We share the distress of our colleagues at the large numbers of children in South Africa who suffer and die from surgically correctable heart disease because there are insufficient human and other resources to provide them with the operations they need (Charlene Smith: Sick children lose heart, lives while they wait. Sunday Independent, June 11). But the plight of children with heart disease only gives us a small glimpse into children's health in South Africa generally and into the crisis affecting the public health sector. Ten years into our new democracy, at a time of rapid economic growth, with children's rights enshrined in the constitution, the health of South Africa's children is getting worse rather than better. This is shown by trends in the Under 5 Mortality Rate (U5MR, the number of children per 1000 expected to die before their 5th birthday). U5MR gives a good indication of child health in a country. In 2003 the U5MR for South Africa was 66 according to the World Health Organisation's 2005 World Health Report (See: http://www.who.int/whr/2005/en/index.html). For a middle income country this is rather poor. For example, while South Africa's GDP per capita was over 10000 US dollars in 2002, Thailand's was 7010 and Cuba's was 5259. Thailand's 2003 U5MR was 26 and Cuba's 7, and in both these countries U5MR is showing a progressive fall. South Africa saw a promising fall of 0,3 percent in U5MR between 1990 and 1994 showing an improvement in child health. This improvement has not been sustained. Between 1995 and 1999 U5MR increased by 1,3 percent, and between 2000 and 2003 by a further1,6 percent to a level worse than a decade earlier. The overwhelming majority of these deaths are due not to heart disease, but to AIDS and other preventable diseases of poverty and underdevelopment such as diarrhoea, acute respiratory infections and problems affecting new-born babies. Malnutrition is an underlying problem in 60 percent of deaths. The downturn in child health is largely due to persistent and growing social and economic inequalities, as well as inequities in access to health care. Socio-economic status is the major determinant of under-nutrition in children. Four out of every 10 children in the poorest fifth of the population are stunted; compared with less than one in the richest fifth. Children who live in the rural, largely black provinces such as the Eastern Cape are 9 times more likely to have no skilled attendants present at birth than those living in the more urbanized and racially mixed provinces such as the Western Cape. Their families are more than twice as likely not to have any food in the home at times, 4 times less likely to have access to safe sanitation and 11 times more likely to be using indoor pollutants such as firewood for cooking and heating. Access to health services such as vaccination is significantly associated with educational status of the mother, an important factor in its own right but also an indicator of socio-economic status. The fact that many children still need operations for rheumatic heart disease is itself an indicator of the effects of socioeconomic status on health. We should see the crisis in the public health sector in this context. The kind of disparities in access to health care Dr Danski describes in your article when he says that 'the lists for babies waiting for heart surgery are very long in the public sector; in the private sector there is no waiting list' show clearly how division of our precious health resources into a public sector (for the poor) and a private sector (for the wealthy) impedes access for the poor. These disparities are not unique to children who need heart surgery. In the public sector, patients stand in long queues for even basic health care services at community health centres. The irony is that while poor children are more likely to be ill they also have less access to health care. We believe that health is a fundamental human right, and that access to health care should be equitable for everyone and not depend on social and economic status. Yet we also know that no health department in the world can do everything for everybody – demands on resources for health always exceed availability, even in the wealthiest countries. This means that painful decisions have to be made daily about how to allocate resources. In the absence of a clear policy framework to guide allocation of resources according to agreed national priorities, doctors at the coalface – the level of individual patients – have to make agonising decisions themselves: should we operate on this child because she is the sickest, or on that child because he has been on the waiting list longer? Should we see patients on a first-come-first-served basis, or should we give priority to the most vulnerable? Should we be offering high-cost treatments that benefit small numbers or allocate more resources to less costly treatments that would benefit larger numbers? We sometimes allocate resources by criteria that don't stand scrutiny such as which particular organ is failing in a patient or how much noise a group of doctors make. Our government and health service administrators must provide more explicit policies and frameworks that guide the allocation of health resources according to agreed priorities. in our view, these should reflect the national burden of disease and be based on agreed national values such as the human rights specified in the constitution and principles of equity and social justice, and conform to accepted medical ethics. Clearly, they should give priority to meeting basic needs first. The process should be accountable, transparent and open to challenge and debate. To meet our Millennium Development Goals we have to achieve an U5MR of 24 by 2015. At present we are moving away from that goal rather than making progress towards it. International experience shows that major gains in health can be achieved by following development strategies that give top priority to meeting the basic needs of poor people and improving their social and economic conditions rather than favouring wealthy elites and private enterprise. Such development strategies involve all sectors and not only the health sector in a co-ordinated effort. Within the health sector the country's resources should be allocated fairly and equitably according to the burden of disease. Louis Reynolds Associate Professor, School of Child & Adolescent Health University of Cape Town Paediatric Pulmonologist Red Cross Children’s Hospital reynolds@ich.uct.ac.za Phone +27216899191 David Sanders Professor and Director of Public Health, University of the Western Cape dsanders@uwc.ac.za Phone +27219592132 Both authors are paediatricians and members of the People’s Health Movement