—Walker et al make some very helpful points. There are complex differences between evolving African countries. South Africa's mortality rate for children under 5 years of age is 72 per 1000 live births compared with 180 in least-developed countries and a mean of 101 in developing countries.1 Forty-nine percent of South Africa's population is urbanized compared with a mean of 28% in sub-Saharan Africa,1 while the maternal mortality rate stands at 83% in South Africa and 600 for sub-Saharan Africa. In most of Africa, 80% of the population remains rural. It is a tribute to the great advances in South Africa that it is so nonrepresentative of most of the continent.Walker et al are, of course, correct that there must be a strengthening of health facilities and infrastructure; nor must we forget referral mechanisms and secondary care. A great failing of many donors and funding
Elmore-Meegan M. Africa on the Precipice: Perspective From South Africa-Reply. JAMA. 1994;271(10):744–745. doi:10.1001/jama.1994.03510340034018
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