the non-urban job holding rate only 19,1 per cent. The corresponding figure for urban women is nearly double at 36,6 per cent. The lower level of job holding in rural areas is reflected in lower household incomes and a high proportion of poor households. The job holding rate is particularly low for people aged 16 to 24, at only 17 per cent, or 31 per cent of those in the age group not undergoing formal education. More people in this age group are actively searching for work than are actually working. This affects all races, but is most severe among Africans.

Very poor households are poorly represented among jobholders. There is a strong association between unemployment and poverty. Only 19 per cent of persons of workforce age in the poorest households have regular work. Three quarters of the working age members of the poorest households are without paid work.

Poverty has reached chronic proportions in South Africa, especially in some of the interior rural areas. There is a widespread spatial distribution of poverty in the majority of rural areas across South Africa. Low per capita income is most prevalent in the former homelands and in the rural areas of "white" South Africa. Although the relative income inequality between races is evident, poverty is concentrated mainly in the African community. The poor section of the population is without formal sector employment and is also excluded from access to formal housing, health and educational facilities.

The percentage of households with income lower than the minimum living level (MLL), as calculated by the Bureau for Marketing Research (University of South Africa), has been established. These calculations are based on the actual income and household size of each household as established by the Central Statistical Service. This is a far more valuable indicator of households in poverty than is per capita income. The relative income inequality between races is reflected in the fact that even the highest category of African per capita income is lower than the lowest category of white per capita income. As noted earlier, the dependency rate of the white population is low because of a limited number of children per woman and low unemployment, which serves to raise the per capita income relative to the African population.

Areas where extreme poverty prevails among the coloured community, and where average per capita income is below the MLL, are found in the interior rural districts. Generally speaking, the Asian population is relatively well off economically compared to both the coloured and African populations.

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In most of the former homeland states more than 73 per cent of households live in poverty. All these areas have predominantly African populations. Metropolitan areas and smaller centres, including mining areas and electricity generating areas, have the lowest percentage of households living in poverty. Much of the Western Cape and almost all of Gauteng fall into the category with less than 40 per cent of households living in poverty (26 and 23 per cent). The two provinces with the highest percentage of poor households are the Northern Province (77 per cent) and the Eastern Cape Province (72 per cent). In terms of absolute numbers, the Eastern Cape has the highest number of households living in poverty. Areas with the highest and the lowest percentages of households living in poverty are closely juxtaposed.

The South African society has experienced an extraordinary level of violence with serious effects on the psychological development of children. South African children face a range of physiological problems associated with malnourishment and poor health. In addition, they are subjected to psychosocial stress and trauma. This has led to a very high prevalence of stress-related psychological symptoms and children with special needs.

2.2.10 OCCUPATION

2.2.10.1 Employed in the formal economy

The type of work done by employed people in the formal economy of South Africa varies by race and gender. Amongst employed Africans, 34 per cent of men, and 50 per cent of women are doing unskilled jobs such as cleaning, garbage collecting and agricultural labour. A further 20 per cent of African men are in operator, assembler and related occupations. Almost one in five (19 per cent) African women are in semi-professional occupations. Fewer than four per cent of African men and two per cent of African women are in managerial posts.

Amongst employed coloureds it is found that, whilst a large proportion of both men (35 per cent) and women (42 per cent) are still found in unskilled occupations, there is some movement among men into more skilled artisan and craft jobs (23 per cent). Among women, there is a move into sales and service (16 per cent) and clerical (16 per cent) jobs. As with Africans, a small proportion of coloured workers (three per cent of men and one per cent of women) are in managerial posts.

The picture for employed Asians is beginning to resemble the picture found amongst whites. Amongst men, an extremely small proportion (one per cent) is found in unskilled occupations, but otherwise they are well represented in other occupational categories. Asian women, on the other hand, tend to be found in clerical occupations (36 per cent).

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Whites, particularly white men, tend to have access to occupations requiring higher levels of competencies. Thus, white men tend to be found in three main occupational categories. In white-collar occupations they are likely to be found in the top echelon of this type of work - management (19 per cent), while in blue-collar jobs they are more likely to be found in top echelon occupations requiring higher level competencies and longer-term training, namely artisans and craft workers (29 per cent), rather than in operator or unskilled occupations. In addition, a relatively large proportion of white men are also found in the semi-professional/technical category, in jobs such as engineering technicians (17 per cent) requiring post-school technical qualifications. White women, however, tend to be found largely in clerical occupations (47 per cent).

