When the HIV / AIDS pandemic hit South Africa with what seemed to be catastrophic force in the mid-1990s, the country's health care system was already under severe pressure.  Following the end of apartheid in 1994, the health system was in the process of being transformed from one that focused on the needs of whites to one that met the needs of the entire population.  AIDS made that transformation even more difficult.  A decade on there are indications that South Africa is beginning to recover.

It was the screening of pregnant black women by the South African public health care system in the mid-to-late1990s that revealed a sudden and dramatic increase in prevalence of HIV, the virus that causes AIDS.  A few years earlier, because of the poor health care available to black South Africans under apartheid, many of those women would probably not have been covered by the public health care net.

But with the end of apartheid, health care, like so many other public services, was expanded to reach all the country's citizens.  Whites-only hospitals were opened to all, and a network of more than 1,000 walk-in clinics was set up throughout the country.  Programs to tackle basic health issues in the black community were established. 

But then, HIV / AIDS hit.  South Africa had a prevalence rate that would soon become one of the worst in the world.   The burden on the health care system was almost overwhelming.

To make the situation worse, many seasoned, mostly white, health care professionals opted to take a government buyout offer aimed at reducing excess support and administration personnel.

Mark Hayward, of the Aids Law Project at Johannesburg's Witwatersrand University, says the loss of trained medical personnel had far-reaching consequences.

"The HIV epidemic tests the country's health system in very significant ways," said Mr. Hayward.  "It puts additional strain on people who work in the health system, on doctors and nurses, because of the additional burden of patients, people who are being admitted to hospitals with opportunistic infections associated with HIV."

And after President Thabo Mbeki came to office in 1999, the practical difficulties of responding to the pandemic were exacerbated when he questioned the causal link between HIV and AIDS.  Hayward says Mr. Mbeki's unorthodox views on AIDS went unchallenged by members of his cabinet, including Health Minister Manto Tshabalala-Msimang, which was particularly damaging.   He says the effects of Mr. Mbeki's beliefs are still being felt.

"I think what worries me and what worries many of us in the [AIDS activist group the] Treatment Action Campaign, is that there is also a crisis of senior management and of political management of the health system -- particularly South Africa's Minister of Health who frequently seems to prefer to deny there are serious problems rather than admit to the problems and find a consensus on how those problems can be solved," he added.

In 2003, the Treatment Action Campaign and other activist groups won a significant constitutional court ruling to force the government to provide life-saving drugs to pregnant women and newborn babies.  That, and other cases, compelled the government to take a different view.  Now, even though President Mbeki has not unequivocally acknowledged that HIV causes AIDS, and Tshabalala-Msimang frequently causes controversy about appropriate responses to the disease, South Africa has implemented a major program to combat AIDS.  Anti-retroviral drugs (ARVs), considered the most effective treatment in fighting AIDS, are a major component of the program.

"Well, the way we view the ARV rollout is that we recognize that South Africa has one of the biggest, if not the biggest treatment program of any country in the world.  We have gone from nothing to 110,000 people in the public sector in the space of two-and-a-half years, and we have to recognize and commend doctors and nurses and health care workers, and health care managers, for that accomplishment," he noted.

In addition to those receiving treatment in the public health care system, some 100,000 more are receiving treatment as private patients, or in programs run by churches and other non-governmental organizations.  But in its widely respected statistical model on the disease, the South African Actuarial Society estimates that as many as 500,000 South Africans currently have full-blown AIDS and require treatment.

Dr. Letitia Rispel of the Human Sciences Research Council in Pretoria, says that the public health system is also slowly tackling other major health issues, such as measles outbreaks, which are now isolated and infrequent.

"I used to work in the Western Cape, one of the problems that used to be there, neo-natal syphilis which is a particular syndrome when the mother has had untreated syphilis the baby suffers from - some instances these children had to be in an incubator in an - it is [now] a rare occurrence to see that in South Africa," said Dr. Rispel.

But Rispel says that major challenges still remain.  Since South Africa was welcomed back into the international community in 1994, the country's health professionals are in demand in the oil-rich countries of the Middle East and in those of European Union.  Many leave and few return.

And most those who remain are reluctant to work in rural and impoverished areas where the need is greatest.  Rispel notes that Gauteng, the richest province with 19 percent the population has 3,000 doctors in the public health sector.  Limpopo, the poorest of the eleven provinces and with 12 percent of the population, employs just 300.

Both Hayward and Rispel says the government must develop policies that will encourage health professionals to stay in South Africa and also to work in rural areas.

Hayward argues that despite some positive developments, the crisis in South Africa's health system demands an urgent shift in focus by political leaders, notably Health Minister Tshabalala-Msimang.  Rispel too urges urgent attention from government leaders to challenges in the health system.  But she also argues that the advances made in a decade of huge demand and much controversy point to a growing strength within the health system that bodes well for the future.