BACKGROUND REPORT March 24, 2009
South Africa's Health System and Challenges
When South Africa’s first democratic election was held in 1994 at the end of the apartheid era, the country’s health system was not structured to serve the entire population.
During apartheid, the vast majority of the public -- black South Africans -- could not access health services and the legacy of inequality left behind by that system meant a centralized health system with a total lack of medical facilities and providers in many of the poorer, more rural provinces.
The constitution of the new democratic South Africa aimed to change all that, proclaiming that every South African has the “right to have access to health care services, including reproductive health care; sufficient food and water; and social security, including, if they are unable to support themselves and their dependants, appropriate social assistance.”
Health care for pregnant women was made completely free, while the cost to the rest of the population is subsidized on a sliding scale based on an individual’s financial position and ability to pay for a service.
Today, primary care in the country is largely provided through a network of community based health clinics. Between 1994 and July 2007, more than 1,600 clinics were built or upgraded, according to the South African Government.
South Africa has a semi-federal government: the federal department of health sets the norms and standards of care but provinces are responsible for delivering that care. There is a private sector accessed by 20 percent of the population.
Despite the good intentions of South Africa’s new democracy, the public health system has been over-burdened from its inception and has not yet caught up with the health needs of the country, according to assessments made by government officials and the Health Systems Trust, an independent South African health policy and research institute.
In 2005, then-Health Minister Manto Tshabalala-Msimang introduced a draft health charter aimed at reducing some of the inequities found in the health system. In her speech presenting the draft she noted that the public health sector was providing care for 38 million people on less money than was spent on seven million people in the private sector. She also acknowledged that between 75 and 80 percent of the population had limited or no access to health services.
Compounding the issue of providing health services to a nation with a high unemployment rate, the HIV/AIDS epidemic raged through the population for many years unchecked. In 2003, the government announced it would provide antiretroviral treatment to HIV positive South Africans for the first time, after a long campaign by AIDS activists.
But the consequences of the delayed response to the epidemic were severe, according to a Harvard School of Public Health study published in the Journal of Acquired Immune Deficiency Syndromes in October of 2008. It concluded that more than 330,000 lives were lost to the disease in South Africa between 2000 and 2005 because of failure to implement an appropriate ARV program.
South Africa now has the largest ARV program in the world, according to the South African Department of Health, but it also has the largest HIV positive population in the world.
In 2007, among the estimated 889,000 HIV South Africans needing ARVs, 42 percent were reported to have started treatment that year, according to the Health System Trust 2008 South Africa Health Review.
One of the other major challenges to the South African health system is a lack of human resources. Doctors Without Borders reports that the private sector pays higher salaries, employs half of the country’s doctors and two-thirds of the nurses. Some of the most talented medical personnel are lured over seas for high paying jobs in other countries.
A 2008 report by the South African Department of Labour concluded that “it is clear that there is a shortage of doctors in South Africa in both absolute and relative terms,” and recommended “urgent measures to recruit doctors and other health professionals back to South Africa.”