2.2.10.2 Economic sector

There is a definite shift in the formal economy away from jobs being found in the primary and secondary industries towards jobs being found in tertiary industries. Almost a third (31 per cent) of South Africans work in the personal services sector. An additional 17 per cent work in trade, catering and accommodation, while only 15 per cent work in the manufacturing and 13 per cent in the agricultural sectors. The rest, namely 24 per cent, are employed in the other sectors, that is, finance and business services, transport and storage, construction, mining and quarrying, electricity, gas and water and other.

2.2.10.3 Informal economy

The informal sector of South Africa is a growing source of employment. Approximately 1,7 million people work in this sector, of whom 1,3 million work for their own account. Africans generally, and African women in particular, predominate in this sector.

Occupations in the informal sector tend to cluster into certain distinct categories or sectors. For example, there are more than three quarters of women own account workers in the informal sector (77 per cent) who tend to be found in the personal services sector, while four in every ten men (40 per cent) are found in the trade, catering and accommodation sector. Relatively few men (9 per cent) and women (5 per cent) are in small-scale informal manufacturing.

More than eight in every ten women (82 per cent) in the informal sector are in informal occupations such as street vending, domestic work and scavenging, while men are found in more diverse occupations, for example, artisan and craft activities such as building, house-painting and wood-working (37 per cent). A large proportion of men (20 per cent) described their occupation in terms of managing or running a micro-business, for example, running a taxi driving or hawking concern.

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2.3 DEMOGRAPHIC CONTEXT

The South African population situation is characterised by:

• relatively high but declining fertility and population growth rates (compared with developed but not with developing countries);
• low overall (but high infant and maternal) mortality rate;
• a young age structure with a certain degree of built-in momentum for future increases in population size (even if the growth rate were to continue to decline in the immediate future);
• growing numbers of elderly people
• a high dependency ratio;
• high rates of immigration;
• a high level of urbanisation relative to provision of infrastructure and services; and
• large rural populations in areas without an adequate productive base, infrastructure or services.

There are substantial differences in the demographic parameters between sub-groups of the population, mostly as a consequence of similar differences in the level of human development, which can be attributed to past patterns of development in the country.

2.3.1 POPULATION SIZE AND GROWTH RATE

The preliminary estimates of Census ‘96 indicate that there were 37,9 million people in South Africa during the time of the census, that is, October 1996. This figure is more than 4 million or ten per cent less than the projected figure of 42,1 million. The most probable explanation for the huge difference in census count and the projected figure is that the estimated fertility rates, especially of Africans, used in the projections were much higher than the actual rates. However, it will only be possible to draw specific conclusions about the reasons for the smaller population size than expected and the implications once the comprehensive census results that include age, population group and fertility are available and have been analysed.

In the light of new estimates by the CSS and the preliminary results of the 1996 census, all previous projections to the year 2000 and beyond should be viewed with caution. Existing projections are merely indicative of future trends.

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Since the only other results included in the preliminary estimates of the 1996 census are population size per province, population distribution by sex and urban/non-urban population disribution, the mid-year population estimate (medium variant) for 1995 done by the CSS is used to illustrate increase in population size over time. This estimate indicates a population size of 37,254 million, having increased from 22,105 million in 1970, and 27,379 million in 1980.

The average growth rate of the population is currently estimated at 1,9 per cent per annum (1995-1996), having declined from about 2,2 per cent per annum in the 1980-90 period. The average annual compound population growth rate for 1970-1995 was about 2,2 per cent. The population growth rate is projected to decline further to dip below 1,9 per cent per annum in the 2000-2010 period.

2.3.2 AGE, SEX AND RACIAL COMPOSITION

South Africa has a relatively youthful population by world standards: 13 per cent of the population are aged four years and under; 37,3 per cent of the population are younger than 15 years; 58,3 per cent are between 15 and 65 years; while 4,4 per cent are 65 years old and older. The proportion of young children under 5 years of age in the population also differs substantially between the Provinces. There are areas of the country where more than 19 per cent of the population is four years of age and under, which indicates a very high growth rate. Virtually all the areas with high percentages of very young children (up to 18 per cent and even more) are within the former homelands and independent states. The largest numbers of young children are found in the Eastern Cape, the Northern Province and KwaZulu/Natal. Almost two thirds of children live in non-urban areas. Parts of the country where less than 10 per cent of the population is aged four years and under largely comprise the metropolitan areas and some of the more rural areas of the country. The young age structure of the population represents a built-in momentum for future increases in the overall size of the population.

It is projected that the percentage of the population in the age group younger than 15 years will decrease from 37,3 per cent in 1995 to 36,1 per cent in the year 2000, to 33,7 in the year 2010, and to 29,9 in the year 2020. This supports the view that the South African population is ageing gradually.

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The 15-64 age group is generally regarded as the potential labour force of the country, which contributes to economic growth and which provides for the needs of children and the elderly. In general it can be said that there is a relatively high proportion of youth in rural areas and a relatively high proportion of the economically active age group in urban areas. The former homelands and independent states have a high number of young people and a relatively lower proportion of economically active people. The latter is an indication of both large scale emigration of adults to economic growth areas in search of work and a high number of young African people resulting from the high population growth in these areas. The higher number of young people and children in rural areas is also attributed to the fact that parents in urban areas often send their children to family members in rural areas to be looked after.

On the other hand, the metropolitan areas contain a high percentage of people in the economically active age group. Economic growth points have attracted people and caused immigration of the economically active age group. Metropolitan areas historically have a better provision of infrastructure and services than rural areas. However, these are also the areas where people are best able to afford services such as education, since the percentage of the population in the economically active age group is relatively high.

It is projected that the percentage of the population in the age group 15-64 will increase from 58,3 per cent in 1995 to 59,4 in the year 2000, to 61,3 per cent in the year 2010, and to 64,1 per cent in the year 2020. These increases represent major challenges for the creation of job opportunities for the potential labour force.

The number of people aged 60 years and older is growing rapidly. This is the retirement age for women, who make up by far the greater proportion of the elderly. It was estimated by the CSS that 2 652 000 of a total of 40 317 000 South Africans were 60 years and older in 1994. This figure represents almost 6,6 per cent of the total population of 1994. The proportional representation of the different population groups calculated on the basis of all those 60 years and older in the country that year is as follows: Africans 63,4 per cent; coloureds 7,2 per cent; Asians 2,5 per cent; and whites 26,9 per cent. The proportion of people aged 60 years and older for each racial group, calculated as a percentage of the total of each population group in 1994, is as follows: Africans 5,5 per cent; coloureds 5,5 per cent; Asians 6,5 per cent; and whites 13,7 per cent. It is projected that the percentage of the population in the age group 60 years and older will increase from 6,2 per cent in the year 1995 to 6,9 per cent in the year 2000; to 7,4 per cent in the year 2010, and to 9,1 per cent in the year 2020. These increases are substantial. Even more substantial will be the increase in real numbers, since the total population will still be increasing during the projection period. This has obvious implications for the provision of health and social welfare services for the growing numbers of elderly people in the country.

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The age dependency ratio is high, at 70,6 per cent (1991). This ranges from 107,5 per cent for the Northern Province and 96,3 per cent for the Eastern Cape to only 50,4 per cent for the Western Cape and 40,9 per cent for Gauteng. This high dependency ratio is due to the large number of dependent children that have to be supported by the economically active population. This situation is further affected by the growing numbers of elderly people in the South African society. The dependency burden is higher than is at first apparent as a large percentage of people in the economically active ages are either unemployed or do not actively participate in the economic life of the country. About 61 per cent of the total national welfare budget (according to the 1995/96 budget) was spent on social security and social welfare services for the elderly. The implementation of a new subsidisation formula for residential care for the elderly resulted in a decrease in the expenditure to 50,4 and 45,8 per cent for the 1996/97 and 1997/98 financial years respectively. There is a growing need for residential care for the elderly which is not being met due to limited funds. Departmental information revealed that less than 10 per cent of the elderly population are currently benefiting from subsidised social welfare services.

The sex ratio (i.e. males per 100 females) for the country was 49 in 1991. According to the preliminary estimates released of the 1996 census, the figure for the total population is 48. However, the sex ratio varies considerably between provinces and rural and urban areas as a consequence of past patterns of internal migration. Since rural to urban migration in the country has been selective of adult men in their most economically productive ages, there is a preponderance of women (as well as children and the elderly) in the rural areas and in the less economically developed provinces, and a preponderance of men in the economically active ages in the urban areas and more industrialized provinces. For instance, sex ratios are 45 in the Northern Province, and 47 both the Eastern Cape and KwaZulu/Natal, while they are 53 in Gauteng, and 52 in the Free State.

As far as the racial composition is concerned, in 1995 Africans constituted 76,3 per cent, coloureds 8,5 per cent, Asians 2,5 per cent, and whites 12,7 per cent of the total population.

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2.3.3 FERTILITY

The crude birth rate (CBR) is estimated at 31,2 per 1000 in the 1985-90 period, down from 37,2 per 1000 in the 1970-75 period. The total fertility rate (TFR) estimates range between 3,9 and 4,09. The fertility structure is characterized by a high incidence of high-risk childbearing. Teenagers and women over 35 years of age accounted for 15 and 16 per cent of births respectively in 1993. There is a considerable gap between preferred and actual family size, indicating that many couples are not able to achieve their preferred family size. The contraceptive prevalence rate is high at an estimated 60 per cent (for married women in 1994). The age at first marriage is increasing. However, the typical negative correlation between age at first marriage and fertility level does not seem to hold in South Africa. It would appear that marriage is becoming less of a social requirement for childbearing.

There are substantial differences in the fertility rates between the various sub-groups of the population, essentially reflecting differences in the levels of human development, as well as in the cultural values attached to children. The estimated total fertility rate of 1,5 for the white population is less than a third of the estimated TFR for Africans (4,3) and lower than the estimated TFRs of 2,2 and 2,3 for Asians and coloureds respectively. The magnitude (and rate) of decline in fertility also varies between the racial groups, being lowest for Africans and highest among coloureds, especially since the mid 1960s. Total fertility rates are higher in rural than in urban areas and in the less developed provinces (especially those that contain the former homelands) compared with the more developed provinces.

An estimate of contraceptive prevalence in South Africa made in 1996 indicates that it was 60 per cent in 1994. The estimated contraceptive prevalence for the whole of South Africa for 1990 was 55 per cent. This estimate was broken down into contraceptive prevalence figures for each of the nine provinces. These figures ranged from as high as 70 per cent in the Western Province and 66 and 65 per cent in the Northern Cape Province and Free State respectively, to as low as 46 per cent in the Eastern Cape Province and 33 per cent in the Northern Province respectively. The corresponding figure for the whole of South Africa was 55 per cent at that time. The contraceptive prevalence rate is highest among whites (at 81 per cent in 1994) and lowest among Africans (at 55 per cent in 1994), with intermediate levels of 74 per cent for Asians and 67 per cent for coloureds. It is also higher in metropolitan than in rural areas. There is a positive correlation between contraceptive prevalence and women’s level of education. The teenage birth rate has been on the increase for the African population, especially since 1980, but has been declining for other racial groups. Preferred family sizes are also much lower in urban areas and among younger women.

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The preferred family size among African women surveyed in the late eighties was smaller in urban areas than in rural areas. Just over 60 per cent of urban women wanted two or fewer children, compared with 31,8 per cent in rural areas. The ideal number of children also differed by age group, with younger respondents wanting smaller families. In urban areas 79 per cent of people aged 16 to 19 years indicated that they preferred two or fewer children compared to only 48 per cent of those aged 30 to 34 years. In rural areas the corresponding figures were 51 per cent and 24,3 per cent respectively.

Women have developed fairly low fertility aspirations. It was found that attitudes and practice in decision making change with age for both men and women. Younger women were far more likely to take decisions jointly with their partner than women in the older age groups. For most respondents financial and economic considerations played a very important role in limiting family size. A survey in the late eighties revealed that 34,4 per cent of the African women interviewed wanted two or fewer children, while the desired number of children for all women surveyed was 3,3. Among younger women the desired number of children fluctuated between 2,6 and 2,9. Another study in 1996 by the Reproductive Health Research Unit of the University of the Witwatersrand, revealed that economic considerations and children’s educational needs play a major role in terms of women’s decision making on family size. It was also found that women’s education was significantly associated with parity and planning of pregnancies. Other studies have found that the use of effective contraception is already relatively high in South Africa.

The survey of the late eighties also revealed a considerable degree of dissatisfaction among women with the family-building process. Approximately 42 per cent of all fecund women indicated that they had not wanted their last pregnancy, while 57,2 per cent of women indicated that their last pregnancy had been unplanned. There is still a considerable disparity between the ideal number of children individuals desire and the actual number of children that individuals have. It was also established that women start with reproduction at early ages, frequently before contracting a formal marriage. Approximately 59 per cent of first births were to mothers under the age of 20.

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The major portion of contraceptive use in South Africa consists of modern contraceptive methods, which are more effective than traditional methods. Among those who use contraception, for both men and women, there are racial and gender variations regarding choice of method. While the majority of men who practice contraception use condoms, the majority of women, especially African women, who practice family planning, use the contraceptive injection. The 1996 study mentioned above revealed that most men and women had heard of the contraceptive injection, the pill, the inter-uterine device (IUD), the condom and female sterilisation. More men than women, however, reported that they had heard of most of the methods except for the pill and the IUD.

A national household survey of health inequalities in South Africa carried out for the Henry J Kaiser Family Foundation indicated that, with respect to age and contraceptive use, the younger the respondents, the more likely they were to go for family planning advice. More than two thirds of those with a sexual partner who went for contraceptive advice went to family planning clinics to seek such advice. A large proportion of women who went for contraceptive advice went to a family planning clinic, while men were in general more likely to go to a private doctor.

This survey also revealed that rural Africans were less likely to seek advice on contraception, than those living in urban or metropolitan areas. As far as the relationship between education and seeking contraceptive advice among Africans is concerned, a quarter of African men with matriculation went to obtain contraceptive advice. Those with no formal schooling who went for contraceptive advice represented a smaller fraction than the first. Among African women, approximately a quarter of those with no formal schooling went for contraceptive advice, which is considerably fewer than the almost three-quarters of those with matriculation who went for contraceptive advice. It was also found that women are far more likely to use contraceptive methods, than men. However, African women are less likely to do so, than whites, coloureds or Asians. In the absence of condom use, women are at greater risk from contracting sexually transmitted diseases and AIDS.

Regarding rural-urban differences in contraceptive use among Africans, it was found that younger, urbanised, more educated people are more likely to seek contraceptive advice, than older, less educated rural ones. Proportionately, more African men living in formal dwellings in metropolitan or urban areas use a contraceptive method, than those living in rural former homeland areas, in metropolitan informal areas, on white-owned farms or urban informal areas. The most common reason given by men for failing to use contraception is that they rely on their partners to do so. The responsibility for family planning tends to be delegated to women. Among women, although contraceptive use is much higher, a similar pattern of urban-rural differences emerges. Regarding education level and contraceptive use among Africans, a similar pattern to the one described for seeking advice on family planning was found.

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International research conducted during the 1970s and 1980s on youth reproductive and sexuality issues indicated that a large number of factors, including developmental, psychological, interpersonal, social, cultural and economic, influence youth reproductive health behaviour and protection. Decisions young people make about their sexuality, the behaviours they engage in, and the values and attitudes they hold, are shaped by their physical and social environments, their life histories and personal qualities. High-risk behaviours, such as alcohol use among young people, are intimately related to sexual risk behaviours and negative sexual outcomes. These international surveys indicate that young people see alcohol use and partner inhibitions against using sexual protection as the main barriers to the effective use of pregnancy prevention measures. These trends are also found in South Africa.

Studies indicate that most young men had their first sexual intercourse before age 17 and most young women before age 18. Also, about half of all young people have had more than one sexual partner. However, there was a strong endorsement from both young men and young women for fidelity in relationships and for gender equity, especially towards sexual and reproductive protection. The majority of young people did not want to have a child; pregnancy was perceived as a significant risk associated with sexual activity. However, only about a third of young people were regularly using contraceptive methods to prevent unwanted pregnancy. Knowledge of reproductive functioning was generally poor, although the necessity of sexual protection in relationships with regular partners was endorsed by a majority of the young people surveyed. In both young men and young women, increased contraceptive use was associated with exposure to a supportive information environment, especially with exposure to supportive information, advice and services from health professionals. A substantial number of young people indicated that they needed information on sexual and reproductive health issues, services and products, including information on matters such as pregnancy and sexually transmitted diseases, sexual intercourse, relationships and characteristics of the opposite sex.

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2.3.4 MORBIDITY AND MORTALITY

Data on mortality and morbidity in South Africa are inadequate. The absence of a comprehensive national health information system, coupled with inadequate reporting of notifiable diseases, poses problems for an analysis of the mortality and health status of different groups according to province, age, sex, etc. Some common inferences can however be drawn on the basis of occasional surveys. Nevertheless, the available data provide sufficient evidence of the inequalities between different races and of the disadvantaged situation of many African children, especially rural, poor African children.

2.3.4.1 Mortality

Like fertility, the mortality rate for South Africa has been declining over time, leading to an increase in the expectation of life at birth. The average figure for estimated life expectancy at birth for the country as a whole is 62,8 years (1991), up from 58,8 years in 1980. The average figures for the different race groups are as follows: Africans 60,3 years; coloureds 66,5 years; Asians 68,9 years, and whites 73,1 years.

The crude death rate (CDR) is estimated at 9,4 per 1000 persons in 1994, down from 14 per 1000 persons in 1970. The infant mortality rate (IMR), an important indicator of the quality of life and level of development of a population, was estimated at 41 per 1000 live-births (1994), which is less than half the rate of 89 per 1000 live-births in 1960. The mortality rate for children under 5 years of age was estimated at 68 per 1000 in 1994. The maternal mortality rate, an important indicator of the reproductive health and socio-economic status of women, was estimated at a high of 230 per 100 000 deliveries in 1993.

There are a number of characteristic features of the structure and pattern of mortality in the country. The level of premature adult mortality is high. In 1985 it was estimated that 38 and 25 per cent of fifteen year old men and women respectively were likely to die before reaching the age of 60, chiefly as a result of factors associated with lifestyle, including the relatively high incidence of crime.

There are also significant differentials in mortality indicators among various sub-groups of the population, which again reflect differences and past inequities in access to services, the quality of life, and thus in the level of human development. A profound manifestation of the extent and impact of poverty in South Africa is reflected in the infant and child mortality rates. These indicators represent a fundamental measure of society’s general well-being. The infant mortality rate of 49 per 1000 live births among the African population is six times the rates of 8,3 and 9 among the white and Asian populations respectively, and double the rate for coloureds at 23. Life expectancy at birth is thirteen years higher for whites than for Africans. Life expectancy is also lower in the less developed provinces. For example, it was found that life expectancy at birth was the highest in the Western Province (67,7 years in 1991, compared to 62,8 years in 1980) and Gauteng (66 years in 1991, compared to 61,7 years in 1980), and the lowest in the Eastern Cape at 60,7 years in 1991 (up from 54,4 years in 1980) and the North West Province at 59,7 years in 1991 (up from 56,3 years in 1980). The magnitude and rate of decline in the infant mortality rate in the recent past has, however, been higher among Africans and coloureds than other racial groups, amongst whom the levels have been much lower in the past.

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A high perinatal mortality rate (PNMR) provides an indication of the quality and availability of antenatal care, as well as adverse health, nutritional and social conditions of childbearing women. Children born to rural women whose pregnancies are not regularly monitored and who give birth at home are significantly more at risk of perinatal deaths. Perinatal mortality is not routinely reported in South Africa. Available statistics reveal that the perinatal mortality rate increased between 1986 and 1989. In 1989 it was estimated at 23,3 per 1 000 births, which may only be applicable to the white population. A more recent estimate is higher at 45-55 per 1 000 births, and even higher in the former homelands.

Perinatal mortality rates point to the inadequacy of antenatal care, since a significant number of deaths in this age category are preventable. Antenatal care is important to ensure that complications are detected and dealt with promptly. The availability of antenatal facilities differs widely according to race, socio-economic standing and locality. Many women in rural areas still give birth at home, assisted by traditional birth attendants. This is mainly due to limited services and inadequate and costly transport. The risk to mother and child are increased with home deliveries, especially when complications arise. Moreover, some women only attend antenatal clinics once, late in their pregnancy.

Teenage pregnancies increase the health risks to both mother and child. The Department of Health indicated that the percentage of teenage births as a proportion of all births varies from 11,8 per cent in the Western Cape to 16,4 per cent in the Northern Province in 1994. Teenage pregnancies are often the outcome of a lack of knowledge about sexuality and contraception and the unequal power relations between men and young women. Many teenagers resort to illegal abortions to terminate pregnancies, which often result in medical complications, infertility and even death, although this problem will diminish with the enactment of liberal abortion legislation. In 1991 the Department of Health revealed that maternal mortality was almost double for women under 20 years of age compared to those over that age. The risks to children include abandonment, higher incidence of still birth, low birth weight and post-natal complications.

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2.3.4.2 Causes of death among children

Six diseases account for the majority of the known causes of death in the first year of life. Of these, perinatal causes were by far the most prevalent. It was found that three quarters of deaths among African infants were due to perinatal causes, diarrhoeal and respiratory diseases.

As with the IMR, estimates of under-five mortality are unreliable in South Africa as data were not routinely collected from all racial groups and the homelands were excluded. A recent analysis of data indicates very high rates of child mortality, especially among rural, poor children. Overall, the under-five mortality rate is estimated by the Medical Research Council to be between 115 and 120 per 1000 live births, and as high as 139 for rural children (1994). This means that one in every seven children born in the rural areas of the country die before the age of five.

Measles was the second most important notifiable disease in South Africa in 1995. It is a leading cause of child mortality and morbidity. Unvaccinated children between nine and twelve months are the most vulnerable. Like tuberculosis, measles is eminently preventable through effective immunisation programmes. Mass immunisation campaigns countrywide by the Department of Health in 1996 and 1997 are expected to reduce the incidence of measles.

Other leading notifiable causes of child mortality and morbidity in South Africa are malaria, viral hepatitis, typhoid fever (which is strongly associated with contaminated drinking water, poor sanitation, and overcrowding), meningococcal disease, and cholera. Acute respiratory infections, likewise, are a major cause of childhood mortality. Diarrhoeal diseases, respiratory infections and allergies outnumber all diseases in both ambulatory facilities and hospital admissions. All these diseases are linked to poverty, poor living conditions and the absence of basic health care messages reaching the population. This situation poses major challenges in terms of the reduction of child mortality rates.

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2.3.4.3 Causes of death among adults

According to the National Department of Health, the 213 279 deaths that occurred in South Africa in 1994 are distributed by cause of death as follows: Unintentional and intentional violence 19,2 per cent; "ill-defined" causes 15,2 per cent; illnesses related to life-style, namely strokes and ischemic heart diseases, collectively 11,4 per cent; and upper respiratory tract infections 4,3 per cent.

Poverty, inadequate primary health care and unhygienic living conditions are major underlying factors of illness and death. Many parasitic and infectious diseases, which are aggravated by poverty, are preventable through immunisation, increased access to primary health care, improvements in living conditions and improvements in income levels.

South Africa is burdened by a very high incidence of tuberculosis. However, the extent and trend of the tuberculosis epidemic is not accurately known. In 1994 the case notification rate for all forms of tuberculosis was 223 per 100 000 total population, and the estimated rate of smear positive cases was 140 per 100 000. The overall incidence in 1994, estimated by the Medical Research Council, was 311 per 100 000, with 80 per cent of these occurring in the 15-49 year age group. In 1995, tuberculosis accounted for more than 80 per cent of communicable disease notifications. It was estimated that at least 140 000 new cases have occurred in the country. Of these, at least one quarter were attributable to HIV infection and one per cent were harbouring multi-drug resistant tuberculosis organisms. An estimated 160 000 cases in 1996 included more than 42 000 cases as a direct result of HIV infection. The rising trend is expected to continue for at least the next 7 years, given optimal tuberculosis and HIV control programmes, after which the incidence of tuberculosis can be expected to stabilise and start to decline. If current trends continue, more than 3 million new cases of tuberculosis will occur in South Africa over the next decade.

These figures confirm tuberculosis as South Africa’s number one public health problem and South Africa as a country with one of the highest incidence rates in the world. There is considerable variation between provincial estimates, with the Western and Eastern Cape having incidence rates approximately twice those of other provinces. Tuberculosis rates are highest in rural areas and particularly amongst people in poor living conditions. Government spent an estimated R500 million on the tuberculosis problem in 1995. In view of the limited success of these activities, the Department of Health has declared tuberculosis a priority and introduced a more cost-effective control strategy countrywide, the Directly Observed Treatment Short Course (DOTS) to reduce the prevalence of tuberculosis.

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Typhoid still ranks among the five most frequently notified diseases in the country, although notification rates have dropped considerably. Even though the available data indicate a decline of the disease in all population groups, the concentration of the disease among the African population relative to the other population groups is noticeable.

2.3.4.4 HIV infection/AIDS

The Department of Health estimates that up to three per cent of the overall population and 7,5 per cent of the sexually active population are infected by the human immunodeficiency virus (HIV) which is spreading rapidly in South Africa. This means that approximately 700 people are becoming infected each day with the rate of new infections doubling every 15 months. There is a rapid increase of HIV infection amongst young women, which reflects their vulnerability in sexual relationships. The problem of children orphaned by AIDS is increasingly becoming an issue.

The nature of the demographic and economic consequences of AIDS in a society is determin